Antrag auf Leistungen zur Teilhabe für Versicherte – Rehabilitationsantrag Instructions

Check this box if you are applying for medical rehabilitation benefits specifically for addiction diseases.

Check this box if the medical rehabilitation for addiction diseases should be provided as an inpatient treatment. Fill only if 'Leistungen zur medizinischen Rehabilitation bei Abhängigkeitserkrankungen' is 'Yes'.

Check this box if the medical rehabilitation for addiction diseases should be provided as a full-day outpatient treatment. Fill only if 'Leistungen zur medizinischen Rehabilitation bei Abhängigkeitserkrankungen' is 'Yes'.

Check this box if the medical rehabilitation for addiction diseases should be provided as an outpatient treatment. Fill only if 'Leistungen zur medizinischen Rehabilitation bei Abhängigkeitserkrankungen' is 'Yes'.

Check this box if the medical rehabilitation for addiction diseases involves a combination of different treatment types. Fill only if 'Leistungen zur medizinischen Rehabilitation bei Abhängigkeitserkrankungen' is 'Yes'.

Please provide any additional address details or suffix.

Check this box if you are applying for aids and technical work aids that are necessary for professional activity due to a disability.

Check this box if you are not currently paying contributions to social security abroad. Fill only if 'Leistungen zur Teilhabe am Arbeitsleben (zum Beispiel: Umschulung, berufliche Weiterbildung)' is 'Yes'.

Check this box if you are currently paying contributions to social security abroad; please also attach Form G0105. Fill only if 'Leistungen zur Teilhabe am Arbeitsleben (zum Beispiel: Umschulung, berufliche Weiterbildung)' is 'Yes'.

Enter the street name and house number of the treating physician's address. Fill only if 'Leistungen zur medizinischen Rehabilitation' is 'Yes'.

Provide any additional address details for the treating physician, such as floor, building, or unit number. Fill only if 'Leistungen zur medizinischen Rehabilitation' is 'Yes'.

Enter the postal code of the treating physician's address. Fill only if 'Leistungen zur medizinischen Rehabilitation' is 'Yes'.

Enter the city or locality of the treating physician's address. Fill only if 'Leistungen zur medizinischen Rehabilitation' is 'Yes'.

Please provide the street name and house number of the representative. Fill only if is 'Yes'.

Please provide any additional address information for the representative, such as apartment number or building name. Fill only if is 'Yes'.

Please enter the postal code of the representative's address. Fill only if is 'Yes'.

Please enter the city or town of the representative's residence. Fill only if is 'Yes'.

Please enter the country of the representative's address. Fill only if is 'Yes'.

Check this box if you were working full-time without shift work, piecework, or night shifts before the application or current incapacity to work. Fill only if 'Arbeitslos gemeldet', 'Heimarbeit' is 'No' and 8 is 'No'.

Check this box if you were working full-time with shift work or piecework before the application or current incapacity to work.

Check this box if you were working full-time with night shifts before the application or current incapacity to work.

Check this box if you were working part-time, less than half of the usual working hours, before the application or current incapacity to work.

Check this box if you were working part-time, at least half of the usual working hours, before the application or current incapacity to work.

Check this box if you were exclusively active as a housewife or househusband before the application or current incapacity to work.

Check this box if you were registered as unemployed before the application or current incapacity to work.

Check this box if you were engaged in homework (working from home) before the application or current incapacity to work.

Check this box if you were employed in a workshop for people with disabilities before the application or current incapacity to work.

Check this box if you are insured with a statutory health insurance fund.

Check this box if you are insured with a private health insurance company.

Check this box if no claims for damages have been asserted (e.g., with private insurance companies).

Check this box if claims for damages have been asserted (e.g., with private insurance companies) and provide the date.

Please provide the date when the claims for damages were asserted. Fill only if 'Claims Asserted' is 'Yes'.

Please specify the institution or party against whom the claims for damages were asserted. Fill only if 'Claims Asserted' is 'Yes'.

Please provide the file number associated with the asserted claims for damages. Fill only if 'Claims Asserted' is 'Yes'.

Check this box if you have not paid contributions to the German pension insurance.

Check this box if you have paid contributions to the German pension insurance.

Check this box if you have not paid contributions to social insurance abroad.

Check this box if you have paid contributions to social insurance abroad.

Please enter the name of the foreign country where social insurance contributions were paid. Fill only if 'ja' is 'Yes'.

Please specify the start date of the period for which social insurance contributions were paid abroad. Fill only if 'ja' is 'Yes'.

Please specify the end date of the period for which social insurance contributions were paid abroad. Fill only if 'ja' is 'Yes'.

Check this box if you are applying for benefits for participation in working life, such as retraining or vocational training.

