INSESO · Forms

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Fields marked * are required. Sections reserved for INSESO are completed at the office.

01 Affiliation details

Full name *Use letters, spaces, hyphens or apostrophes (2–120 characters).Date of birthSocial security number *3–60 characters: letters, numbers, spaces, full stops, slashes or hyphens.EmployerMaximum 180 characters; do not use < or >.ResidenceMaximum 180 characters; do not use < or >.Phone6–26 characters: numbers, a + prefix, spaces, hyphens or parentheses.

02 Medical assistance requested

Other assistanceMaximum 180 characters; do not use < or >.Total amount of invoices submitted (FCFA) *Non-negative amount, without thousands separators; up to two decimal places.

03 Required / submitted documents

Select the documents submittedYou may select several options.

Consultation or hospital discharge medical report, signed, stamped and validated by managementReferral from INSESO health centres, signed and validated by the medical directorateCopy of the DIP and valid social insurance card or renewal receiptPrescription from an INSESO health-centre doctor, with authorisation to buy unavailable productsMedical order for paraclinical examinationsCertificate that the medical assistance is unavailable at INSESO centresOriginal invoices for services or medicines, signed and stamped

04 Assistance details

Health centre where care was received, except prescriptionsMaximum 180 characters; do not use < or >.Date of assistanceTime of assistanceEnter the time in 24-hour format.PlaceMaximum 180 characters; do not use < or >.Application date

INSESO prices will be reconciled with the invoices submitted, as stated in the original form. Do not attach medical reports on this page.

Applicant’s or responsible person’s signature

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Signatory’s full name *

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I confirm that I am the signatory and that the information provided is correct. *This typed-name signature does not include a digital certificate.

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