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The undersigned

Applicant’s surname

Applicant’s name

Applicant’s date of birth

Place of birth

Applicant’s tax code

Country of residence

Applicant’s E-mail

Applicant’s telephone number

Applicant’s Identity Document

Any other attachment

Aware that pursuant to art. 76 of DPR 445/2000 the release of false declarations is punished according to the Criminal Code and special laws on the matter, under his/her own responsability

DECLARES

That he/she is registered in AIRE in the city of

That he/she has temporarily returned to Italy at the following domicile:

City

Street/Square…

Prov.

Toghether with the following relatives who are also registered in AIRE in the same city as above

That he/she is a pension recipient paid by

That he/she is not entitled to a public or private insurance coverage

That he/she is entitled to a public or private insurance coverage

And furthermore declares:

That he/she has already benefited in the current year from

Number of health care days

at this Local Health Authority

During his/her stay in Italy from

to

DECLARATION ACCORDING TO PRIVACY REGULATION

I have read the privacy policy on personal and health data treatment in AULSS 3 Internet site at the following link https://www.aulss3.veneto.it/privacy and I agree to my personal data treatment for administrative purposes, according to the European Regulation (GDPR n. 2016/679) and Italian Privacy Code (D.Lgs. n. 196/2003, as amended and supplemented by D.L. n. 101/2018).

READ AND AGREED

Health care request for AIRE-registered citizens who temporarily return to Italy