Pre-Hospitalisation Claim Assessment Form

Pre-hospitalisation Claim Assessment Form

入院前索償評估表格

Name of Policyholder:
保單持有人姓名：

Policy No.:
保單號碼：

Insured No.:
受保人號碼：

Example 範例: 0012 or 或 0012C01

Name of Insured (Patient):
受保人（病人）姓名：

Contact Telephone No.:
聯絡電話：

Email Address:
電郵地址：

Fax No.:
傳真號碼：

Treatment Details and Assessment

治療詳情及評估

Diagnosis:
診斷：

Date of Admission:
入院日期：

Intended Level of Accommodation:
預計入住的病房級別：

Name of Hospital:
醫院名稱：

Surgical Procedure(s)/Treatment(s)
to be performed:
將進行之手術／治療：

Estimated Expenses (if applicable)

預算費用（如適用）

Surgeon's Fee:
外科醫生費用：

HK$

Anaesthetist's Fee:
麻醉科醫生費用：

HK$

Operating Theatre:
手術室費用：

HK$

Physician's Hospital Visit (Per day):
醫生巡房費用（每日）：

HK$

Miscellaneous Hospital Charges:
醫院雜項費用：

HK$

I / WE HEREBY DECLARE AND AGREE:

I / We understand that the issuance or completion of this application does not constitute admission of liability or guarantee payment of the claim on behalf of Blue Cross.
Assessment of the estimated eligible claim amounts in this form and any other communication in relation to this assessment, whether verbal or written, are computed based on Hospital and Surgical Benefits of insurance policy and are solely for customers’ reference, actual eligible claim amounts will be subject to the final claim decision. All benefits payable are subject to the terms and conditions and the full list of policy exclusions. Should there be any discrepancy between this assessment and the final claim decision, the final claim decision shall prevail.
I / We understand that if any claim in progress is not reflected in this estimation.
I / We have read and understood the Personal Information Collection Statement as accompanied with this form.

本人／我們謹此聲明並同意：

本人／我們明白發出或填妥此評估表格並不代表藍十字確認責任或保證賠償。
此表格之可賠償金額之評估及其他與此評估有關之口頭或書面通訊是根據保單內住院及手術保障所計算，只供客戶參考之用，實際賠償金額以最終理賠決定為準。所有保障項目只會在符合所有保單條款及細則及所有不保之事項的情況下支付。如此評估與最終理賠有任何差異，均以最終理賠為準。
本人／我們明白如任何處理中的索償申請並未於此評估中反映。
本人／我們已閱讀及明白隨本表格附上的收集個人資料聲明。