Formulaire

Request for prior transport agreement - medical prescription for transport (Form 11575*07)

Cerfa 11575*07 (S3139g)

Form template uploaded for information

For your gait, you must use the original form provided by the healthcare professional.

    Fill out the 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 24 October 2023 - Directorate for Legal and Administrative Information (Prime Minister)