Formulaire

Medical prescription for large appliances (Form 12042*02)

Cerfa 12042*02 (S3135b)

Form template uploaded for information.

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

The form contains a leaflet n°50561#03.

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    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 08 April 2020 - Directorate for Legal and Administrative Information (Prime Minister)