This form is intended for people living abroad who might qualify for a sickness or WIA benefit. You will only need to fill in this form if you have received a letter from us asking you to do so. It is important that you complete the form before the date mentioned in the letter.

Let us know where you would like to have the medical examination by completing the form Preference for medical examination in your country of residence or in the Netherlands. You will need either a DigiD account or a valid European electronic ID (‘Europees erkend inlogmiddel’) to access this form.

Once we have received your form, we will contact you with more information about the medical examination.

Having an examination in your country of residence

If you would prefer to have a medical examination in your country of residence, the benefits organisation in that country will contact you directly.

Having an examination in the Netherlands

If you would prefer to have a medical examination in the Netherlands, we will send you an invitation for an appointment as well as information about how to claim travel and accommodation costs. 

This form is also available in Dutch, French, German and Polish: