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

National Health Insurance Fund (Cnam) - Cerfa n° 11575*07
Autre numéro : S3139g

Form template uploaded for information

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

Go to the online administrative form

Verified 24 October 2023 - Legal and Administrative Information Directorate (Prime Minister)

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.