2000/748/EC: Administrative Commission of the European Communities on social security for migrant workers - Decision No 177 of 5 October 1999 on the forms necessary for the application of Council Regulations (EEC) No 1408/71 and (EEC) No 574/72 (E 128 and E 128 B) (Text with EEA relevance)
Date: 1999-10-05
Institutions: Administrative Commission on Social Security for Migrant Workers, European Commission
Subjects: EU Member State, form, free movement of workers, self-employment, social security, wage earner

1.12.2000

EN

Official Journal of the European Communities

L 302/65

COMMISSION

ADMINISTRATIVE COMMISSION OF THE EUROPEAN COMMUNITIES ON SOCIAL SECURITY
FOR MIGRANT WORKERS

DECISION No 177

of 5 October 1999

on the forms necessary for the application of Council Regulations (EEC) No 1408/71 and (EEC) No
574/72 (E 128 and E 128 B)

(Text with EEA relevance)

(2000/748/EC)

THE ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS,

Having regard to Article 81(a) of Council Regulation (EEC) No 1408/71 of 14 June 1971 on the application
of social security schemes to employed persons, to self-employed persons and to members of their family
moving within the Community (1), under which it is the duty of the Administrative Commission to deal
with all administrative questions or questions of interpretation arising fom Regulation (EEC) No 1408/71
and subsequent Regulations,

Having regard to Article 2(1) of Council Regulation (EEC) No 574/72 of 21 March 1972, under which it is
the duty of the Administrative Commission to draw up models of certificates, certified statements,
declarations, applications and other documents necessary for the application of the Regulations,

Having regard to Decision No 165 of 30 June 1997 laying down and adapting certain model forms
necessary for the application of the said Regulations,

Whereas:

(1)

(2)

(3)

(4)

(5)

Forms E 128 and E 128 B are to be amended in order to take account of Council Regulation (EC) No
307/1999 of 8 February 1999 which extended to students the provisions governing entitlement to
sickness benefits in kind.

The Agreement on the European Economic Area of 2 May 1992, as supplemented by the Protocol of
17 March 1993, Annex VI, implements Regulations (EEC) No 1408/71 and (EEC) No 574/72 within
the European Economic Area.

By Decision of
forms necessary for the application of
Regulations (EEC) No 1408/71 and (EEC) No 574/72 shall be adapted and used within the European
Economic Area.

the EEA Joint Committee,

the model

For practical reasons, identical forms should be used within the Community and within the European
Economic Area.

The language in which the forms should be drawn up has been decided by Recommendation No 15
of the Administrative Commission,

(1) OJ L 149, 5.7.1971, p. 2.

L 302/66

EN

Official Journal of the European Communities

1.12.2000

HAS DECIDED AS FOLLOWS:

1. Forms E 128 and E 128 B, concerning benefits in kind required during a stay in a Member State without
imposing a condition of immediate need, as contained in Decision No 165 of 30 June 1997, shall be
replaced by the attached models.

2. The competent authorities of the Member States shall make available to those concerned (rightful
institutions, employers, etc.) the forms according to the attached models.

claimants,

3. Each form shall be available in the official languages of the Community and laid out in such a manner
that the different versions are perfectly superposable, thereby making it possible for each person or body
to which a form is addressed (rightful claimants, institution, employer, etc.) to receive the printed form
in their own language.

4. This Decision shall be published in the Official Journal of the European Communities. It shall be applicable

from the first day of the month following its publication.

The Chairman of the Administrative
Commission

Jorma PERÄLÄ

EUROPEAN COMMUNITIES
EUROPEAN ECONOMIC AREA (*)

E 128

(1)

(See instructions)

CERTIFICATE OF ENTITLEMENT TO NECESSARY BENEFITS IN KIND DURING A STAY IN A MEMBER STATE

(Note: this document establishes no entitlement if the purpose of the journey is to receive medical treatment abroad)

Social Security Regulations: Regulation No 1408/71: Articles 22(b) and 34(b)

The competent institution is to complete this form in block letters and issue it to the person concerned, or send it to the
institution in the place of stay if the form has been drawn up at the latter’s request

1.

Beneficiary:

(cid:1) activity in a Member State other than the competent State: employed/self-employed

person (2)

(cid:1) student

1.1 Surname (3):

................................................................................................................................

