Calculation of assumed costs of scheduled cross-border health care and confirmation on the possible acceptation of the policyholder

The policyholder (name, surname, birth date):......................................................................
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filed an application for consent under § 9f paragraph. 1 of the Act. 580/2004 Coll. on health insurance and on amendments to Act no. 95/2002 Coll. on insurance and on amendments to certain laws, as amended (the "Act"), the General health insurance company, a.s.,
the payment of cross-border healthcare (according to the performance of the Ministry of Health of the Slovak Republic no. 341/2013 Coll. establishing cross-border healthcare, which is subject to prior approval by the relevant health insurance company for the purpose of reimbursement)
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........................................................................................................................................................................................................................................................................................................ the health care provider in another Member State of the European Union (name, address, contact): 
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Therefore, please provide calculation of supposed costs of the above treatment.

Breakdown of supposed costs according to items		
1. Costs of the stay (rate per day x number of days)		
2. Costs of the execution/operation		
3. Other costs (please, specify)		

Supposed costs total:……………………………………………………………………………..

We are confirming that our unit can accept the above policyholder for the scheduled treatment:
           
           □   yes                                                         □   no            

Date:....................      

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                                                                                           Name, signature and stamp
                                           				      of the foreign health care provider