Hospitalization Form.cdr

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					                  PRUbenefits GROUP MEDICAL INSURANCE
                      Hospitalization & Surgical Claim Form
    Claim Instructions
    1. Completing Claim Form                                                                                    1.
       Part I : To be completed by Employee / Member
       Part II: To be completed by attending physician / surgeon (any cost incurred is to be borne
                   by the Employee / Member)
    2. Submitting your claim
       Submit claim form with original medical receipt(s) and all supporting documents. In all
       circumstances, including follow-up visits at a later date, a fresh claim form is required.
        Claim must be submitted within 90 days of the expenditure being incurred. Before returning
        the form, check that all parts have been completed and that you have attached the supporting
        documents and original medical receipt(s). Receipt(s) will not be returned unless requested.

        All payment receipts must clearly indicate the consultation date, patient's name, description
        of charges, diagnosis and operation, if any, together with the attending physician's signature.
        Prudential reserves the right to request for further information if information on receipt is
        No Reimbursement of Claim shall be made for:
           Claim(s) submitted after 90 days from the date of discharge.
           Insufficient of required information.                                                                3.
    3. Attach Pre-authorization confirmation, if applicable.
    4. Returning the completed claim form to:                                                                                               -
       The Prudential Assurance Co. Ltd. - Employee Benefits                                                                                25
       25th Floor, One Exchange Square, Central, Hong Kong                                                                          3656 8300
       Customer Service Hotline: 3656 8300

PART I - To be completed by Member
(By Employee if Member aged under 18)
Name of Employer :                                                                                    Contract No. :

Name of Employee (same as HKID) :                                                                     HKID No. :
        (                    )
Name of patient (if other than Employee) :                                                            HKID / Birth Certificate No. of Patient :
        (           )                                                                                              /
Date of Birth :                                         Sex :                                         Date of Claimed Treatment : From                                         To
                                                                                                                                                DD    / MM   / YYYY                  DD   / MM   / YYYY
Employee's Mobile Phone No. :

If hospitalization was due to illness (must be completed)                     (         )             If hospitalization was due to accident
1. Describe the symptoms and abnormalities which led to the hospitalization                           1. When did it happen?                      ?

                                                                                                          Date                                                          Time
2. Name and address of doctor / hospital the patient first consulted for the illness                  2. Where and how did it happen?                               ?

3. Date of the first consultation

4. Since when had these symptoms first appeared?                                       ?              3. Injured area, type and severity of the injury.

5. Has the patient been treated by other doctor(s) or admitted to hospital for similar or
   related illness in the past?                                                           ?
   Yes              No                If Yes, please specify                                          4. Did the patient report to the police?                 ?
                                                                                                          Yes          A Copy of the police report to be attached               No
   Treatment Date
                                                                                                      5. Was there any concurrent / predisposing illness at the time of the accident?
   Name & address of the doctor / hospital         /                                                                                           ?

                                                                                                      6. Other information
   Other information                                                                                     Did you submit a claim for workmen's compensation? If yes, please specify the result.

Are you making any other insurance or compensation claim as a result of this treatment?                                           Yes                        No
If yes, please specify the name of the Insurance Company / Organization :                                                       Policy No. / Membership No.:

Declaration & Authorization
I hereby declare that the above information given is true and correct, I further authorize any hospital, doctor, insurance company, organization or any person that has any record or knowledge of health,
or that of the named patient, to furnish such information to The Prudential Assurance Co. Ltd. ("Prudential"). A photocopy of this authorization shall be considered as effective and valid as the original. I
understand that if I or that of the named patient fail(s)to provide any information requested in this Claim Form, Prudential may not be able to accept or process this claim.

I hereby further declare and agree that any personal information of me and the claimant collected or held by the Prudential (whether given by me or otherwise obtained) may be held, used, disclosed and
transferred by Prudential to any related companies/organizations or any selected parties (within or outside Hong Kong) for the purpose of processing this claim or other claims submitted previously and
in the future to communicate with me for such purposes. I have the right to obtain access and request correction of any personal information held by Prudential. Such request can be made to the
Prudential's principal office in Hong Kong.

 Date                                                                                                                  Signature of Member
PART II - To be completed by Attending Physician / Surgeon

Name of Patient              :                                                                            HKID / Birth Certificate No. of Patient :
Admission Date               :                                                                            Discharge Date               :

A. Clinical History
         1. Date on which the patient first consulted you for the hospitalized illness or bodily injury.

         2. Please describe the symptoms and complaints of the patient for this hospitalization.

         3. According to the medical history given by the patient, how long had the patient been experiencing these symptoms before the first consultation?

                                Day(s)                       Month(s)                                   Year(s)    , or since
         4. What was your clinical diagnosis and when was it made?

         5. How long, in your opinion, has the patient suffered from these symptom(s)?

B. Hospitalization History

   Final diagnosis :                                                When was it made?                                                Operation performed

   Date of operation :                                                                       Name of Surgeon

   Recommended treatment & the reason for the treatment

   Recommended diagnostic tests & the reason for the tests

   1. If you have referred other Physician to the patient during the hospitalization, please provide the following relevant information.
       Name of referred Physician                                        Reason of referral                                                     What treatment performed

   2. Brief discharge summary (including onset & duration of sign & symptoms / illness, etiology, types & results of major examination, treatment, complication & follow up plan)

   3. Has the patient taken any home leave during this hospitalization?
      No                       Yes            Please state the date, time and reason

   Remarks: please attach copies of histopathology, endoscopic, diagnostic / laboratory test report, operation theatre summary

C. Professional Comment                :
   1. In your opinion, was the hospitalized illness a recurrent episode or a chronic disease? If so, when would be the first episode?

   2. Has the patient ever had the same or similar symptom(s) before?                                                 ?
      No                    Yes          Please state when and describe details

   3. Was the above condition due to or associated with the following problems? (circle the appropriate answers)
      accidental bodily injury \ abuse of drugs or alcohol \ AIDS/HIV related illness \ venereal disease or sexually transmitted disease \ pregnancy, infertility or sterilization \ eye refraction \
      cosmetic or plastic surgery \ mental or nervous disorder \ congenital condition \ hereditary condition \ developmental condition \ self-inflicted injury \ general check up or vaccination \

   4. Had the patient been previously treated or hospitalized for this or any other illness? If so, please give brief summary (including onset & duration of sign & symptoms / illness; etiology; type &
      results of major examination; treatment, complication & follow up results)                                                                                  (                /

      Date               Illness / Disorder / Complaint                          Details of treatment / hospitalization                        Name of Physician or Surgeon / Hospital

      (Please use any separate sheet with the signature of Physician or Surgeon on it if more space is needed) (                                                                         )
D. Others        :
   1. Are you the patient's usual Physician or Surgeon?                                     /
      i. Yes     Please fill in question 2                 2
      ii. No     Does the patient have any other usual / family Physician(s)/Surgeon(s)? If Yes, please give us the name(s).                                     /
  2. Please fill in the date of consultation, the symptoms and complaints of the patient for each consultation
     Consultation date                                               Symptoms / Complaints                                                      Recommended tests / treatment                /

  3. If you are referred by other Physician/Surgeon, please provide the name, contact number and address of the Physician/Surgeon.                                       /

Signature & Chop of attending Physician / Surgeon / Hospital Stamp
     /                        /
                                                                                                           Name of attending Physician / Surgeon                     /

                                                                                                           Address & Telephone

Date :                                                                                                     Date :

                                                                                                                                                                             EB1/FR00021B/P01 (07/06)

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