Previous names (3):

................................................................................................................................

Forenames:

................................................................. Date of birth (4): .......................................

Permanent address: Street:

................................................................................................................................

Town: ............................................... Postcode: ........................................ Country (1):

...................................

1.2 D.N.I. (5): ....................................................................................................

Identification No (6): .........................

2.

Members of the family travelling temporarily to another Member State

2.1

Surname (3)

Previous names (3)

Forenames

Date of birth (4)

Identification No (6)

..............................
..............................
..............................
..............................
..............................
..............................

.............................
.............................
.............................
.............................
.............................
.............................

..............................
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..............................
..............................

.............................
.............................
.............................
.............................
.............................
.............................

..............................
..............................
..............................
..............................
..............................
..............................

2.2 Permanent address (7): Street:

.............................................................................................................................

Town: ..............................................

Postcode: .......................................

Country (1):

...................................

3.

This document enables the above-named persons to obtain the necessary benefits in kind from insurance bodies in the
country of stay in the event of sickness or maternity and, provisionally, in the case of an accident at work or occupational
disease,

in (1): ..............................................

from (4):

..........................................

to:

....................................

inclusive

4.

Competent institution

4.1 Name:

..................................................................................................

Code No (8): ......................................

4.2 Address: Street:

................................................................................................................................................

Town:

............................................

Postcode:

.....................................

Country (1):

...................................

4.3 Stamp:

Date (4):

................................................................

Signature:

................................................................

5.

Extension of period of validity

5.1

From:

............................

to:

....................................

5.3 From: ......................

to: ....................................

5.2 Stamp:

Date:

.........................

5.4 Stamp:

Date:

........................

Signature:

.........................

Signature:

........................

INSTRUCTIONS FOR THE INSURED PERSON AND THE MEMBERS OF HIS FAMILY

a) When one of the persons concerned has to seek benefits, including hospitalisation, he should submit this form to the insurance

body in the country in which he is staying, i.e.:

in Belgium: the ‘mutualité' (local sickness insurance fund) of his choice;

in Denmark: general practitioners, dentists and hospitals belonging to the public health service. Specialist treatment may be
obtained on the basis of a referral from the general practitioner. Further information may be obtained from the local regional
authority;

in Germany: the sickness insurance fund of his choice, which will, on receipt of the form, issue a certificate establishing entitlement
to all care without imposing a condition of immediate need;

in Greece: normally the regional or local office of the Social Insurance Institute (IKA), which issues the person concerned with a
‘health book', without which no benefits in kind can be provided;

in Spain: the medical and hospital services of the Spanish public health service. The form must be submitted, together with a
photocopy;

in France: when applying for reimbursement, to the ‘Caisse primaire d’assurance maladie' (local sickness insurance fund) or directly
to the hospital

in the event of hospitalisation;

in Ireland: the Health Board in whose area the benefit is claimed;

in Italy: normally the ‘Azienda sanitaria locale' (ASL, the local health administration unit) responsible for the area concerned; for
mariners and for civilian aircrews, the ‘Ministero della sanità — Ufficio di sanità maritima o aerea' (Ministry of Health, the navy or
aviation health office responsible for the area in question);

in Luxembourg: the ‘Caisse de maladie des ouvriers' (Sickness Fund for Manual Workers);

in the Netherlands: the ‘ANOZ Verzekeringen' (Netherlands General Sickness Insurance Fund), Utrecht, which will, on receipt of
the form, issue a certificate establishing entitlement to all care without imposing a condition of immediate need;

in Austria: the ‘Gebietskrankenkasse' (Regional Fund for Sickness Insurance) responsible for the place of stay;

in Portugal: for metropolitan Portugal: the ‘Administração Regional de Saúde' (Regional Health Administration) of the place of stay;
for Madeira: the ‘Direcção Regional de Saúde Pública' (Regional Public Health Directorate) in Funchal; for the Azores: the ‘Direcção
Regional de Saúde' (Regional Health Directorate) in Angra do Heroísmo;

in Finland: the local office of the ‘Kansaneläkelaitos' (Social Insurance Institution), if reimbursement is sought for medical expenses
incurred in the private sector. Benefits in kind can be obtained from municipal health centres and public hospitals by presenting this
certificate;

