Who is the application sent to, and when is it written?
You need this letter when the cost of a specific operation, treatment, examination or medical item has not been covered, or not fully covered, by another source and you are asking the state for individual assistance. Under Government Resolution No. 321 of 2022, which amended Resolution No. 331, the commission is set up within the non-commercial legal entity Solidarity Fund of Georgia. The Fund organises the meetings: it explains to the applicant what to submit, receives and registers the documents and communicates the decision orally, by technical means or in writing.
So you name the commission in the addressee field, but physically hand the package to the Fund. The wording "through the Fund" reflects both facts and saves the applicant from getting confused by the terms. Check the address for submissions and the electronic channel in advance with the Ministry of Health hotline or the clinic's medical manager, as the official source does not publish them separately.
Please note: Solidaroba.ge is not the Fund and neither accepts nor reviews applications. This template is free supporting material. What the Referral Services Programme is, what share it funds for whom and how the review works is described separately in the referral programme guide, and the history of the Fund and its role today on the Solidarity Fund page.
What should you attach to the application?
The rules under Resolution No. 331 name three mandatory attachments, and Resolution No. 169 of 2026 specified their content. The other documents are not mandatory, but they show the commission your situation more quickly.
| Attachment | Who issues it | What they pay attention to |
|---|---|---|
| Copy of an identity document | The applicant or their representative | The expiry date, and that the first name and surname match Form 100 |
| Form No. IV-100/a | The treating clinic | Every item filled in in detail with ICD-10 or NCSP codes; for a request abroad, the doctor's recommendation that the service is needed outside the country |
| Invoice with cost estimate | The clinic that will provide the service | Costs broken down item by item; for a foreign document, a notarised Georgian translation and a split between medical and non-medical costs |
| Power of attorney or proof of kinship | Notary, civil registry | Needed when someone other than the patient signs the application |
| Replies from other sources | Clinic, agency, City Hall, insurer | What has already been covered by others and what remains unpaid |
| Proof of social status or disability status | The relevant agency | Affects the state's share, if you have such a status |
The first three attachments are mandatory; the rest depend on your situation. The requirement to translate and certify a foreign invoice applies from 1 May 2026.
How to fill in Form 100 correctly is covered separately in the Form 100 guide. A translation of the foreign clinic's cost estimate, together with notarisation, is prepared by the financial document translation service, and you can check the price and turnaround in advance in the Translation price calculator.
What deadlines do you need to keep in mind?
The commission's rules do not set their own deadline for reviewing an application. In that case Article 100 of the General Administrative Code applies: a decision is normally taken within one month of the application being submitted, and if the circumstances need more time to examine, the body sets the deadline by a separate decision, which cannot exceed three months in total. A request for treatment abroad also needs the opinion of a specialist expert of the Ministry, which adds time.
The second deadline starts after a positive decision. Under the 2025 amendment made by Resolution No. 552, the service must start no later than one month afterwards in Georgia and no later than two months afterwards abroad; the deadline can be extended only once, and once it expires the decision is deemed cancelled. So give a realistic planned treatment date in the application: a date that is too early will rush you, and one that is too late will lead to a request for an extension.
Application template
Replace the highlighted fields with your details, and delete the conditional points in brackets if they do not apply to your case. Copy the text into an editor, or print it and fill it in by hand. The letter itself is submitted in Georgian: the Georgian version of this page (language switch at the top) has the original text to copy.
To the Referral Services Commission at the Solidarity Fund of Georgia
(submitted through the non-commercial legal entity Solidarity Fund of Georgia)
Applicant: [first name and surname], personal number [personal number], address [actual address], phone [mobile number], email [email address]
Patient (complete if the applicant is not the patient): [patient's first name and surname], date of birth [date of birth], personal number [patient's personal number]; grounds for representation: [power of attorney, parenthood or legal representation]
Application for funding of the cost of medical services
1. The patient has been diagnosed with: [diagnosis as stated in Form IV-100/a], ICD-10 code [code]. On the recommendation of the treating doctor, the following is required: [name of the service], NCSP code [code, if applicable], which is planned to take place at [name of the clinic, city, country] on [planned date].
2. According to the clinic's cost estimate, the total cost of the service is [amount and currency]. Of this cost, the amount covered by other sources is [source and amount, or the word "none"], and the amount remaining unpaid is [amount].
3. For the purpose of determining the funding status, I inform you of the following: [registration in the database of socially vulnerable families and rating score, disability status, pensionable age or other circumstance; if none applies, state your source of income].
4. (For treatment abroad) Form IV-100/a contains the treating doctor's recommendation that the service is needed outside Georgia. The foreign clinic's invoice and cost estimate have been translated into Georgian and notarised, and the costs are divided into medical and non-medical parts.
5. (If treatment cannot be postponed) [date and short summary of the doctor's opinion: why the stated timeframe matters].
6. (If you do not fit the standard conditions) Since [the circumstance that makes your case exceptional], I ask you to review the application taking into account the commission's power under the rules to allow an exception.
In view of the above, I ask you to review my application and to fund [name of the service] [in full or for a specific amount].
Please notify me of the decision at [phone, email or postal address] and, if the application is granted, provide me with written confirmation of the decision to present to the clinic.
I confirm that the information in the application and its attachments is accurate. I am aware that submitting false information to the commission entails liability. I consent to the processing of my personal data and the patient's personal data, including data on health status, for the purpose of reviewing the application.
Attachments:
1. Copy of an identity document, [number] page(s);
2. Form No. IV-100/a, [date of issue];
3. Invoice with cost estimate, [clinic and date];
4. [power of attorney, reply from another source, status extract, doctor's opinion].
