Co-insurance application § 123 ASVG

Please consider the preconditions and proofs stated in the fact sheet!

1. Information on the insured person

Insurant Last and first name  female Insurance policy number
 male
Address (ZIP, city, street and number)

Civil status Citizenship

 single   married/in civil union   widowed
 divorced/civil union terminated
Phone number E-mail-address
2. Information on the co-insurant/the family member
Co-insurant Last and first name  female Insurance policy number
 male
Address (ZIP, city, street and number)

Civil status Citizenship

 single   married/in civil union   widowed
 divorced/civil union terminated
3. Relationship between co-insurant and insurant
3a.  Child  Foster child with official authorisation 
  Stepchild  Foster child without remuneration
 Grandchild  Related foster child
If the child is older than 18 years: Tick what applicates!
 child is currently attending school, studying or doing vocational training.
 child has been jobless since termination of school, university or vocational training
 due to an illness, child is has been unable to work since being more than 18 years old or since
termination of school, university or vocaional training
 child is participating in a programme of the EU to promote mobility of young adults

3b.  Marital or civil partner   care-giving relative with predominant

demand, not employed

3c.  not related person running the   related person running the household
household (e. g. partner)

There has been an uninterrupted shared household and unpaid housekeeping since _____________ and
there is no marital or union partner able to work living in the shared household.

10-ÖGK 32/19. 01.01.2020

 4. Further information on the relative (Tick what appliactes)
  Compulsory health insurance or
obligatory insurance abroad
Country
 Working abroad
Country
Monthly income in €
 Employed by the following
international organisation:
 Drawing retirement pension from abroad a
 Drwaring retirement pension from an
international organization
 Permanent stay abroad
Country
 Member of one of the following chambers:
Chamber of docotrs, veterinarians, lawyers,
architects and chartered engineering consultants,
Austrian patent agents, pharmacists, chartered
accountants or persons subject to compulsory
insurance under the Notaries's Insurance Act
 Receiving an age-related, occupational disability
or death benefit from a statutory professional
representative
 Pension benefits for freelance workers (FSVG),
for self-employed workers (GSVG) or notaries
(NVG)
 Agricultural management for own account
 Compulsory health insurance in Austria

  Nothing applies
5. Information on the examination after moving in (entry) from abroad
Reason for entry:
  vacation   visiting relatives   doctor's appointment 
 permanent residence in Austria
Planned duration of stay in Austria:
 up to 3 months   other duration:   permanently
Final declaration
I confirm that Austria is the above-mentioned relative(s)' centre of vital interests and economic
existence.
I declare that all statements are correct and complete.
If it turns out later that the information provided is not true, I acknowledge that I will have to
compensate the health insurance institution for any damage caused by this.
I am obligated to report all changes (of the information given in this form) immediately.
I acknowledge that according to § 51 d ASVG a monthly health insurance contribution basis is to be
paid for certain dependents (if applicable, retrospectively for up to five years).

Insurant's signature
 Information on the status of relatives
Ein Anspruc die angeführten Angehörigen, wenn sie weder
nach dem Allgemeinen Sozialversicherungsgesetz noch nach einer anderen gesetzlichen Vorschrift
krankenversichert sind, keiner Krankenfürsorgeeinrichtung angehören und grundsätzlich ihren gewöhnlichen
The relatives listed are entitled
Aufenthalt im Inland to health
haben.insurance benefits if they are not insured under the General Social Insurance Act or
any other statutory provision,
Bei Zuzug aus dem do not belong to any health
Ausland care institution
ist neben and are generally habitually resident
dem Versicherungszeitennachweis des inausländischen
Austria.
In the case of immigration from abroad, in addition to the proof of insuranceperiod from the foreign
Versicherungsträgers (EU, EWR, Schweiz und bilaterale Vertragsstaaten) ein zusätzlicher Nachweis über insurance institution (EU,
den
EEA, Switzerland and bilateral treaty states), additional proof of habitual residence in Austria is required
gewöhnlichen Aufenthalt im Inland erforderlich (z.B. Aufenthaltstitel, Niederlassungsbewilligung, Anmelde- (e. g. residence
permit, settlement permit, registration
bescheinigung, certificate, confirmation of kindergarten/school attendance).
Kindergarten-/Schulbesuchsbestätigung).
Even if the relatives live in an EU,
Auch wenn die Angehörigen EEA country or Switzerland,
in einem or permanently
EU-, EWR-Land oder derreside in a bilateral
Schweiz contracting
leben, oder state, there
sich ständig in einem
may be an entitlement as a relative. In this regard, please contact the Austrian Health Insurance Fund.
bilateralen Vertragsstaat aufhalten, kann eine Anspruchsberechtigung als Angehörige/r bestehen. Diesbezüglich
In addition, there
wenden areSie
further
sich requirements. Please enclose
bitte an die Österreichische copies of the required certificates.
Gesundheitskasse.
Darüber hinaus gibt es noch weitere Voraussetzungen. Legen Sie die erforderlichen Nachweise in Kopie bei.

