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

The policyholder (name, surname, birth date):......................................................................
....................................................................................................................................................
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.,
should approve the following for scheduled treatment within the following scope:........................................................................................................................................
....................................................................................................................................................
........................................................................................................................................................................................................................................................................................................
at the health care provider (name, address, contact): 
........................................................................................................................................................................................................................................................................................................
Therefore, please provide calculation of supposed costs of the above treatment.

Breakdown of supposed costs according to items	Paid by the competent institution*	Not paid by the competent institution*	
1. Costs of the stay (rate per day x number of days)			
2. Costs of the execution/operation			
3. Other costs (please, specify)			
4. Supposed costs total			
5. Surcharges to be paid by the policyholder	X		

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

The following are the contracting health insurance companies (name and address): 
........................................................................................................................................................................................................................................................................................................

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

Out unit accepts the portable document S2 (within the meaning of Article 20(2) of the Regulation of the European Parliament and the Council 883/2004), or the portable document DA1 (within the meaning of Article 36(2) of the Regulation of the European Parliament and the Council 883/2004) for the scheduled treatment:

           □   yes                                                         □   no
                                       
Date:....................                                                               ...........................................

                                                                                                  Signature and stamp
                                           				      of the foreign health care provider 

* Competent institution, which carries out social security in another Member State.