Date: [day, month, year]
Signature: [applicant's signature]
How do you fill in the template step by step?
Collect the attachments first
You write the application last: the diagnosis, codes and amounts have to be copied exactly from Form 100 and the cost estimate. Every inconsistency, such as a different amount or a diagnosis worded differently, triggers an additional question.
Decide who signs
If the patient is an adult and can sign, they are also the applicant and the second paragraph is deleted. A parent writes on behalf of a child; in other cases, a representative with a power of attorney. The signatory's contact details must be accurate, because the decision is communicated to them.
Write the amounts in figures
In point 2, the total, the part already covered and the balance must add up. If the Universal Healthcare Programme or City Hall has refused you, say so and attach the reply: it shows that you are turning to the commission as the last source.
Choose the conditional points
Point 4 stays only for treatment abroad, point 5 only if you have a doctor's opinion, and point 6 only when you do not fit the standard framework and have a specific reason for it.
Number the attachments and make a copy
Every document on the list must be in the package. Keep a copy of the whole package, and note down the registration number and date when it is accepted.
Which mistakes delay the review?
- A request without an amount. "Please help" does not tell the commission what to fund. Always name the service and the amount you are short.
- An emotional story instead of facts. Describing the family's situation is understandable, but the decision rests on facts confirmed by documents. One sentence on the diagnosis and one on the doctor's recommendation carry more weight than a page of general text.
- A mismatch between Form 100 and the cost estimate. If the certificate plans one operation and the invoice another, the package will not be considered complete.
- An untranslated foreign invoice. A document in English, or one showing a single total figure, does not meet the 2026 requirements.
- Unreliable contact details. A phone that is often switched off, or an email you do not check, delays notification of the decision, and the deadline for starting treatment runs in the meantime.
- Exaggerated or understated information. Misrepresenting your income or situation entails liability; the last paragraph of the template is there for a reason.
What happens after you hand in the application?
The Fund checks the package and lets you know if anything is missing, so keep a close eye on your phone in the first weeks. After a positive decision, you inform the clinic of the funding yourself and start treatment within the set deadline. If the plan changes, ask for an extension before the deadline expires, and do so in writing.
If the commission refuses or approves only part of the amount, first ask for the decision in writing and then weigh up which is better: applying again with a corrected package or appealing. A ready structure for an appeal is in the administrative complaint template, and the deadlines and the court stage are in the guide to appealing a refusal. If treatment is planned abroad, the remaining steps are described in the article on funding treatment abroad, and the clinic search service can help you choose a clinic.
Frequently asked questions about the application
Should the application be addressed to the Fund or to the commission?
The commission takes the decision, so name it as the addressee. Under the 2022 amendment to Resolution No. 331, the commission is set up within the Solidarity Fund of Georgia, while the Fund receives and registers the documents and notifies you of the decision. That is why the template shows both: the commission as the addressee and the Fund as the organisation through which the application is filed. If a Fund officer offers you a different application form or an additional blank form, use it and keep our template only to check the content. Either way, ask for a registration number when you hand it in.
Can a family member file the application on my behalf?
Yes, if they have grounds to do so. A parent acts on behalf of a child and proves this with the birth certificate. For an adult patient, a family member or anyone else needs a power of attorney; if the patient is abroad or in hospital, the power of attorney can also be executed remotely. The representative's details and the grounds for representation go in the second paragraph of the template, and a copy of their ID is added to the attachments. Bear in mind that the decision is communicated to the signatory, so give their phone number and email accurately.
What amount should I state as the sum requested?
State the part that remains unpaid after other sources have covered what they can, and base it on the clinic's cost estimate. If you have not yet applied to any other source, write the full cost of the service and note that you have no other funding. The commission sets the state's share itself, according to your status and income, so the amount requested will not be approved automatically. What matters is that the figures in the application match the invoice and the replies from other sources, so the commission can see exactly how much you are short.
If I am asking for treatment abroad, is the application written differently?
The structure is the same, but point 4 of the template must stay in. In Form IV-100/a the doctor has to state that the service is needed outside Georgia, and the foreign clinic's invoice and cost estimate must be translated into Georgian and notarised. The costs are split: the non-medical part, such as transfers, hotel and an accompanying person, and the medical part, by type of treatment. The request is assessed by a specialist expert of the Ministry, so the review may take longer. Allow for this time in the planned treatment date.
Does using the template guarantee funding?
No. The template helps make the application complete and clear, but only the commission takes the decision, under its own rules and within its budget. Nobody, including us, can promise you a positive answer, and if someone offers a "guarantee" in exchange for a fee, treat it as a warning sign. Our lawyers can check how well your package meets the requirements of the rules and word the application more clearly, but they cannot take responsibility for the outcome. The commission's rules do not provide for any fee for reviewing an application.
Sources and official pages
- Government of Georgia Resolution No. 331 of 3 November 2010, on the referral services commission and its rules of procedure: matsne.gov.ge/ka/document/view/1088054 (accessed 2026-10-12)
- Government of Georgia Resolution No. 321 of 14 June 2022, on the commission at the Solidarity Fund: matsne.gov.ge/ka/document/view/5494642/0 (accessed 2026-10-12)
- Government of Georgia Resolution No. 169 of 2026, on the requirements for Form IV-100/a and the invoice: matsne.gov.ge/ka/document/view/6848972 (accessed 2026-10-12)
- Government of Georgia Resolution No. 552 of 2025, on the deadlines for starting treatment: matsne.gov.ge/ka/document/view/6704064 (accessed 2026-10-12)
- General Administrative Code of Georgia, Article 100: matsne.gov.ge/ka/document/view/16270 (accessed 2026-10-12)