Declare your treating physician (Form 12485*03)

National Health Insurance Fund (Cnam) - Cerfa n° 12485*03
Autre numéro : S3704b

Form to be filled in with the doctor of your choice during a consultation.

The form contains a cerfa leaflet n°51041#03.

Go to the online administrative form

Verified 29 March 2021 - Directorate for Legal and Administrative Information (Prime Minister)

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