Angehörige Weitere Voraussetzungen Erforderliche Nachweise

Relatives
Ehegattin/Ehegatte Further preconditions Requirements
Heiratsurkunde
Spouse/husband
Eingetragene Partnerin/ Marrige certificate
Urkunde über die eingetragene
Civil eingetragener Partner Certificate ofPartnerschaft
the civil union
partner Kind, Wahlkind Geburtsurkunde, Bestätigung über
Child Ab Vollendung des Adoption
Birth certificate, bzw.certificate
adoption Gerichtsbeschluss,
or
From the age18. Lebensjahres
of 18, see * siehe * allenfalls Urkunde
court order, at best certificate ofüber die
paternity
or parenthood Vaterschaft/Elternschaft
(acceptance/judicial (Anerkennun
assessment) gerichtliche Feststellung)
Stiefkind Ständige Hausgemeinschaft mit Geburtsurkunde, aktuelle
Stepchild Ab Vollendung des der/dem Versicherten
permanently shared household Heiratsurkunde,
Birth certificate, Urkunde über die
current marriage
From the age18.
of Lebensjahres siehe * with the insurant eingetragene Partnerschaft
certificate or certificate of the civil union
18, see * Enkelkind Ständige Hausgemeinschaft mit Geburtsurkunde des Kindes sowie
GrandchildAb Vollendung des permanentlyder/dem
sharedVersicherten
household Geburtsurkunde
Birth certificate of the child asjenes
well Elternteiles,
as
welcherofmit
theder/dem
directly Versicherten in
From the age18. Lebensjahres
of 18, see * siehe * with the insurant the birth certificate related
parent direkter Linie verwandt ist
Pflegekind mit Behördlich bewilligtes Geburtsurkunde, behördlich bewilligte
behördlicher
Foster child with Bewilligung Pflegschaftsverhältnis Pflegenachweis
Birth certificate, proof of foster care
offical authorisation
Ab Vollendung des officialy approved foster care approved by the authorities
From the age18. Lebensjahres
of 18, see * siehe * relationship
Pflegekind mit - Ständige Hausgemeinschaft mit Geburtsurkunde
Foster childunentgeltlicher Verpflegung der/dem Versicherten
- permanently shared household with Birth certificate
without remuneration
Ab Vollendung des - Unentgeltliche Verpflegung
the insurant
18. Lebensjahres
From the age of 18 , see * siehe * (Versorgung)
- No remuneration for subsistence
Pflegekind mit - Ständige Hausgemeinschaft mit Urkunden über das Verwandtschafts-
Verwandtschaftsverhältnis
Related foster child - permanently der/dem
sharedVersicherten
household Certificate ofbzw.
the Verschwägerungsverhältnis
family relationship
Ab Vollendung des Verwandt oder verschwägert
with the- insurant bisin-law relationship
or the
zum dritten Grad
From the age18. Lebensjahres
of 18, see * siehe * related or in-lawed
- up to the 3rd
Verwandte degree - Person aus dem Kreis der Eltern, Urkunden über das
haushaltsführende Person
Related person - Person from Wahl-, Stief- circle
the family und Pflegeeltern,
of der
Certificate ofVerwandtschaftsverhältnis
the family relationship
running the household Kinder, Wahl-,
parents, step-parents andStief-
fosterund
Pflegkinder,
parents; children, der Enkel oder der
step-children
Geschwister
and foster children, grandchildren
- Seit mindestens zehn Monaten
or sibling
- household bestehende Hausgemeinschaft
community existing
und unentgeltliche
for at least ten months and
Haushaltsführung
unpaid household management
- kein/e arbeitsfähige/r
- no marital or Ehegattin/Ehegatte
civil partner beingoder able
eingetragene
to work of the Partnerin
insurant living in the/
eingetragener Partner der/des
shared household
Versicherten im gemeinsamen
Haushalt
HV-KV051.01/2017
HV-KV051.01/2017
Not related person running
the household (e. g. partner)
Care-giving relative
* Co-insurance for children and grandchildren older than 18 years:
Reasons for extension
School, university or
vocational training
Until the age of 27 at the longest
Mobility project for young
people by the European
Union
Until the age of 27 at the longest
Unemployment
for a maximum period of 24
months
Inability to work
Note: Certain groups of people are excluded from the status of relatives by law.
If you have questions, contact ÖGK.
- household community existing for
at least ten months and unpaid
household management
- no marital or civil partner being
able to work of the insurant living in
the shared household
- Receipt of care allowance by the Certificates of the family relation or
insurant, at least in the amount of the in-law relation
level 3
- Non-profit care in a domestic
environment from among the
following persons:
o Spouse/husband; civil partner;
Persons who are related to the
person in need of care in a
strait line or who are related or
in-lawed up to the fourth
degree of the side line; Step-
children and foster children;
Step-parents and foster
parents;
o not related person running the
household (further
preconditions --> see above)
Further preconditions Requirements
- Receipt of family allowance Confirmation of school or university
- School attendance or attendance (per school or academic
vocational training year), transcript (at least eight positive
- Serious and determined semester hours or 16 ECTS-Punkte
completion of one's studies per academic year)
Confirmation of participation
Unemployment since reaching the age Confirmation of the termination of
of 18 or the end of school, university or school, university or vocational training
vocational training
Inability to work due to illness of Current medical opinion on the
affliction since reaching the age of 18 or inability to work or receipt of elevated
since termination of school, university or family allowance
vocational training