ALL WALES EEA REIMBURSEMENT FORM - Health in Wales 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin with Section 1, entering your personal details such as forename, surname, address, and National Insurance number. Ensure you indicate if you have lived in the UK for more than one year.
3. Proceed to Section 2, where you will provide information about the European organization offering treatment. Fill in the company name, address, and contact details.
4. In Section 3, list the clinician supporting your request. Include their name, job title, and contact information to facilitate communication with your health board.
5. Section 4 requires detailed information about the intervention you are seeking. Specify the type of treatment and provide a summary of your condition along with any supporting evidence.
6. Complete Section 5 by adding any additional relevant information that may support your application.
7. In Sections 6 and 7, confirm your consent for further clinical information requests and sign the form to validate your application.

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