Appendix No. 1 to the Regulation No. 52/2013
of the President of the National Health Fund
of 19 September 2013
APPLICATION FOR VOLUNTARY HEALTH INSURANCE IN THE NATIONAL HEALTH FUND |
NOTE: THE APPLICATION FORM SHOULD BE FILLED IN
WITH A BALLPOINT OR OTHER PEN IN CAPITAL LETTERS
........................................................................ PESEL* [National Identification Number] |
........................................................................ |
..................................................................................................................................................... ..................................................................................................................................................... ..................................................................................................................................................... ..................................................................................................................................................... ..................................................................................................................................................... Street, house No., flat No. ..................................................................................................................................................... Postal code, place
Registered family members***
PESEL, name and surname, degree of kinship
|
* if you are a non-resident who has not been granted your PESEL number, please enter the series and number of your Residence Card
** if you have not been granted your PESEL number or NIP number, please enter the series and number of your Identity Card
*** if necessary, please extend the table concerning family members reported
........................................ Regional Branch
of the National Health Fund
with its registered office in .......................
I kindly ask you to include me in the voluntary health insurance scheme in the National Health Fund from ................................................................................. .
(day) (month) (year)
I hereby declare that:
1) I am not included in any compulsory health insurance scheme;
2) the period in which I have not been included in any health insurance scheme has lasted for less than 3 months/ has lasted for ................. months.
I hereby declare that my monthly income is ....................................... PLN,
say: ...............................................................................................PLN.
I additionally declare that the registered family member:
1) is not included in any compulsory health insurance scheme;
2) qualifies to be reported because he/she is:
a) own child, child of the other spouse, adopted child, grandchild or a child for whom custody has been established, or a foster child ****,
- aged less than 18 years****,
- aged less than 26 years (because of education)****,
- no age restrictions because (s)he has a certificate confirming a significant degree of disability or other equivalent certificate ****
b) spouse****,
c) ascendants living together with the insured person in the same household****.
I hereby affirm that the information contained above is consistent with all legal requirements and specifications and accurately reflects the actual situation. I also hereby declare that I will immediately inform the Fund of any change in the information provided which occurs during the insurance period. I also declare that I have been informed that my personal details collected by The Regional Branch of the National Health Fund with its registered office in .................................. at .................................... (address) may be processed for the purposes in accordance with art. 188 of the Act of 27 August 2004 on healthcare services financed from public funds (Dz. U. [Journal of Laws] No. 164 item 1027, as amended), as well as about the legal duty to reveal them, about the right to access and correct them and that these details will be made available for parties that are authorised to receive them under legal regulations.
..................................................... ..........................................
place, date signature
*** if it is necessary, please extend the table concerning family members reported
**** delete as appropriate
APPENDIX H SURROGATE CONSENT PROCESS ADDENDUM THE
LOCAL ENTERPRISE OFFICE CAVAN MENTORING PANEL APPENDIX
(APPENDIX) INSTRUCTIONS FOR FOREIGN EXCHANGE SETTLEMENTS OF ACCUMULATED NT
Tags: appendix, regulation, 522013