门诊医疗计划赔偿表（3页）.pdf

This form is applicable to Outpatient claims 

本表格适用住门诊赔偿

Master Contract no. :

Sub-Contract no. :

Name of Employee Staff no. :

僱员姓名： 员工编号

#For Group Insurance Policy only #只适用于团体保单

* 为必须填写项目* Mandatory information

代码

Code

*求诊日期

*Incurred Date

代码

Code 保障项目 Benefit Items * *Incurred Date 求诊日期

*收费

*Presented Amount

** Doctor Referral Letter with diagnosis to be attached

（连同注册西医的转介信副本，副本上需包括诊断之病症）

声明及授权书 :

病人签署 (18 岁以下病人，需由家长代签)

Signature of Patient (Parent if patient aged under 18)

*Name of the

Name of Employer 僱主名称： Policy No. 保单号码:

(Please note: If the claim was fully reimbursed,

 Certified True Copy will not be returned. If Certified 

True Copy is requested for other purpose, please state

the reason) 如欲索回医生的发票和收据正式认证副本，请在空格内填上「」号

(请注意：如申请已获全数赔偿，正式认证副本将不获退回。如正式认证副本需用作其他用途，请注明原因)