Key Benefits:
Minister of Health and Sports,
Considering Directive 2005/36/EC of the European Parliament and the Council of 7 September 2005 on recognition of professional qualifications;
Vu le Public Health Code,
Stop it!
The form of the pre-service delivery declaration provided for in theArticle D. 4364-11-9 of the Public Health Code as well as the list of parts to be provided are contained in the annex.
The Director of Hospitalization and Care Organization is responsible for the execution of this Order, which will be published in the Official Journal of the French Republic.
A N N E X E
FORM OF DECLARATION (1)
1. This statement concerns:
A first service delivery in France (please complete items 2 to 5 and 7).
Annual renewal (2) (please complete items 2 to 6 and 7).
A change in the provider's situation (please complete items 2 and 5).
2. Applicant's identity:
2.1. Name(s):
2.2. First name:
2.3. Nationality(s):
2.4. Gender: Female Male
2.5. Date of birth:
2.6. Place of birth: City:
2.6. Place of birth: Country:
2.7. Coordinates in the State of establishment, member of the European Union or party to the agreement on the European Economic Area (required):
Address:
Telephone (with prefixes):
E-mail:
2.8. Contact details in France (optional):
Address:
Telephone:
E-mail:
3. Profession concerned :
3.1. Profession exercised (3) in the State of establishment, member of the European Union or party to the agreement on the European Economic Area (4):
Specify the specialty, if applicable:
Profession for which you ask access in France:
Specify the specialty, if applicable:
Indicate the types of acts envisaged (optional):
Specify the location of the first service delivery (optional):
3.2. Are you part of a professional order or equivalent agency?
Yes No
If yes, please indicate its name and contact information, as well as your registration number (5):
4. Professional insurance:
Coverage of insurance under civil liability or other means of personal or collective protection relating to professional liability, for the acts you are going to practise in French territory (6).
Name of insurance company:
Contract number:
Important: If the supplier exercising a liberal position does not have an insurance coverage, it is required to subscribe to an insurance coverage under the provisions of Article L. 1142-2 of the Public Health Code. If he does not exercise in a liberal capacity, he or she is required to verify the extent of the warranty that his or her employer has made.
Possible comments:
5. Mandatory evidence to be attached to this statement:
5.1. Photocopy of an ID. To complete, if not provided for, a document certifying the applicant's nationality.
5.2. Photocopy of the training title(s).
5.3. Attestation of the competent authority of the State of establishment, a member of the European Union or a party to the agreement on the European Economic Area, certifying that the person concerned is legally established in that State and that, when the certificate is issued, no prohibition, even temporary, of exercising.
The documents referred to in 5.2 and 5.3 shall be translated into French by a translator accredited to the French courts or authorized to intervene with the judicial or administrative authorities of a Member State of the European Union or a party to the agreement on the European Economic Area.
6. Information to be provided in case of renewal (7):
6.1. During which period(s) did you take services in France?
From // to //
From // to //
From // to //
From // to //
From // to //
Possible comments:
6.2. Please indicate the professional activities carried out during the periods in which you provided services:
7. Other observations:
Date:
Signature:
Done in Paris, February 19, 2010.
For the Minister and by delegation:
By preventing the director
Hospitalization
and the organization of care:
The chief of service,
C. d'Autume
