Formulaire

Request for supplementary health solidarity (Form 12504*11)

Cerfa 12504*11 (S3711I)

Please enter your Caf Allocator Number.

This form allows you to request the complementary health solidarity.

This form includes an integrated package leaflet.

The form lists the supporting documents to be submitted and the information to be supplied concerning the composition and resources of your household, the specific situations related to the RSA and the choice of the complementary organism.

    Fill out the form

    To whom shall I send this form ?

    For details, please use the practical information sheets :

    J'ai réalisé une démarche administrative

    Je donne mon avis sur Services Publics +. L'administration concernée me répondra.

    Je donne mon avis

    Émetteur du formulaire administratif : National Health Insurance Fund (Cnam)

    Verified 16 July 2024 - Directorate for Legal and Administrative Information (Prime Minister)