GroupInsuranceClaimForm团险索赔申请表SectionBMedical.pdfVIP

Group Insurance Claim Form 团险索赔申请表 Section B Medical Information B. 医疗信息 *To be completed by the attending physician, photocopy of medical reports including details below may replace this page. * 以下部分由主治医生填写，涵盖下面各项信息的医疗报告复印件可替代此页信息。 Name of Attending Physician 主治医生姓名 Name of Hospital/Clinic Information of 医疗机构名称 Care Provider Telephone# 电话号码 就诊机构信息 Email 电子邮箱 Address 地址 Treatment is related to （please tick related category and fill in information as required ） 治疗内容关于（请勾选下列相关选项） □ Routine Physical Exam 常规预防性体检 □ Immunization 疫苗接种 Treatment □ Psychiatric/Psychological Consult 精神及心理咨询 □ Optical Care and Glasses验光配镜 Category □ TCM therapy (i.e. acupuncture, massage... ) 中医疗法 □ TCM Herbal Remedy 中草药诊疗 □ Physical Therapy/Chiropractic, please specify diagnosis 就诊类别 物理治疗/脊椎指压治疗，请详述具体诊断 □ Maternity, please specify gestational weeks 产检或生育，请详述孕周数 □ General Injury or Illness, please fill in treatment details as per below format 伤病治疗，请按照如下格式填写就诊详情 Chief Complaint 病人主诉： Relevant Medical History 相关病史: Physical Exam and Tests 检查及化验： Treatment Details Diagnosis/Impression 治疗详情 诊断或印象： Suggestions/Treatments 医嘱/处置： Signature of Date Attending Physician dd/mm/yy 主治医生签名 日期 Reminder to the beneficiary: You may go through the following claim checklist to obtain adequate materials from th