Register for doing physical sessions only

To be allowed to attest the pseudocodes in the convention you need to digitally “agree” with the convention tele agreement

Weekly we have to send a list to RIZIV with the physiotherapist who agreed with the convention and followed the

Digitally 'sign' the teleagreement mentioned above:*
- I read the tele agreement and I agree and sign off for it
Name*
First Last
Email*
Phone*
Preferred language*
- English
- Dutch
- French
RIZIV number*
Your national identity number (for login via Itsme)*
Your IBAN number for payments*
Name of your practice or organisation*
Company number (KBO)*
Address of your practice or organisation*
Street Address Address Line 2 City ZIP / Postal Code Country
We want to show your practice or organisation info and address on our website and on a google map. Do you give your consent?*
- Yes
- No
Remarks