保险文件下载-ClaimForm091109

DOB生日:MM月/DD日/YY年MailingAddress邮寄地址:Tel.电话:Fax传真:Email电子邮箱:3.PaymentInformation银行转帐信息(Pleasecompleteclearly请务必清楚填写)RMBBankAccountInformation(BankaccountmustbelocatedinMainlandChina)人民币帐户(仅限中国大陆地区):Account#帐号:NameontheAccount帐户名:Date日期:MM月/DD日/YY年Theaboveanswersaretrueandcorrecttothebestofmyknowledgeandbelief.Iauthorizeanyphysician,medicalinstitution,druggist,insurancecompany,employer,laborunion,orassociationtoreleaseinformationtotheServiceCenterincludingcopiesofrecords,concerningadvice,careortreatmentprovidedtomeormydependentasisrequiredtoproperlypayallbenefits,ifany,dueme,ormydependentforthisclaim.Ifthisclaimisdirectbilled,IacknowledgethatIamresponsibleforanyfeesthatmyinsurancepolicydoesnotcover.Aphotocopyofthisauthorizationshallbeconsideredaseffectiveandvalidastheoriginal.尽我所知所信，以上回答是正确属实的。如果此理赔需要，为使我、我的附属被保险人完全得到应偿付的所有保险金，我授权任何医生、医疗机构、药剂师、保险公司、雇主、工会或协会将我、我的附属被保险人就医治疗、接受护理的相关病历、病史等资料信息（包括复印件）提供给服务中心。此理赔如属于直接付费，我愿意承担此保险所不承担的所有费用。此授权的复印件与原件具有同等效力。DependentInformation附属被保险人信息Tel.电话:Fax传真:MemberID会员号:□Spouse配偶□Female女□Child子女RelationshipwithPrimaryInsured与主被保险人关系:□Male男ClaimForm-PartAPatientInformationNameofbankandbranch开户银行：Province省City市Bank银行EnglishName英文姓名:ChineseName中文姓名:Areyoualsocoveredbyanotherinsurancepolicy?您购买了其他的保险吗？□Yes是□No否DOB生日:MM月/DD日/YY年MailingAddress邮寄地址:InsuranceCompany：保险公司：Policy#保单号:Nameofotherinsurancecompany其他保险公司的名称:2.DescribeInjuryorIllness受伤或疾病描述Ref.#(refertoinsurancecard):代码（见保险卡）:附属被保险人签字:PrimaryInsured'sSignature:主被保险人签字Dependent'sSignature:IsthisthefirsttimeyousoughttreatmentforthisInjury/Illness?受伤/疾病是第一次就诊吗？□Yes是□No否IfNo,givethedateyoufirstconsultedaphysicianforthesameIllness/Injury如不是，请写出第一次就诊日期:Email电子邮箱:理赔申请书–A部分病人信息NameofPolicyholder(Grouppolicyonly):投保人名称（仅限于团体保险）:Policy#(refertoinsurancecard):保单号（见保险卡）:Foraclaimtobevalid,thefollowingtwopages(PartAandB)mustbecompletedandsubmittedtoMSHCHINAENTERPRISESERVICESCO.,LTD./SHANGHAITAIKAIBUSINESSMANAGEMENTCO.,LTD.(hereinafterServiceCenter)whichistheappointedServiceProviderappointedbyyourinsurancecompanywithin180daysafterthedateofservice.为确保有效理赔，您必须完整填写以下内容（A与B两部分），并在从治疗之日后的180天之内向为您承保的保险公司指定的医疗保险服务机构上海万欣和企业服务有限公司/上海泰凯企业管理有限公司（以下简称“服务中心”）提出理赔申请。Pre-authorizationisrequiredforcertaintreatments.Failuretoobtainpre-authorizationwillresultincertainco-payment.某些治疗需事先授权。未经事先授权将导致一定比例的自付额。ChineseName中文姓名:EnglishName英文姓名:□Male男1.WhoisthisClaimfor?理赔申请人:□PrimaryInsured主被保险人□Dependent附属被保险人NOTE:IfclaimisforthePrimaryInsured,pleasedonotfilloutDependentInformation.注：如果理赔申请人是主被保险人，则无需填写附属被保险人信息。PrimaryInsuredInformation主被保险人信息□Female女□ImmunizationorWellnessCheckup注射疫苗或单项体检Hospital'sName医院名称:Address地址:Patient'sChiefComplaint病人主诉:PhysicalExamination体格检查:NecessaryLabTests病人需要做的实验室检查有:Labtests'Results实验室检查结果:Diagnosis/Impression诊断/印像:Detailsoftreatmentprovided治疗措施：Pleasestatenameofdrug(s)anddosage(s)药品的名称和剂量:WillIllness/Injuryrequirefollowuptreatment?Ifso,pleasegivedetails.受伤/疾病需要后续治疗吗？如果需要，请说明详情:□ChineseTraditionalMedicine中医□Vision视力□FullBodyCheckup全身体检DateofService治疗日期DescriptionofMedicalProcedure医疗费用明细ClaimForm-PartBMedicalInformation理赔申请书–B部分医疗信息Doctor'sName医师姓名:Phone#电话:4.MedicalInformation-TobeCompletedbytheTreatingPhysician医疗信息–由主诊医师填写Pleasenote:Aphotocopyofthemedicalrecord(s)fromthevisit(s)mayreplacePartBofthisClaimForm.备注：病历复印件可取代理赔申请书B面信息。Whendidpatientseektreatmentforthisconditionforthefirsttime?病人第一次就诊此疾病的时间?（第一次确诊的时间?）Date日期:MM月/DD日/YY年□PhysicalTherapy物理治疗Treatmentfee(s)治疗费□Maternity产前检查或生育Treatmentisrelatedto(Pleasecheckboxifrelatedtooneofthefollowingitems)本次治疗是否与以下相关（如是，请标出）:Charges收费Others其他PrintNameandTitle姓名和职位:Date日期:MM月/DD日/YY年SubmitClaimstoServiceCenter•理赔资料寄送至服务中心EastUnit,5thFloor,NorthTower,Building9,LujiazuiSoftwarePark,No.20,Lane91,EShanRoad,Pudong,Shanghai,P.R.C200127上海浦东峨山路91弄20号陆家嘴软件园9号楼北塔5楼东单元邮编：200127Tel:[phone]•Fax:[phone]•Email:[e-mail]ysician治疗医生签名:*PleasesendthiscompletedClaimForm,alongwiththeoriginalInvoice(s)/Receipt(s),photocopyofyourmedicalrecord,prescription(ifany)anddischargesummary(forinpatientclaims),totheServiceCenter.请将此填写完整的理赔申请书及原始发票、病历报告、处方(如果有)、出院小结（住院治疗）的复印件一起寄至服务中心。□Dental牙科Consultationfee(s)诊疗费Drugfee(s)药费Labtestfee(s)实验室检查费