CHIS F01 - Claim for reimbursement of medical expenses 2026

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4.9 out of 5

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The document is a declaration form for reporting a non-occupational accident under the CERN Health Insurance Scheme (CHIS). It requires the main member to provide personal details, accident specifics, and information about any other insurance coverage. The form also includes sections for detailing transport and treatment after the accident, involvement of third parties, witnesses, and subrogation rights regarding medical expenses. The completed form must be returned to UNIQA GlobalCare SA with the first reimbursement claim.

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Click ‘Get Form’ to open it in the editor.
Begin by filling in your details as the Main Member. Enter your surname, first name(s), and CHIS ID in the designated fields.
If the patient is not the Main Member, provide their surname, first name(s), and CHIS ID. Include their home address if different from yours.
Indicate if other insurance covers the medical expenses related to the accident. If yes, provide the insurance name and policy number.
Fill in the date and time of the accident, along with a detailed description of where it occurred and its circumstances.
Specify how you were transported to treatment and provide details about the care provider.
Complete sections regarding any third parties involved, including witnesses, if applicable.
Finally, review all information for accuracy before signing and dating the form at the bottom.

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Versions	Form popularity	Fillable & printable
2019	4.9 Satisfied (43 Votes)

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is a claim for reimbursement of medical expenses?

A reimbursement claim is a request made to an insurer or employer to cover expenses already paid by the claimant. It involves submitting proof of payment and other relevant documents to receive compensation for incurred costs.

How do I submit a claim for UnitedHealthcare reimbursement?

List of documents to furnish Original hospital final bill. Original numbered receipts for payments made to the hospital. Complete breakup of the hospital bill. Original discharge summary. All original investigation reports along with prescriptions. All original medicine bills with relevant prescriptions.

Can an Ichra reimburse medical expenses?

ICHRA reimburses individual health insurance premiums and medical expenses. ICHRA also has different compliance and regulatory requirements compared to traditional HRAs. Traditional HRA is typically paired with a group health plan and cannot reimburse individual insurance premiums.

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