O wiadczam, ze wszystkie dane zawarte w formularzu s zgodne ze

O wiadczam, ze wszystkie dane zawarte w formularzu s zgodne ze

2 ZLDGF]DP]HZV]\VWNLHGDQH]DZDUWHZIRUPXODU]XV ]JRGQH]HVWDQHPSUDZQ\PLIDNW\F]Q\P=RERZL ]XM VL GR
QLH]ZáRF]QHJRLQIRUPRZDQLD1DURGRZHJR)XQGXV]X=GURZLDR]PLDQDFKMDNLHQDVW SXM ZWUDNFLHWUZDQLDXEH]SLHF]HQLD
-HGQRF]H QLH R ZLDGF]DP H ]RVWDáDPáHP SRLQIRUPRZDQ\ R W\P H PRMH GDQH RVRERZH ]ELHUDQH
SU]H] 2GG]LDá :RMHZyG]NL 1DURGRZHJR )XQGXV]X =GURZLD ] VLHG]LE Z
SU]\ XO V SU]HWZDU]DQH Z FHODFK Z\QLNDM F\FK ] DUW XVWDZ\ R SRZV]HFKQ\P XEH]SLHF]HQLX Z 1DURGRZ\P )XQGXV]X =GURZLD '] 8 1U SR] ] Sy Q ]P D WDN H R
RERZL ]NX LFK SRGDQLD SUDZLH ZJO GX GR W\FK GDQ\FK L ZQRV]HQLD SRSUDZHN RUD] R W\P H GDQH WH E G XGRVW SQLDQH
SRGPLRWRPXSUDZQLRQ\PGRLFKRWU]\PDQLDQDPRF\SU]HSLVyZSUDZD
! " # $ %&'
( )%*(+,"-*
,QIRUPDFMDGODZ\SHáQLDM FHJRGHNODUDFM Z\ERUX
=JRGQLH ] DUW\NXáHP XVW XVWDZ\ ] GQLD VW\F]QLD U R SRZV]HFKQ\P XEH]SLHF]HQLX Z 1DURGRZ\P )XQGXV]X
=GURZLD RVRE\ XEH]SLHF]RQH PDM SUDZR GR Z\ERUX OHNDU]D SLHO JQLDUNL SRáR QHM Z SRGVWDZRZHM RSLHFH ]GURZRWQHM QLH
F] FLHM QL GZD UD]\ Z URNX :\ERUX WHJR GRNRQXMH VL SRSU]H] Z\SHáQLHQLH QLQLHMV]HM GHNODUDFML L ]áR HQLH Z VLHG]LELH
ZLDGF]HQLRGDZF\
8EH]SLHF]RQ\P jest osoba (art. 6 ust 1, art. 6 ust. 2 i art. 7):
1) SRGOHJDM FD RERZL ]NRZL XEH]SLHF]HQLD ]GURZRWQHJR XEH]SLHF]DM FD VL GREURZROQLH E G FD F]áRQNLHP URG]LQ\
RVRE\QDOH FHMGRMHGQHM]GZyFKSRSU]HGQLFKNDWHJRULL
=DF]áRQNDURG]LQ\XZD DVL QDVW SXM FHRVRE\DUWSNW
1) G]LHFNR ZáDVQH G]LHFNR PDá RQND G]LHFNR SU]\VSRVRELRQH ZQXND DOER G]LHFNR REFH GOD NWyUHJR XVWDQRZLRQR RSLHN DOERG]LHFNRREFHZUDPDFKURG]LQ\]DVW SF]HMGRXNR F]HQLDSU]H]QLHODWDMH HOLNV]WDáFLVL GDOHM–GRXNR F]HQLD
ODW QDWRPLDVW MH HOL SRVLDGD RU]HF]HQLH R ]QDF]Q\P VWRSQLX QLHSHáQRVSUDZQR FL OXE LQQH WUDNWRZDQH na równi – bez
ograniczenia wieku,
2) PDá RQN 3) NUHZQ\FK ZVW SQ\FK URG]LFyZ G]LDGNyZ SUDG]LDGNyZ SR]RVWDM F\FK ] XEH]SLHF]RQ\P ZH ZVSyOQ\P JRVSRGDUVWZLH
domowym.
2EMD QLHQLHVSRVREXZ\SHáQLDQLDGHNODUDFMLZ\ERUX
'HNODUDFMD VWDQRZL GRNXPHQW SRWZLHUG]DM Fy wybór OHNDU]D lub SLHO JQLDUNL lub SRáR QHM 2]QDF]D WR L RVRED PD SUDZR
]áR \üGHNODUDFMHSRMHGQHMGODND GHM]Z\PLHQLRQ\FKRVyE
, : WHM F] FL GHNODUDFML QDOH \ ZSLVDü GDQH RVRE\ GHNODUXM FHM VL GR OHNDU]D SLHO JQLDUNL SRáR QHM SRGVWDZRZHj opieki
zdrowotnej.
:SU]\SDGNXQLHQDGDQLDRVRELHQXPHUX3(6(/QDOH \ZSLVDüQXPHU1,3DZSU]\SDGNXMHJREUDNXURG]DMLQXPHUGRZRGX
WR VDPR FL 'OD XEH]SLHF]RQHJR FXG]R]LHPFD SU]HE\ZDM FHJR QD WHU\WRULXP 53 QD SRGVWDZLH NDUW\ SRE\WX – URG]DM VHUL L
numer tej karty.
.RG2GG]LDáX:RMHZyG]NLHJR1)=–QDOH \ZSLVDüNRG2GG]LDáX1)=QDWHUHQLHNWyUHJRSDFMHQWGRNRQDáZ\ERUX
.RG\2GG]LDáyZ:RMHZyG]NLFK1)=
09 – Podkarpacki
01 –'ROQR O VNL
02 – Kujawsko-Pomorski
10 – Podlaski
03 – Lubelski
11 – Pomorski
04 – Lubuski
12 – O VNL
05 –àyG]NL
13 – ZL WRNU]\VNL
06 –0DáRSROVNL
14 –:DUPL VNR-Mazurski
07 – Mazowiecki
15 – Wielkopolski
08 – Opolski
16 – Zachodniopomorski
,,:WHMF] FLQDOH \RNUH OLüSRUD]NWyU\ZGDQ\PURNX8EH]SLHF]RQ\GRNRQXMHZ\ERUXOHNDU]DSLHO JQLDUNLSRáR QHM
,,,:WHMF] FLGHNODUDFMLQDOH \ZSLVDüQD]ZLVNRLLPL OHNDU]DSLHO JQLDUNLSRáR QHM
,9:WHMF] FLGHNODUDFMLQDOH \]áR \üSRGSLVRUD]ZSLVDüGDW ]DGHNODURZDQLD3RGSLV]JáDV]DM FHJRVNáDGDRVREL FLHRVRED
SHáQROHWQLD OXE RSLHNXQ SUDZQ\ Z LPLHQLX QLHSHáQROHWQLFK G]LHFL E G LQQ\FK RVyE GOD NWyU\FK XVWDQRZLRQ\ ]RVWDá RSLHNXQ
prawny.
9=JáRV]HQLHQLHSHáQROHWQLHJRF]áRQNDURG]LQ\RVRE\SRGOHJDM FHMXEH]SLHF]HQLXPR HGRNRQDüZ\á F]QLHRVREDSHáQROHWQLD
W tHMF] FLZSLVDQHSRZLQQ\E\üGDQHWHMRVRE\