BupaClinicalClaimForm保柏门诊赔偿申请表.PDFVIP

Bupa Clinical Claim Form 保柏門診賠償申請表 For all clinic services (including clinical operations) 所有門診服務 (包括診所手術) OP/BCFC-CC/0119 Please complete in BLOCK letters and preferably in English. Patient’s membership number is MANDATORY and MUST be provided. 請以英文正階填寫。必須提供病人會員編號。 To be completed by Patient or Parent / Legal Guardian if Patient is below 18 years of age. 由病人填寫。如病人未滿18歲，須由家長/ 合法監護人填寫。 Membership No. of Patient 病人會員編號 (16 digits位 MANDATORY 必須提供) Name of Employer (for group contract only) 僱主名稱 (只適用於團體合約) Name of Subscriber / Employee (Surname followed by Given name, please leave a space between words) 投保人 / 僱員姓名 (先填姓氏，再寫名，每組字後請留一空格) Name of Patient (If other than Subscriber / Employee)(Surname followed by Given name, please leave a space between words) 病人姓名 (如非投保人或僱員)(先填姓氏，再寫名，每組字後請留一空格) Date of Birth Mobile Number 出生日期 流動電話號碼 DD 日 MM 月 Pre / Post hospitalisation follow-up visit 入院前 / 出院後之跟進覆診 Yes 是 No 否 Please fill in the nature of claims and breakdown of charges 請填上索償性質及各項收費 Date of Nature of Reimbursement 索償性質 (Please put a “ ✓” in the appropriate box 請在適用的方格內加上 “ ✓” ) If currency is other When did the symptoms No. treatment Physiotherapy / Diagnostic Chinese Other (please specify, than HKD, please tick first occur? 序 診治日期 GP Specialist* Chiropractic* Imaging Herbalist / e.g. Dental, Maternity) Amount on receipt 如有關款額 有關症狀於何日首次出現？ 號 DD 日／MM月／YY年 普通科醫生 專科醫生* 物理治療 / Lab tests* Bonesetter# 其他 (請註明 ， 收據金額 並非以港幣支付， DD 日／MM月／YYYY年