HealtHInsuranceclaImFormandorPrIoraPProvalrequest健康.pdfVIP

HealtH Insurance claIm Form and/or PrIor aPProval request 健康保险索赔表及/或预批申请表 This form must be completed in English (please print clearly) 请务必用英文填 写 (请用大写字母填写工整) If you need help filling out this form please contact Sovereign on 0800 500 108 如果您在填表时需要帮助，请联系Sovereign保险公司，电话0800 500 108 Are you applying for prior approval? Yes No YesYes NoNo 您是要申请预批吗? 是 否 Is your referral letter attached? 是是 否否 (If your referral letter does not include the below, please have your doctor complete section 5 of this form) Would you like to receive your prior Yes No approval confirmation letter by email? 是 否 您的转诊介绍信是否已附上? (如果您的转诊介绍信不包括以下内容， 您希望通过电子邮箱接收您的预 请找您的家庭医生填写本表的第5栏) 批确认函吗? Please ensure your referral letter contains the following: Is your claim ACC related? Yes No 请确保您的转诊介绍信包含以下内容: (If you answered ‘Yes’ please attach your ACC 是 否 decision letter) Initial consultation date History of condition 您的索赔与ACC有关吗? 初诊日期 个人病历 (如果回答“是”，请附上ACC的理赔决定函) Treatment received 接受的治疗 Have you attached a pre-printed bank Yes No Please attach all original itemised accounts or Yes No deposit slip? 是 否