Check this box if you do not receive any benefits that are regularly paid until the start of a retirement pension. Fill only if 'Beziehen Sie eine Rente oder haben Sie aktuell einen entsprechenden Antrag gestellt?' is 'nein'.

Check this box if you receive a benefit that is regularly paid until the start of a retirement pension (e.g., company pension, early retirement benefit, miner's compensation benefit). Fill only if 'Beziehen Sie eine Rente oder haben Sie aktuell einen entsprechenden Antrag gestellt?' is 'nein'.

Please provide the type of benefit received until the start of retirement pension. Fill only if 'Yes (Benefits Until Retirement Pension)' is 'Yes'.

Please enter the city or town where you were born.

Please enter the country where you were born.

Please provide your birth name.

Please enter any suffix related to your birth name, for example, 'Freifrau' or 'Graf'.

Please enter any prefixes related to your birth name, for example, 'von', 'van', or 'de'.

Please enter your telephone number.

Please enter your fax number.

Please provide the country.

Please provide your date of birth.

Check this box if you want to receive documents in large print due to your disability. Fill only if 'Sind Sie auf die Bereitstellung eines Gebärdensprachdolmetschers beziehungsweise anderer geeigneter Kommunikationshilfen angewiesen oder nutzen Sie behinderungsbedingt ein anerkanntes Hilfsmittel (zum Beispiel Rollstuhl, Führhund oder Assistenzhund)?' is 'Yes'.

Check this box if you want to receive documents in contracted Braille due to your disability. Fill only if 'Sind Sie auf die Bereitstellung eines Gebärdensprachdolmetschers beziehungsweise anderer geeigneter Kommunikationshilfen angewiesen oder nutzen Sie behinderungsbedingt ein anerkanntes Hilfsmittel (zum Beispiel Rollstuhl, Führhund oder Assistenzhund)?' is 'Yes'.

Check this box if you want to receive documents in uncontracted Braille due to your disability. Fill only if 'Sind Sie auf die Bereitstellung eines Gebärdensprachdolmetschers beziehungsweise anderer geeigneter Kommunikationshilfen angewiesen oder nutzen Sie behinderungsbedingt ein anerkanntes Hilfsmittel (zum Beispiel Rollstuhl, Führhund oder Assistenzhund)?' is 'Yes'.

Check this box if you want to receive documents on a CD as a text file (e.g., .doc format) due to your disability. Fill only if 'Sind Sie auf die Bereitstellung eines Gebärdensprachdolmetschers beziehungsweise anderer geeigneter Kommunikationshilfen angewiesen oder nutzen Sie behinderungsbedingt ein anerkanntes Hilfsmittel (zum Beispiel Rollstuhl, Führhund oder Assistenzhund)?' is 'Yes'.

Check this box if you want to receive documents as an audio medium in CD-DAISY format due to your disability. Fill only if 'Sind Sie auf die Bereitstellung eines Gebärdensprachdolmetschers beziehungsweise anderer geeigneter Kommunikationshilfen angewiesen oder nutzen Sie behinderungsbedingt ein anerkanntes Hilfsmittel (zum Beispiel Rollstuhl, Führhund oder Assistenzhund)?' is 'Yes'.

Check this box if the person filing the application is acting as a legal representative. Fill only if is 'Yes'.

Check this box if the person filing the application is acting as a guardian (Vormund). Fill only if is 'Yes'.

Check this box if the person filing the application is acting as a court-appointed caregiver or supervisor (Betreuer). Fill only if is 'Yes'.

Check this box if the person filing the application is acting as an authorized agent or proxy (Bevollmächtigter). Fill only if is 'Yes'.

Check this box if proof of the insured person's lack of insight or ability to consent is attached with the application. Fill only if 'Wird der Antrag durch andere Personen gestellt?' is 'ja'.

Check this box if proof of the insured person's lack of insight or ability to consent will be submitted at a later date. Fill only if 'Wird der Antrag durch andere Personen gestellt?' is 'ja'.

Please provide any former names you have used. Fill only if 'Birth Name' is filled.

Check this box if your gender is male.

Check this box if your gender is female.

Check this box if you prefer not to state your gender.

Check this box if your gender identity is diverse or falls outside the traditional male/female categories.

Provide your insurance number.

Please enter your insurance number.

Check this box if you are NOT dependent on the provision of a sign language interpreter or other suitable communication aids, and do NOT use a disability-related recognized assistive device (e.g., wheelchair, guide dog, or assistance dog). Fill only if 'Wird der Antrag durch andere Personen gestellt?' is 'nein'.

Check this box if you ARE dependent on the provision of a sign language interpreter or other suitable communication aids, or DO use a disability-related recognized assistive device (e.g., wheelchair, guide dog, or assistance dog). Fill only if 'Wird der Antrag durch andere Personen gestellt?' is 'nein'.

