Formulaire de demande de couverture de maladie universelle complémentaire 196s4x

With the Cerfa form n°12504*05, you can make a de for universal complementary health coverage or assistance for complementary health. You do not have to choose between the two yourself, the rights for one of the two organizations will be granted to you according to your income.

In the form, you will find all the ing documents required to prepare your application and file. You will also find a list of information you need to know about your home, your resources and the choice of a complementary organization.

To complete your request for universal complementary health coverage or assistance for complementary health insurance, simply , print and complete the form. All you have to do is send your request and ing documents to your primary health insurance fund.