in Sweden: the ‘försäkringskassan' (Social Insurance Office). Assistance from the medical services (hospital, doctor, dentist, etc.)
may be sought without first contacting the said institution;

in the United Kingdom: assistance may be obtained from the medical services without first contacting the competent institution; this
form should be presented when assistance is sought;

in Iceland: the ‘Tryggingastofnun rikisins' (State Social Security Institute), Reykjavik; assistance may be obtained from the medical
services without first contacting the said institution; this form should be presented when assistance is sought;

in Liechtenstein: directly from the medical services (doctor, hospital, etc.);

in Norway: the ‘lokale Trygdekontor' (local Insurance Office). Assistance may be obtained from the medical services without first
contacting the said institution; this form should be presented when assistance is sought.

b) In order to receive cash benefits, the person concerned shall, within three days of commencement of incapacity for work, apply to
the institution of the place of stay by submitting a notification of having ceased work or, if the legislation administered by the
competent institution or by the institution of the place of stay so provides, a certificate of incapacity for work issued by the doctor
providing treatment for the person concerned.

NOTES

(*) For the purposes of the EEA Agreement on the European Economic Area, Annex VI, Social Security, this form is also valid for

Iceland, Liechtenstein and Norway.

(1) Symbol of the country: B = Belgium; DK = Denmark; D = Germany; GR = Greece; E = Spain; F = France; IRL = Ireland; I = Italy;
L = Luxembourg; NL = the Netherlands; A = Austria; P = Portugal; FIN = Finland; S = Sweden; GB = United Kingdom; IS = Iceland;
FL = Liechtenstein; N = Norway.

(2) Delete as appropriate.
(3) In the case of Spanish nationals state both names at birth.

In the case of Portuguese nationals state all names (forenames, surname, maiden name) in the order of civil status in which they
appear on the identity card or passport.

(4) Give the date in the following order: day/month/year.
(5) In the case of Spanish nationals state the number appearing on the national identity card (DNI) if available, even if the card is out of

date. Failing this, state ‘none'.

(6) In the case of Italian nationals indicate, if possible, the insurance number and/or ‘codice fiscale'.
(7) Complete only if the address of the members of the family differs from that of the worker or student.
(8) To be completed where this exists.

EUROPEAN COMMUNITIES
EUROPEAN ECONOMIC AREA (*)

SCHEMES FOR SELF-EMPLOYED PERSONS

E 128

B (1)

(See instructions)

CERTIFICATE OF ENTITLEMENT TO NECESSARY BENEFITS IN KIND DURING A STAY IN A MEMBER STATE

(Note: this document establishes no entitlement if the purpose of the journey is to receive medical treatment abroad)

Social Security Regulations: Regulation No 1408/71: Articles 22(b) and 34(b)

The competent institution is to complete this form in block letters and issue it to the person concerned, or send it to the
institution in the place of stay if the form has been drawn up at the latter’s request

1. (cid:1) Self-employed person pursuing an activity in a Member State other than the competent State

(cid:1) Student under the terms of Article 34(b)

1.1 Surname (2):

................................................................................................................................

Previous names (2):

................................................................................................................................

Forenames:

................................................................. Date of birth (3): .......................................

Permanent address: Street:

........................................... No: .................................. Box: ...............................

Town:

............................................. Postcode:

...................................... Country (1):

...................................

1.2

Identification No: .................................................................................................................................................

2.

Members of the family

2.1

Surname (2)

Previous names (2)

Forenames

Date of birth (3)

Identification No

..............................
..............................
..............................
..............................
..............................
..............................

.............................
.............................
.............................
.............................
.............................
.............................

..............................
..............................
..............................
..............................
..............................
..............................

.............................
.............................
.............................
.............................
.............................
.............................

..............................
..............................
..............................
..............................
..............................
..............................

2.2 Permanent address (4): Street:

.............................................................................................................................

Town:

............................................

Postcode:

.....................................

Country (1):

...................................

3.

This document enables the persons referred to in box 1 and/or box 2 who are staying temporarily in a Member State other
than the competent State to obtain necessary benefits in kind only in the event of hospitalisation from insurance bodies in
the country of stay:

in (1): ..............................................

from (3):

..........................................

to:

....................................

inclusive

4.

