Pre-hospitalisation Claim Assessment Form
入院前索償評估表格
*
Name of Policyholder:
保單持有人姓名:
Please input Name of Policyholder 請輸入保單持有人姓名
*
Policy No.:
保單號碼:
.
GP
IF
Please input Policy No. 請輸入保單號碼
*
Insured No.:
受保人號碼:
Example 範例: 0012 or 或 0012C01
Please input Insured No. 請輸入受保人號碼
Please input valid Insured No. format 請輸入正確受保人號碼格式
*
Name of Insured (Patient):
受保人(病人)姓名:
Please input Insured Name 請輸入受保人姓名
Contact Telephone No.:
聯絡電話:
*
Email Address:
電郵地址:
Please input Email Address 請輸入電郵地址
Please input valid Email format 請輸入正確電郵格式
Fax No.:
傳真號碼:
Treatment Details and Assessment
治療詳情及評估
*
Diagnosis:
診斷:
Please input Diagnosis 請輸入診斷名稱
*
Date of Admission:
入院日期:
Please select Admission Date
*
Intended Level of Accommodation:
預計入住的病房級別:
Please select 請選擇
Private 私家房
Semi-private 半私家房
Ward 普通房
Day Case/Clinical 日間/診所手術
Please select Room Class 請選擇住院級別
*
Name of Hospital:
醫院名稱:
Please select 請選擇
Alice Ho Mui Ling Nethersole Hospital 雅麗氏何妙齡那打素醫院
Bradbury Hospice 白普理寧養中心
Canossa Hospital 嘉諾撤醫院
Caritas Medical Centre 明愛醫院
Castle Peak Hospital 青山醫院
Cheshire Home, Chung Hom Kok 舂磡角慈氏護養院
Cheshire Home, Shatin 沙田慈氏護養院
Duchess of Kent Children's Hospital 大口環根德公爵夫人兒童醫院
Evangel Hospital 播道醫院
Fanling Hospital 粉嶺醫院
Fung Yiu King Hospital 東華三院馮堯敬醫院
Gleneagles Hong Kong Hospital 港怡醫院
Grantham Hospital 葛量洪醫院
Haven of Hope Hospital 靈實醫院
Hong Kong Adventist Hospital 港安醫院
Hong Kong Adventist Hospital (Tsuen Wan) 港安醫院(荃灣)
Hong Kong Baptist Hospital 浸會醫院
Hong Kong Buddhist Hospital 香港佛教醫院
Hong Kong Eye Hospital 香港眼科醫院
Hong Kong Sanatorium & Hospital 養和醫院
Kowloon Hospital 九龍醫院
Kwai Chung Hospital 葵涌醫院
Kwong Wah Hospital 廣華醫院
MacLehose Medical Rehabilitation Centre 麥理浩復康院
Margaret Trench Medical Rehabilitation Centre 戴麟趾夫人復康院
Matilda & War Memorial Hospital 明德醫院
Nam Long Hospital 南朗醫院
North District Hospital 北區醫院
Our Lady of Maryknoll Hospital 聖母醫院
Pamela Youde Nethersole Eastern Hospital 東區尤德夫人那打素醫院
Pok Oi Hospital 博愛醫院
Precious Blood Hospital 寶血醫院
Prince of Wales Hospital 威爾斯親王醫院
Princess Margaret Hospital 瑪嘉烈醫院
Queen Elizabeth Hospital 伊利沙伯醫院
Queen Mary Hospital 瑪麗醫院
Ruttonjee Hospital 律敦治醫院
Shatin Hospital 沙田醫院
Shatin lnternational Medical Centre Union Hospital 沙田國際國務中心仁安醫院
Siu Lam Hospita| 小欖醫院
St John Hospital 長洲醫院
St Paul's Hospital 聖保祿醫院
St Teresa's Hospita| 聖德肋撤醫院
Tai Po Hospital 大埔醫院
Tang Shiu Kin Hospital 鄧肇堅醫院
Tsan Yuk Hospital 贊育醫院
Tuen Mun Hospital 屯門醫院
Tung Wah Eastern Hospital 東華東院
Tung Wah Hospital 東華醫院
United Christian Hospital 基督教聯合醫院
Wong Chuk Hang Hospital 黃竹坑醫院
Wong Tai Sin Hospital 東華三院黃大仙醫院
Yan Chai Hospital 仁濟醫院
Others 其他
Please select Hospital & please input hospital name if you select "Other" 請選擇醫院.如你選擇「其他」, 請請入醫院名稱.
*
Surgical Procedure(s)/Treatment(s)
to be performed:
將進行之手術/治療:
1.
2.
3.
4.
Please input at least 1 Surgery and 1st Surgery field must be filled.
請輸入最少一項手術, 以及第一個輸入方格必須填寫.
Estimated Expenses (if applicable)
預算費用(如適用)
Surgeon's Fee:
外科醫生費用:
HK$
Please input valid currency format 請輸入正確銀碼
Anaesthetist's Fee:
麻醉科醫生費用:
HK$
Please input valid currency format 請輸入正確銀碼
Operating Theatre:
手術室費用:
HK$
Please input valid currency format 請輸入正確銀碼
Physician's Hospital Visit (Per day):
醫生巡房費用(每日):
HK$
Please input valid currency format 請輸入正確銀碼
Miscellaneous Hospital Charges:
醫院雜項費用:
HK$
Please input valid currency format 請輸入正確銀碼
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
。
Please Read & Agree The Declaration, And Tick The Checkbox! 請閱讀及同意聲明,並在空格上剔一剔
© Copyright. Blue Cross (Asia-Pacific) Insurance Limited 2010. All rights reserved.
© 版權所有。藍十字(亞太)保險有限公司2010。不得轉載。