Formulaire

Dental-maxillofacial orthopedic treatments - Request for prior agreement - Doctor

Cerfa 10522*01 (S 3155)

  • Insurance policy
  • Service free
  • 3 steps
  • Language French

Fill out the form

Comment faire ?

  1. Have filled the form by the doctor
  2. Sign the form
  3. Send the form at the dental check of your health insurance fund
General scheme
Who shall I contact
Agricultural scheme
Who shall I contact

Et après ?

The cash register's response must be addressed by the 15th day following receipt of the form. Failure to reply within that period shall constitute an agreement.

J'ai réalisé une démarche administrative

Je donne mon avis sur Services Publics +. L'administration concernée me répondra.

Je donne mon avis

Verified 30 January 2026 - Entreprendre Public Service / Directorate of Legal and Administrative Information (Prime Minister)