Family benefits Information about health insurance country. Udbetaling Danmark Kongens Vænge Hillerød. A. Personal data

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1 Mail to Udbetaling Danmark Kongens Vænge Hillerød Family benefits Information about health insurance country A. Personal data Name Danish civil registration (CPR) number Address Telephone number Name of the municipality to which you have moved You can read how to complete this form on the last page. B. Information about your nationality Of which country are you a national? (If you have dual nationality: State both countries) I am a national of an EU/EEA country or Switzerland go straight to item D I am a national of a country outside the EU/EEA or Switzerland go straight to item C You can find a list of EU/EEA countries on the last page of this form. C. Information about your last country of residence In which country were you last registered before you moved to Denmark? I was last registered in an EU/EEA country or Switzerland go straight to item D I was last registered in a country outside the EU/EEA or Switzerland go straight to item K You can find a list of EU/EEA countries on the last page of this form. D. Information about your situation in Denmark Here you must provide information about your situation after you have moved to Denmark. Employee or self-employed go straight to item E Job-seeker go straight to item F Student go straight to item G Pensioner go straight to item H Recipient of benefits other than pension go straight to item I Accompanying family member go straight to item K Other go straight to item J Benefits other than pension may, for example, be maternity/paternity benefit, sickness benefit, parental leave allowance or early retirement benefit. side 1 af 5

2 E. Please complete if you are going to work as an employee or be self-employed Here you must provide information about your work as an employee or as self-employed. Information about your posting Have you been posted by an employer outside Denmark to work in Denmark? Yes No If Yes, have you been posted from an EU/EEA country or Switzerland? Yes, please state which country complete the Documentation section Information about work in other countries Are you going to work fully or partly in a country/countries other than Denmark? Yes If Yes, are you going to work in Switzerland or an EU/EEA country other than Denmark? Yes, please state which country complete the Documentation section Documentation Do you have one of the following documents? A valid European health insurance card One of the European health insurance forms E 106, S072 or S1 A decision on social security/a1 form A refusal of an A1 form. F. Please complete if you are searching for a job in Denmark Here you must provide information about any unemployment benefit you receive while you are searching for a job in Denmark Are you receiving unemployment benefit from an unemployment fund or authority outside Denmark while searching for a job in Denmark? Yes If Yes, do you have a European health insurance card from a country other than Denmark? Yes please enclose a copy of the card and continue to item K G. Please complete if you are studying in Denmark Here you must provide information about your studies in Denmark. Are you a Danish or foreign student? Danish student go straight to item K Foreign student You are a foreign student if you have moved to Denmark to study for a period. If you have been studying abroad and are returning to Denmark to complete your studies, you are a Danish student. If you are a foreign student, do you have a foreign European health insurance card or one of the EU health insurance forms E 109, S072 or S1? side 2 af 5

3 H. Please complete if you are a pensioner Here you must provide information about your pension. Are you receiving old-age, disability or survivor s pension from an authority outside Denmark? Yes If Yes, are you also receiving pension from a Danish authority? Yes go straight to item K Danish pension may be state pension, early retirement pension or public servant pension. No If No, do you have a foreign EU health insurance card or one of the EU health insurance forms E 121, S072 or S1? I. Please complete if you receive benefits Here you must provide information about any public benefits you receive, e.g. maternity/paternity benefit, sickness benefit, parental leave allowance or early retirement benefit. Are you receiving benefits from an authority outside Denmark? Yes If Yes, which benefits do you receive? Maternity/paternity benefit Early retirement benefit Sickness benefit Other benefits, please state which : Do you have a foreign EU health insurance card or one of the EU health insurance forms E 106, S072 or S1? J. Please complete if you have selected Other under item D What is the purpose of your stay in Denmark? Go straight to item K side 3 af 5

