Claims
Type *
Patient
Associated company
Collaborator/to
Other
Chooses one of the following options *
Provisions
Healthcare
Treatment
Organisation
Social aid
Other
Email *
Full name *
NATIONAL ID NUMBER *
Telephone *
Address *
City/Town *
Postcode *
Province *
Company *
Company ID (CIF)
Centre in which has been looked after/to *
Comment *
I accept and have read
legal statuses
Send