Contact form – request to issue  the Provisional Replacement Certificate to EHIC

The service is intended for healthcare providers.

The response to the request is expected directly from the competent institution.

In case of contact, please replace (at) with the correct @ symbol.

Contact email : nc.nkm(at)udzs-sk.sk

Name of applicant/ health care provider *

E-mail address of the applicant/ health care provider *

Registered office/mailing address of the applicant/health care provider *

Address Line 1

City

State / Province / Region

Postal Code

Name and surname of the patient *

First

Last

Date of birth of the patient *

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Personal number of the patient

Patient's health insurance company

Pacient's address

Address Line 1

City

State / Province / Region

Postal Code

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Patient treatment/hospitalization from: *

Patient treatment/hospitalization to: *

Note

File Upload

Click or drag files to this area to upload. You can upload up to 5 files.

Submit