永安医疗险理赔申请书（2页）.pdf-业务单证-保险资料库

永安医疗险理赔申请书（2页）.pdf

申请人填写部分 To BE COMPLETED BY PATIENT OR PRIMARY INSURED
保单号：POLICY No.
区(District)
城市(City)
省市(Province)
邮编(Zip Code)
区(District)
城市(City)
省市(Province)
邮编(Zip Code)
主被保险人信息（仅当主被保险人与病人非同一人时填写）
PRIMARY INSURED INFORMATION (Complete on if
primary insured is other than patient)
赔款指示PAYMENT INSTRUCTIONS
我授权理赔款直接支付给医疗帐单中载明的医疗服务机构。
I atuhorize payment to be made directly to
the healthcare provider(s) indicated on the enclosed bill(s).
1.姓名 PATIENT’S NAME
2.卡号CARD No.
3.性别 SEX
4.出生日期 DATE of BIRTH
5.证件类型 ID TYPE
6.证件号码ID No.
7.联系电话 TEL NO
8.电邮 EMAIL
帐号ACCOUNT #
帐户名 NAME
开户行BANK NAME
银行转帐 BANK TRANSFER
医疗险理赔申请书MEDICAL BENIFITS CLAIM FORM
19.电邮 EMAIL
9.就诊人地址（街道，号码） PATIENT’S ADDRESS (Street, NO.)