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Apply Healthcare mediation
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Apply mediation
At HollandZorg, you can simply apply for healthcare mediation online. Please complete the healthcare mediation application form. One of our members of staff will contact you within two working days to discuss your options.
Fill in the following form
Gender*
Madam
Sir
Initials*
Inserts
Surname*
Postal code*
House number*
Addition
Street name*
City/town*
Date of birth*
Phone number*
Email adress*
Waiting list mediation
How can we help you? (Attention: We advise you not to share any medical information or BSN with us through this form)
Name care provider/care institution
Location care provider/care institution
In case of hospital care: specialism
What is the current waiting time?
Have you had a first call yet?
Yes
No
