门诊医疗计划索偿申请表OutpatientMedicalPlan-HangSengBank.PDF

門診醫療計劃索償申請表 Outpatient Medical Plan Claim Form (IMPORTANT NOTE) 【重 要 提 示】 Before you submit your claim for outpatient medical reimbursement, please ensure you have complied with the following: 在你提交門診醫療索償前，請確定你已遵循以下程序： 1. Each claim form may only be used for one insured patient. 每張索償表格只限一位受保病者使用。 2. The insured patient’s medical card no. name of employer must be provided; otherwise the claim will not be processed. 受保病者必須填寫醫療卡號碼及僱主名稱；否則，本公司將不會處理此索償申請。 3. Please select benefit item 003 “SP Consultation benefit” if you have previously submitted the general practitioner’s referral letter or if the referral letter has been waived by us for such specialist treatment. 若在較早前已提供普通科西醫的轉介信，或該轉介已獲我們豁免轉介信，請選取保障項目 003 「專科門診賠償」。 4. The original receipt of your medical expenses must contain the patient’s name, date of consultation, diagnosis and doctor’s signature his/her official chop. 你的醫療費正本收據上需包括病人的姓名、就診日期、診斷和醫生簽名及其印章。 5. Please send the original receipt and the claim form to the above post box within 60 days of incurring expenses. 請在就診日期起計 60 天內申請索償，並把收據正本及索償表格郵寄至以上郵政信箱。 Full Name of Patient (in English) 病者的英文姓名： Name of Employer 僱主名稱 (compulsory field 必須提供) ： Patient’s Medical Card Number 病者醫療卡號碼(compulsory field 必須提供) ： Incurred Date 求診日期： 聲明及授權書 DECLARATION AND AUTHORISATION 本人聲明上述資料完整及正確無訛。本人並無隱瞞任何重要資料。本人明白公司可要求更多資料。本人/吾等確認本人/吾等已細閱昆士蘭保險 (香港)有限公司的收集個人資料聲明(「通知」),並知悉及同意有關於本人/吾等於是次申請由本人/吾等提供的所有個人資料及其他資料將可能被持有、 使用、處理或披露予有關各方以用作「通知」上所載的用途上。 I declare that the above information is true and complete to the best of my knowledge and belief and I have not withheld any material information connected with this claim. I understand that the Company can request for more information. I/We confirm that I/We have read the QBE General Insurance (Hong Kong) Limiteds Personal Information Collection Statement