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工银装置盛全球医疗保管理赔央寻求表(4页)

发布时间:2019-02-10 04:29编辑:[db:作者]阅读(

      【信介】

      Please complete clearly in block capitals. 敬请用楷体皓晰堵写以下情节。

      Please remember these important points about filling in yo ur claim form: 堵写时剩意以下要紧事项:

      Assessment of your claims may be delayed if you and your medical or dental

      practitioner do not fill in all the necessary sections of this form.

      敬请剩意若主治水医师或牙医不供完整顿医疗信息,能招致理赔延深。

      Return this form to us within six (6) mo nths of the first treatment date.

      请于初诊后6( 六)个月内提提交此表格。

      Always send us the original invoice s with this form. Photocopies, receipts and

      credit card statements will not be accepted.

      同时附上原始发票,骈印件、收执及信誉卡笔据将不予接受。

      Make sure that you fill i n sections A to F and that all doctors who have treated

      you fill in section G (or section H for dental treatment).

      请确保您完整顿堵写保单第壹到第六片断,看病医生堵写第七片断(牙医堵写第八片断)。

      C -- Further information 其他信息

      Symptoms/condition needing treatment 症状/就症情景:

      A -- Patient details 病人信息

      B -- Main member details 首要成员信息

      Does the patient have another insurance policy that covers medical costs您能否还拥有其他保单保障该项医疗费 Yes 是 No 否

      If yes, please give details on a separate sheet. 若拥有,请供皓细。

      1

      D -- Payment details 给付信息

      Have you personally had to pay costs for the treatment that you are claiming