Formulaire
Care Sheet - Pharmacist (Specimen) (Form 11389*05)
Cerfa 11389*05 (S3115h)
Form template uploaded for information. For your gait, you must use the original form submitted by your doctor (except for the Vitale teletransmission).
The form contains leaflet n°50652#05.
Contact the entity in charge of this form
For details, please use the practical information sheets :
J'ai réalisé une démarche administrative
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Émetteur du formulaire administratif : National Health Insurance Fund (Cnam)
Verified 01 April 2020 - Directorate for Legal and Administrative Information (Prime Minister)