Basic (03-25)

GN 01764.320 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.