Choose a subject : SelectGeneral informationsAppointment and hospitalizationEstimate of your costs or reimbursementsA doctors feesInternational PatientsMember program, donations, bequestsContact the patient relations departmentYour hospitalization fileA doctors accreditation? Votre courrier signé Your signed letter .pdf, .doc, .docx, .odt, .jpg, .jpeg, .png - Poids max : 3Mo All fields marked with an * are required Please attach a signed letter to your request. If you make this request for a third party, additional supporting documents will be requested by our teams. Your request concerns a patient French French Your request concerns a patient that speaks Chinese Japanese English or other Your request concerns - Select -A scheduled medical / surgical hospitalizationEmergency hospitalization (medical evacuation)A preventive health checkA checkup on symptoms Attach a file Attach file .pdf, .doc, .docx, .odt, .jpg, .jpeg, .png - Poids max : 3Mo Your request Votre demande détaillée Your location At home In a medical facility Your financial support is provided by * - Select -An insurance A paying agency (business, government)Yourself Medical specialty requested: Your first name Your surname Your Email Votre Birthdate Your Phone Number Adress Adress City Postal code Country - None -AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua & BarbudaArgentinaArmeniaArubaAscension IslandAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia & HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCanary IslandsCape VerdeCaribbean NetherlandsCayman IslandsCentral African RepublicCeuta & MelillaChadChileChinaChristmas IslandClipperton IslandCocos (Keeling) IslandsColombiaComorosCongo - BrazzavilleCongo - KinshasaCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d’IvoireDenmarkDiego GarciaDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard & McDonald IslandsHondurasHong Kong SAR ChinaHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao SAR ChinaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmar (Burma)NamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorth KoreaNorth MacedoniaNorwayOmanOutlying OceaniaPakistanPalauPalestinian TerritoriesPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSamoaSan MarinoSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia & South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSt. BarthélemySt. HelenaSt. Kitts & NevisSt. LuciaSt. MartinSt. Pierre & MiquelonSt. Vincent & GrenadinesSudanSurinameSvalbard & Jan MayenSwedenSwitzerlandSyriaSão Tomé & PríncipeTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad & TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks & Caicos IslandsTuvaluU.S. Outlying IslandsU.S. Virgin IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWallis & FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Please provide us with a copy of your passport Please provide us with a copy of your passport .pdf, .doc, .docx, .odt, .jpg, .jpeg, .png - Poids max : 3Mo Please send us an ID Merci de nous fournir une pièce d'identité .pdf, .doc, .docx, .odt, .jpg, .jpeg, .png - Poids max : 3Mo How would you like to receive your documents? Secure messaging Mailing (letter with acknowledgment of receipt) Pick up in person Do you wish be contacted by phone ? Oui Non You wish to be contacted between ? and Phone N° Would you like to receive information on? The Membership Program Our Ongoing Projects Bequests, Donations and Life Insurance Votre identifiant patient (NIPP) Computing and Freedom --“By sending this form, I agree that my information will be used by the American Hospital of Paris to respond to my request. My data is processed in accordance with the Privacy Policy. In accordance with the modified data protection act of January 6, 1978, I can exercise the rights of access, rectification, deletion and portability on my data by writing to [dpo@ahparis.org] with proof of identity. »* American Hospital of Paris 63 Boulevard Victor Hugo Neuilly-sur-Seine, France 92200 +33146412525
