太平财富环球医疗保险索赔单★

太平财富环球医疗保险索赔单★ TaiPing Wealth Worldwide Health Plan Claim Form 太平赣富赣球赣医保赣索赣赣 Please mail this form and ORIGINAL invoices to,赣将此理赣表格赣同原始赣赣赣寄到,Euro-Alarm (Beijing) Co., Ltd., 302, Bld. C, East Lake Villas, 欧国区赣旅行援助～中北京市赣城赣直赣外大街35号35 Dongzhimenwai Dajie, Dongcheng District, 100027 Beijing, China.赣湖赣墅C座302～ 赣赣: 100027Insured’s NamePolicy No. Personal 姓名 保赣号 information 被保赣人人信个Insurance Plan E-mail 息保赣赣 划赣子赣件 Mailing addressTel. 赣寄地址赣赣Compensation Expenses incurred on the account of the CurrencyAmountclaimed illness/injury?与赣/病相赣的赣用赣赣金赣(please attach original documents) 赣赣申赣 (赣附上原始赣赣) Payment Bank name Bank 赣行名称 Account Account holder Bank Address ;Pls specify to the branch,付款赣行赣赣赣名赣行地址 ;赣具到支体行, Bank account No. 赣 号 Signature I hereby accept that the Insurance Company or the Assistance Provider appointed by the insurance company procures information about the state of my health with a view to obtaining the information 赣名necessary for the evaluation of the insurance event and for the assessment of the claim. My acceptance comprises medical reports from the date of which the policy came into force and until the final assessment date of the benefit, and any other supplementary medical records that may be deemed necessary by the Insurance Company or the Assistance Provider for the purpose of evaluating issuance event or assessing claims. The reports can be procured from the health care sector, hospitals and healthcare institutions, public authorities, insurance companies and pension funds.Other insurance companies, pension funds and other authorized persons within the health care sector, involved in the case, are allowed to become acquainted with the medical records procured. I hereby authorize the Insurance Company via its appointed Assistance Provider Euro-Alarm (Beijing) Co., Ltd. to act on my behalf and settle payments directly with hospitals, clinics and other service providers. By this authorization I furthermore accept that the insurance payments for said services will be paid directly from the Insurance Company via the Assistance Company to the service providers. 本人在此同意～“保赣公司”或其指定的“救援服赣公司”赣赣估状况本人保赣事宜及核定保赣索赣之目的～有赣赣得有赣本人健康的信 息～包括自保赣生效之日起至保赣赣益的最赣核定之日止的赣赣赣～医估及“保赣公司”或其指定的“救援服赣公司”在赣、核定赣程中赣 赣必要的其他赣充性医赣赣赣。 赣赣可从医医医构众构赣部赣、院、赣机、公赣威机、保赣公司和赣老基金那里赣得。 其他保赣公司、赣老基金、医与医赣部赣及其他赣授赣人士～凡本人保赣事宜有赣的～亦有赣了解所取得的赣赣赣。 本人在此授赣“保赣公司”赣其指定的“救援服赣公司” 即欧“赣旅行援助;北京,有限公司Euro-Alarm (Beijing) Co. Ltd.” 代表本人直接与医构并将院、赣所、和其他服赣机赣行交涉直接付款。在此授赣中～本人赣一步同意～有赣赣等服赣的保赣付赣～由“保 赣公司”赣“救援服赣公司”直接支付赣服赣机。构 Applicant’s signature Date 申赣人赣名 日期 ___________________________________________________ ________________________To be completed by the treating doctor in English or Chinese or alternatively please attach the original diagnosis and prescription 以下由主治医填写生用正楷中文或英文或者附原始病赣及赣方 Medical Name of DoctorQualificationsprovider 医赣姓名赣称information 医赣提供方信息Name of hospitalTel. 医称院名赣赣 AddressE-mail address 地址赣箱 Medical Has treatment guaranty been obtained? Yes NoInformation是否收到付款保赣, 是 否医赣信息 Has treatment been received for similar illness before? Yes No 以前是否因赣相似疾病接受赣治赣, 是 否 If yes, please indicate first date. (dd/mm/yyyy) 如果是～赣指出首先接受治赣的日期。 ;日/月/年, Details of treatmentPlease provide full details of the medical condition requiring treatment, including the ICD-Code 9 or 10 (International Classification of Disease)治赣赣情 赣提供需要接受治赣的病情～包括ICD赣赣9或者10。 Doctor’s signature 医赣赣名 Date ;dd/mm/yyyy, 日期;日/月/年,