Personal statement from
the claimant and partner
Please send this form to:
Helfo
Postboks 2415
3104 Tønsberg
NORWAY
In order to receive reimbursement from Helfo for your
expenses for infertility treatment , you must fulfill the
requirements for the treatment of childlessness in the
biotechnology Act. Helfo can verify that the
information you provide in the form is correct.
1. Personal data
Name of applicant
Navn of partner
Date of birth and national ID. number
Date of birth and national ID. number
2.Concerning the type of treatment (tick)
Fertilisation outside the body (IVF or ICSI)
Hormonal stimulation
Artificial insemination (AIH or AID)
PGD screening
3. Previous treatment(s)
The Norwegian National Insurance Scheme reimburses expenses on up to 3 attempts per
child regardless of whether the procedure is performed in Norway or another EEA country. A
'complete attempt' is defined as an IVF or ICSI procedure to harvest eggs and transfer fertilised
eggs to the uterus.
Fill out if you have previously undergone assisted fertilization in Norway or another EEA-country
State the number of complete attempts
State name of clinic(s) that provided the
treatment
Date(s) of when treatment was provided
Fill out if you have been reimbursed expenses for previous attempts by Helfo
State the number of attempts you have previously received reimbursements for
4. Concerning the criteria of the Norwegian Biotechnology Act Chapter 2 (tick)
We are married or cohabitants in marital-like relationships
YES
NO
Fill out by insemination treatment or by fertilization outside the body
We use sperm from a donor
If YES - is the sperm donor registered in a donor register that gives the
child access to the donor's identity when the child reaches the age of 18?
YES
NO
YES
NO
We used eggs from another woman
YES
NO
Donation of eggs or partial egg donation from one woman to another is prohibited by
law in Norway.
The following conditions must be fulfilled, cf. the Biotechnology Act sections §§2-7 to 2-9,
§2-11 third paragraph and §2-13:
• The sperm donor is registered in a donor register that gives the child access to the
donor's identity when the child reaches the age of 18.
• The sperm donor must be over 18 and not be deprived of legal capacity in personal
affairs.
• The use of donor sperm can not take place after the donor is dead.
• Treatment of the sperm prior to fertilization to affect the choice of the child's gender is only
allowed if the woman is a carrier of a severe hereditary gender-related illness.
Helfo 05-24.14 Engelsk Ny 05.2017
5. Preimplantation genetic diagnosis (PGD)
PGD (genetic examination of fertilized eggs outside the body prior to insertion into the
uterus), including gender examination, can only be performed under authorisation from
the PGD Board in Norway.
Preimplantation diagnostics:
We will be having a genetic examination of fertilized eggs
YES
NO
YES
NO
Fill out if you have answered yes to the question above:
Has the PGD Board granted your application for PGD? If 'YES' to the
question above: Enclose the PGD Board's authorisation letter.
6. Expenses you are claiming for
State the total amount
7. List of enclosures supporting your claim*
Tick to
Documentation of infertility treatment
confirm
Enclosure
no.
For non-hospital treatment: a copy of the treatment provider's licence to
practice or specialist authorisation from the country providing the treatment
Medical record/discharge summary from abroad
Any records from previous infertility treatment in Norway
Referral letter from a Norwegian healthcare professional
Original itemised bill
Original receipt or other proof of payment such as a bank statement.
Statement from the treating physician regarding assisted reproductive
treatment abroad
Documentation for the purchase of drugs
Prescriptions
Package or copy of package showing active substance
Original receipts itemising the name of the drug, number of packs
and price
If you are claiming reimbursement for drugs not marketed in Norway:
Completed form: «Reimbursement for drugs not marketed in Norway
- infertility treatment»
Documentation for PGD treatment
Authorisation letter from the PGD Board in Norway
* All documentation must be in Norwegian, Danish, Swedish or English. For more information on this, see general
information on the last page.
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8. Consent* og signature from from claimant and partner
I give my consent for my claim and supporting documentation to be transmitted to the
specialist health service if Helfo requires assistance in determining my entitlement to
reimbursement and the amount of any reimbursement.
I also give my consent for Helfo, the Norwegian specialist health service and regional
health authority units to exchange relevant health data on me or the status of other
claims if necessary for processing my claim. In signing this form, I consent to procurement
and use of my health data; see the Norwegian Health Registry Act and Personal Data
Protection Act.
We hereby certify that the information provided in the personal statement is accurate and complete:
Place and date
Claimant's signature
Place and date
Partner's signature
*If you do not give your consent for exchange of information between Helfo and the specialist health service, Helfo may not be able
to process your application because it is not supported by sufficient medical information.
Information on the translation requirement
All documentation must be in Norwegian, Danish, Swedish or English. You should therefore try to
get the documentation issued in one of these languages.
If the documents are in another language, Helfo may ask you to provide a state-authorised
translation. You must pay for the translation yourself.
Helfo 05-24.14 Engelsk Ny 05.2017
Helsenorge.no