Waiting list mediation group health insurance

Do you soon have to undergo a treatment in the hospital or are you already on a waiting list?
Fill in the information below and we will see if you can be helped faster.

Name and group number (if you have one) *

Which insurance company do you have health insurance? *

Which basic insurance do you have?

What additional packages do you have?

For which treatment do you want waiting list mediation?

How far are you willing to travel from your home?

Initials *

Last name *

Male or Female

Date of birth *

Postal Code *

House number *

Street

Venue

E-mail adres *

Phone number

Policy number

Any remarks

I agree that the above information will be communicated with the insurer indicated by me. *