OUTPATIENTCLAIMFORM门诊索偿申请表-CityUniversityof.PDF

29/F, BEA Tower, Millennium City 5, 418 Kwun Tong Road, Kwun Tong, Kowloon, Hong Kong 香港九龍觀塘道418 號創紀之城5 期東亞銀行中心29 樓 Tel 電話: 3608 2988 Fax 傳真: 3608 2989 .hk OUTPATIENT CLAIM FORM 門診索償申請表 Claim Notes 索償注意事項 1. This form is applicable to outpatient claim. 1. 此申請表適用於門診索償。 2. Each claim form is for one Insured (Patient) only. 2. 每名受保人 （病人）須獨立填寫申請表 。 3. You can find the Policy number and Insured number on Blue Cross Certificate of Insurance or Blue 3. 您可於藍十字保險證明書或藍十字醫療卡上查看保單號碼及受保人號碼，您 Cross Healthcare Card, you may also visit .hk/supercare to view account 亦可登入.hk/supercare 查閱賬戶資料 。 information after logging in. 4. Please print this claim form on A4 size paper and send it together with the original receipts to 4. 請以A4 紙打印此索償申請表，並於治療後90 天內，連同收據正本一併交回 Medical Claims Department of Blue Cross (Asia-Pacific) Insurance Limited (“The Company”) within 藍十字 （亞太）保險有限公司（「本公司」）醫療保險理賠部。隨本申請表附 90 days from treatment date. The Company’s Personal Information Collection Statement as 上的收集個人資料聲明，是供閣下參閱及保留之用 ，請無需於提交索償申請 accompanied with this form is for your reference and retention, please do not return it along with 時退回 。 your claim application.