REQUEST FOR A REFUND
of costs of electronically prescribed drugs

Personal details of the individual filing the request:

you can find this number on your assistance card as well as in your Digital Clinic registration confirmation e-mail

Personal details of the individual who was issued the e-prescription
(if the e-prescription was issued to a minor under the age of 18, only fill in their first name, last name and date of birth)

Personal details of the individual who is filing the request
(if not the person stated on the e-prescription or the benefit holder)


Please, attach a copy of the receipt from the pharmacy *