Competent institution

4.1 Name:

..................................................................................................

Code No:

.........................................

4.2 Address: Street:

...............................................................................................................................................

Town:

............................................

Postcode:

.....................................

Country:

BELGIUM

4.3 Stamp:

Date (3):

................................................................

Signature:

................................................................

INSTRUCTIONS FOR THE INSURED PERSON AND THE MEMBER OF HIS FAMILY

When one of the persons concerned has to enter hospital, he should submit this form to the insurance body in the country in which he
is staying, i.e.:

in Denmark: general practitioners, dentists and hospitals belonging to the public health service. Specialist treatment may be obtained
on the basis of a referral from the general practitioner. Further information may be obtained from the local/regional authority;

in Germany: the sickness insurance fund of his choice in the place of stay;

in Greece: normally the regional or local office of the Social Insurance Institute (IKA), which issues the person concerned with a ‘health
book', without which no benefits in kind can be provided;

in Spain: the medical and hospital services of the Spanish public health service. The form must be submitted, together with a
photocopy;

in France: when applying for reimbursement, to the ‘Caisse primaire d’assurance maladie' (local sickness insurance fund) or directly to
the hospital

in the event of hospitalisation;

in Ireland: the Health Board in whose area the benefit is claimed;

in Italy: normally the ‘Azienda sanitaria locale' (ASL, the local health administration unit) responsible for the area concerned; for
mariners and for civilian aircrews, the ‘Ministero della sanità — Ufficio di sanità marittima o aerea' (Ministry of Health, the navy or
aviation health office responsible for the area in question);

in Luxembourg: the ‘Caisse de maladie des ouvriers' (Sickness Fund for Manual Workers);

in the Netherlands: the ‘ANOZ Verzekeringen' (Netherlands General Sickness Insurance Fund), Utrecht, which will, on receipt of the
form, issue a certificate establishing entitlement to all care without imposing a condition of immediate need;

in Austria: the ‘Gebietskrankenkasse' (Regional Fund for Sickness Insurance) responsible for the place of stay;

in Portugal: for metropolitan Portugal: the ‘Administração Regional de Saúde' (Regional Health Administration) of the place of stay; for
Madeira: the ‘Direcção Regional de Saúde Pública' (Regional Public Health Directorate) in Funchal; for the Azores: the ‘Direcção
Regional de Saúde' (Regional Health Directorate) in Angra do Heroísmo;

in Finland: the local office of the ‘Kansaneläkelaitos' (Social Insurance Institution), if reimbursement is sought for medical expenses
incurred in the private sector. Benefits in kind can be obtained from municipal health centres and public hospitals by presenting this
certificate;

in Sweden: the ‘försäkringskassan' (Social Insurance Office). Assistance from the medical services (hospital, doctor, dentist, etc.) may
be sought without first contacting the said institution;

in the United Kingdom: assistance may be obtained from the medical services without first contacting the competent institution; this
form should be presented when assistance is sought;

in Iceland: the ‘Tryggingastofnun rikisins' (State Social Security Institute), Reykjavik; assistance may be obtained from the medical
services without first contacting the said institution; this form should be presented when assistance is sought;

in Liechtenstein: the ‘Amt für Volkswirtschaft' (Office of National Economy), Vaduz;

in Norway: the ‘lokale Trygdekontor' (local Insurance Office). Assistance may be obtained from the medical services without first
contacting the said institution; this form should be presented when assistance is sought.

NOTES

(*) For the purposes of the EEA Agreement on the European Economic Area, Annex VI, Social Security, this form is also valid for

Iceland, Liechtenstein and Norway.

(1) Symbol of the country: B = Belgium; DK = Denmark; D = Germany; GR = Greece; E = Spain; F = France; IRL = Ireland; I = Italy;
L = Luxembourg; NL = the Netherlands; A = Austria; P = Portugal; FIN = Finland; S = Sweden; GB = United Kingdom; IS = Iceland;
FL = Liechtenstein; N = Norway.

(2) In the case of Spanish nationals state both names at birth.

In the case of Portuguese nationals state all names (forenames, surname, maiden name) in the order of civil status in which they
appear on the identity card or passport.

(3) Give the date in the following order: day/month/year.
(4) Complete only if the address of the members of the family differs from that of the worker or pensioner.