AetnaInternational理赔申请表.pdf

Aetna International Claim Form Aetna International 理赔申请表 Please submit this completed Claim form with itemized bills and receipts. A separate Claim Form is needed for each family member. Please tape small receipts on a full size sheet of paper. Failure to complete all sections of this form may result in claim processing delays. 请填写本理赔申请表并与明细账单和收据一同提交。每一名家庭成员需要单独一份理赔申请表。请将较小收据贴在一整张纸上。本申请 表要求填写的各个部分如有遗漏，可能延误理赔的办理。 Please refer to your policy documents to verify the cover available through your Plan. 请参阅您的保单文件，确认您保险计划中涉及的保险责任范围。 If the claim amount is above RMB 10,000, USD 1,000 or equivalent, please attach the valid ID card / passport copy of the beneficiary. 如果索赔金额高于1万元人民币或者外币等值1千美元，请附上受益人的有效的身份证/护照复印件。 Please note Aetna International is not responsible for any costs associated with the completion of this form or for any further information/document requested by Us to assess Your claim. The issuing of this Claim Form is in no way an admission of liability. Aetna International将不承担与本申请表填写或者我们为评估您索赔所要求的任何其他信息/文件所产生的任何相关费用。提供本理赔申 请表不代表我们以任何方式承认任何责任。 1. Patient Information – Must be completed 患者信息 （必须填写） Policyholder Name Policy Number 投保人名称 保单编号 Patients Full Name 患者全名 Patients Date of Birth Patient’s Aetna Identification Number 患者出生日期 会员编号 Gender Male Female Relationship Self Spouse Child Other 性别 男 女 与主被保险人关系 本人 配偶 子女 其他 ? If the claim amount is above RMB 10,000, or in case the claim amount is in non-RMB currencies, for any claim amount above USD 1,000 or equivalent, please complete the following. ? 如果索赔金额高于 1 万元以上或者外币等值 1 千美元以上的，请务必完成以下部分。 Type of ID