Expense form for hospitalisation and outpatient expenses

You can submit your medical costs via this online form. Fields with an asterisk (*) are mandatory.
  • Date Format: DD slash MM slash YYYY
  • Drop files here or
    Possible documents: Receipts from the health insurance fund, proof of payment of fees actually paid (if not stated on the settlement from the health insurance fund), Mod. 704N forms or 'Certificate of pharmaceutical performances covered under an additional insurance' form from the pharmacist. I will keep the original of the (scanned) copy and will immediately make it available to Vanbreda Risk & Benefits if so requested. I hereby confirm that I will only request the reimbursement of these costs via Vanbreda Risk & Benefits. I will immediately inform Vanbreda Risk & Benefits if I receive a reimbursement of these costs in any other way. In that case I am not entitled to a reimbursement via Vanbreda Risk & Benefits. Attention: Total size of uploaded files is limited to 8 MB.
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