Spa treatment - Support questionnaire (accompanied by a declaration of resources). (Form 11139*03)

National Health Insurance Fund (Cnam) - Cerfa n° 11139*03
Autre numéro : S3185c

Form template uploaded for information.

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

The form contains an explanatory note (cerfa n°50270#03).

Go to the online administrative form

Verified 26 March 2024 - Directorate for Legal and Administrative Information (Prime Minister)

For details, please use the practical information sheets :

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