Basic (10-23)
GN 01772.320 Icelandic Medical Exam Reimbursement Form
The Icelandic Liaison Agency will use the SSA 2960 IS-USA 3 (U.S.A. – Iceland Agreement
on Social Security Transmittal/Request/Certification Form) for reimbursement of medical
expenses regarding requests for exams, and will attach a detailed statement of expenses
incurred as a result of the medical examination.