4 You must tell us if your situation changes You must notify us immediately if there are changes in the information you have provided. This also applies if your circumstances change, as it may affect where you are covered by social security. You must provide us with the information we need to determine whether another country is to pay when you use the Danish health service. When you provide us with the information, you accept that we may obtain information from other authorities, employers etc. when necessary to process your application. Udbetaling Danmark may exchange information As an authority, Udbetaling Danmark is obliged to obtain and disclose information about you. Therefore, please be aware of the following: We may obtain information from other authorities and unemployment funds without your consent if this is necessary to decide your case. We may share information about your health insurance rights with the local authorities, the regions and the National Agency for Patients Rights and Complaints without your consent. We register the information we receive and send it to the authorities and other parties which are entitled, under Danish legislation, to get the information or which are cooperating with us. We receive and send information electronically. You are entitled to know what information we have about you, and you may demand that we correct any incorrect information. You can read more in Sections 10, 11(1), 11a(1)-(2) and (4)-(5) and 11b of the Danish Consolidation Act on Legal Protection and Administration in Social Matters (Retssikkerhedsloven), Chapters 9 and 10 of the Danish Act on Processing of Personal Data (Persondataloven), and Sections 5-8 and 12h of the Danish Act on Udbetaling Danmark (Udbetaling Danmark-loven). You can find the acts at K. Your declaration, consent and signature I declare that the information I have provided is correct and that I am aware of the following: I am obliged to help procure information in the matter and will notify Udbetaling Danmark immediately of any changes in the information provided that may affect where I am covered by social security. I have been informed of my rights and obligations under the Danish Act on Processing of Personal Data (Persondataloven), the Danish Consolidation Act on Legal Protection and Administration in Social Matters (Retssikkerhedsloven) and the Danish Act on Udbetaling Danmark (Udbetaling Danmark-loven). I consent to Udbetaling Danmark obtaining information from employers, unemployment funds, the local authority and other public authorities. Date Signature side 4 af 5

5 Guidelines You must complete all relevant fields on the form. Below you can see whether you need to complete the form, why you need to complete it and how. The completed form must be sent to Udbetaling Danmark, Kongens Vænge 8, 3400 Hillerød, Denmark. Who must complete the form? You must complete the form if you are over 18 years of age and: are a national of an EU/EEA country or Switzerland or have moved to Denmark from an EU/EEA country or Switzerland. Why must you complete the form? You must complete the form to enable Udbetaling Danmark to determine which country is to pay when you use your health insurance card in the Danish health service. When you move to Denmark and register with the Danish National Register, you will receive a health insurance card from your municipality. The health insurance cards entitles you to use the Danish health service. In special cases, you may be covered by another country s social security system. This means that this country must pay when you use your health insurance card, for example if you: work in another EU/EEA country or Switzerland have been posted by a foreign employer to work in Denmark receive pension from another EU/EEA country or Switzerland receive maternity/paternity benefit, unemployment benefit, sickness benefit or early retirement benefit from another EU/EEA country or Switzerland. You must submit documentation You must enclose documentation with the form in some cases. Any requested documentation is indicated under each item in the form. In some instances, you will be asked to send a decision on social security/a1 form or a refusal of this form. The A1 form is a document which indicates by which country s social security system you are covered. If you have been posted by a foreign employer to work in Denmark, you must apply for an A1 form from the authorities in your country of residence. If you are working in several countries, you must submit your application to Udbetaling Danmark, International Social Sikring. Read more at (in Danish). You may also be asked to submit the blue European health insurance card or one of the European health insurance forms E 106, E 109, E 121, S072 or S1. If you have both a health insurance card and a health insurance form, you only need to submit the form. If you have one of the health insurance forms, you do not need to submit a decision on social security/a1 form. You must always submit the form You must submit the Information about health insurance country form even if information or documentation is lacking. You must, however, submit the lacking documentation as soon as you have it. What happens once the form has been submitted? Udbetaling Danmark will determine whether you are covered by Danish health insurance or another country s health insurance, i.e. which country is to pay when you use the Danish health service. We will determine your health insurance country based on the information and documentation you provide. If we need additional documentation, we will contact you. What are the EU/EEA countries? On the form, you may be asked to state whether you will be working in an EU/EEA country or Switzerland. The EU/EEA countries are Belgium, Bulgaria, Cyprus, Denmark, Estonia, Finland, France, Greece, Ireland, Iceland, Italy, Croatia, Latvia, Lichtenstein, Lithuania, Luxembourg, Malta, the Netherlands (Holland), Norway, Poland, Portugal, Romania, Slovakia, Slovenia, Spain, the UK, Northern Ireland, Sweden, the Czech Republic, Germany, Hungary and Austria. More information Read more about health insurance countries at www. borger.dk/sygesikringsland. You are also welcome to contact Udbetaling Danmark on tel if you have questions. side 5 af 5