Please specify the communication aid or recognized assistive device you require, such as a sign language interpreter, wheelchair, guide dog, or assistance dog. Fill only if 'ja' is 'Yes'.

Please provide the representative's telephone number. Fill only if is 'Yes'.

Please provide the representative's fax number. Fill only if is 'Yes'.

Please provide a detailed and precise description of your last occupation or profession.

Check this box if you do not currently receive, have not previously received, and have not applied for benefits from the Jobcenter.

Check this box if you currently receive, have previously received, or have applied for benefits from the Jobcenter.

Please provide the name of the Jobcenter and your file number (Aktenzeichen). Fill only if 'Ja' is 'Yes'.

Check this box if the person is single and has never been married or in a registered partnership.

Check this box if the person is currently married or in a registered partnership.

Check this box if the person is divorced or their registered partnership has been dissolved.

Check this box if the person's spouse or registered partner has passed away.

Check this box if you are applying for medical rehabilitation benefits.

Check this box if you are applying for inpatient medical rehabilitation, meaning you would stay overnight at the rehabilitation facility. Fill only if 'Leistungen zur medizinischen Rehabilitation' is 'Yes'.

Check this box if you are applying for full-day outpatient medical rehabilitation, meaning you would attend the facility during the day without staying overnight. Fill only if 'Leistungen zur medizinischen Rehabilitation' is 'Yes'.

Check this box if you have NOT received medical rehabilitation benefits from any rehabilitation provider in the last 4 years.

Check this box if you HAVE received medical rehabilitation benefits from any rehabilitation provider (e.g., health insurance, supply office, accident insurance provider) in the last 4 years.

Please provide the name of the institution that last provided medical rehabilitation benefits. Fill only if 'ja' is 'Yes'.

Please provide the file number associated with the medical rehabilitation benefits received. Fill only if 'ja' is 'Yes'.

Please provide the start date from which the medical rehabilitation benefits were received. Fill only if 'ja' is 'Yes'.

Please provide the end date until which the medical rehabilitation benefits were received. Fill only if 'ja' is 'Yes'.

Check this box if the escort of a person in need of care is not required. Fill only if 'stationär (Leistungen zur medizinischen Rehabilitation)' is 'Yes'.

Check this box if the escort of a person in need of care is required and you will attach form G0111. Fill only if 'stationär (Leistungen zur medizinischen Rehabilitation)' is 'Yes'.

Check this box if you have not applied for mother-child or father-child benefits (prevention or rehabilitation) with your health insurance, and such benefits have not been prescribed, immediately before this rehabilitation application.

Check this box if you have applied for mother-child or father-child benefits (prevention or rehabilitation) with your health insurance, or such benefits have been prescribed, immediately before this rehabilitation application, and then provide the date and insurance details.

Please enter the date when you submitted an application for Mother-Child/Father-Child benefits to your health insurance. Fill only if 'Yes' is 'Yes'.

Please provide the full name of the health insurance fund. Fill only if 'Yes' is 'Yes'.

Please enter the file reference number from your health insurance related to the application. Fill only if 'Yes' is 'Yes'.

Check this box if you are applying for motor vehicle assistance benefits as part of your rehabilitation.

Please enter the last name of the person.

Please enter the first name of the person.

Please enter the last name of the treating physician. Fill only if 'Leistungen zur medizinischen Rehabilitation' is 'Yes'.

Please enter the first name of the treating physician. Fill only if 'Leistungen zur medizinischen Rehabilitation' is 'Yes'.

Please enter any name suffixes of the treating physician, such as 'Freifrau' or 'Graf'. Fill only if 'Leistungen zur medizinischen Rehabilitation' is 'Yes'.

Please enter any prefixes to the treating physician's name, such as 'von', 'van', or 'de'. Fill only if 'Leistungen zur medizinischen Rehabilitation' is 'Yes'.

Please enter the academic or professional title of the treating physician, such as 'Prof. Dr. med.'. Fill only if 'Leistungen zur medizinischen Rehabilitation' is 'Yes'.

Please provide the full name, first name, or the name of the department/office of the representative. Fill only if is 'Yes'.

Please enter any additional name component or suffix, such as 'Freifrau' or 'Graf'. Fill only if is 'Yes'.

Please enter any prefixes or prepositions associated with the name, such as 'von', 'van', or 'de'. Fill only if is 'Yes'.

Please provide any academic or professional titles, such as 'Prof.' or 'Dr. med.'. Fill only if is 'Yes'.

Please provide any name suffixes, such as 'Freifrau' or 'Graf'.

Please provide any name prefixes, such as 'von', 'van', or 'de'.

Please provide your academic or professional title, such as 'Prof.' or 'Dr. med.'.

Please provide the full name of the health insurance company.

Please enter the street name and house number of the health insurance company.

Please provide any additional address information for the health insurance company, such as a building part, floor, or department.

Please enter the postal code of the health insurance company.

Please enter the city or town where the health insurance company is located.

Please provide your current nationality, and if applicable, any former nationalities along with the date until which you held them.

Check this box to request benefits for oncological rehabilitation.

Check this box if the oncological rehabilitation should be provided as inpatient care. Fill only if 'Leistungen zur onkologischen Rehabilitation' is 'Yes'.

Check this box if the oncological rehabilitation should be provided as full-day outpatient care. Fill only if 'Leistungen zur onkologischen Rehabilitation' is 'Yes'.

Please provide the full name of the health insurance fund. Fill only if 'Hat die gesetzliche Krankenkasse, die Agentur für Arbeit oder das Jobcenter schriftlich aufgefordert, diesen Antrag zu stellen?' is 'ja, die Krankenkasse'.

Please enter the institutional identification number of the health insurance fund. Fill only if 'Hat die gesetzliche Krankenkasse, die Agentur für Arbeit oder das Jobcenter schriftlich aufgefordert, diesen Antrag zu stellen?' is 'ja, die Krankenkasse'.

Please enter the date. Fill only if 'Hat die gesetzliche Krankenkasse, die Agentur für Arbeit oder das Jobcenter schriftlich aufgefordert, diesen Antrag zu stellen?' is 'ja, die Krankenkasse'.

Please enter the place and date where the consent for section 16.1 was given. Fill only if 'Ist die Mitnahme einer pflegebedürftigen Person erforderlich?' is 'ja'.

Please enter the signature corresponding to the consent in section 16.1. Fill only if 'Ist die Mitnahme einer pflegebedürftigen Person erforderlich?' is 'ja'.

Please enter the place and date where the commitment for section 16.3 was made.

Please enter the signature corresponding to the commitment in section 16.3.

Please enter the postal code for your address.

Please enter the city of your residence.

Check this box if no health disorders have been officially recognized for you as listed in section 12.4.

Check this box if health disorders have been officially recognized for you as listed in section 12.4.

Please provide the name of the authority or office that recognized your health disorders. Fill only if 'Yes, recognized health disorders' is 'Yes'.

Please enter the file number associated with the recognized health disorders. Fill only if 'Yes, recognized health disorders' is 'Yes'.

Please describe the specific health disorders that have been recognized. Fill only if 'Yes, recognized health disorders' is 'Yes'.

Check this box if you have not currently submitted a corresponding application related to recognized health disorders.

Check this box if you have currently submitted a corresponding application related to recognized health disorders.

Please provide the name of the authority or office where you have currently submitted an application related to your health disorders. Fill only if 'Yes, current application submitted' is 'Yes'.

Check this box if the reduction or significant endangerment of earning capacity, leading to the rehabilitation application, is NOT a consequence of an accident or caused by other persons.

Check this box if the reduction or significant endangerment of earning capacity, leading to the rehabilitation application, IS a consequence of an accident or caused by other persons.

Check this box if you do not receive a pension and have not currently applied for one.

Check this box if you receive a pension or have currently applied for one.

Please provide the full name of the pension insurance provider. Fill only if 'ja' is 'Yes'.

Check this box if neither the statutory health insurance fund, the employment agency, nor the Jobcenter formally requested you to submit this application.

Check this box if the statutory health insurance fund formally requested you to submit this application.

Check this box if the employment agency formally requested you to submit this application.

Check this box if the Jobcenter formally requested you to submit this application.

Check this box if no employment is being exercised from which a pension entitlement is guaranteed, and if there is no insurance exemption in the statutory pension insurance due to reaching an age limit.

Check this box if an employment is being exercised from which a pension entitlement is guaranteed, or if there is an insurance exemption in the statutory pension insurance due to reaching an age limit.

Please enter the street name and the house number for your current residence.

Please provide the phone number of the health insurance company, reachable during the day.

Please provide the telephone number of the treating physician, reachable during the day. Fill only if 'Leistungen zur medizinischen Rehabilitation' is 'Yes'.

Provide the full name and address of your first preferred rehabilitation facility. Fill only if 'Leistungen zur medizinischen Rehabilitation' is 'Yes'.

Provide the full name and address of your second preferred rehabilitation facility. Fill only if 'Leistungen zur medizinischen Rehabilitation' is 'Yes'.

Provide the full name and address of your third preferred rehabilitation facility. Fill only if 'Leistungen zur medizinischen Rehabilitation' is 'Yes'.