GROUP MEDICAL INSURANCE

Hospital & Surgical Claim Form

Claim Instructions

patient

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Completing Claim Form

Submitting the claim form

No Reimbursement of Claim shall be made for:

Attach Pre-authorization confirmation, if applicable.

Returning the completed claim form to:The Prudential Assurance Co. Ltd. - Employee Benefits

Part I : To be completed by Employee / Member

Part II: To be completed by attending physician / surgeon (any cost incurred is to be borneby the Employee / Member)

Submit this claim form with original medical receipt(s) and all supporting documents. In allcircumstances, including follow-up visits at a later date, a fresh claim form is required.

Claim form and all relevant receipt(s) must be submitted within 90 days of the expenditurebeing incurred. Before returning the form, check that all parts have been completed andthat 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, name of , descriptionof 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 isinsufficient.

Claim(s) submitted after 90 days from the date of discharge.

Insufficient of required information.

25th Floor, One Exchange Square, Central, Hong Kong

Customer Service Hotline: 3656 8300

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3656 8300

PART I - To be completed by Member

Declaration & Authorization

(By Employee if Member aged under 18)

Name of Employer : Policy No. :

HKID No. :

HKID / Birth Certificate No. of Patient :

/

Date of Claimed Treatment :

Date Time

ToFrom

YesYes NoA Copy of the police report to be attached

Treatment Date

Name & address of the doctor / hospital /

Policy No. / Membership No.:

Are you making any other insurance or compensation claim as a result of this treatment?

?

If yes, please specify the name of the Insurance Company / Organization :

/

Other information

No If Yes, please specify

DD / MM / YYYY DD / MM / YYYY

Name of Employee (same as HKID) :( )

Name of patient (if other than Employee) :( )

Date of Birth :

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? ?

2. Where and how did it happen? ?

3. Injured area, type and severity of the injury.

4. Did the patient report to the police? ?

5. Was there any concurrent / predisposing illness at the time of the accident?

?

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

?

7. Other information

2. Name and address of doctor / hospital the patient first consulted for the illness

/

3. Date of the first consultation

4. Since when had these symptoms first appeared? ?

5. Has the patient been treated by other doctor(s) or admitted to hospital for similar or

related illness in the past? ?

Sex :

Mobile Phone No. of Employee :

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. Iunderstand that if I and/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 named patient 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 submittedpreviously and in the future to communicate with me for such pu poses. I have the right to obtain access and request correction of any personal information held by Prudential. Such request can bemade to the Prudential's principal office in Hong Kong.

r

Yes No

Date Signature of Member

1. Are you the patient's usual attending Physician or Surgeon? /

2. Please fill in the date of consultation, the symptoms and complaints of the patient for each consultation

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

/

Consultation date Symptoms / Complaints Recommended tests / treatment /

D. Others :

i. Yes

ii. No Does the patient have any other usual / family attending Physician(s)/Surgeon(s)? If Yes, please give us the name(s).

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/

3. Was the above condition due to or associated with the following problems? (circle the appropriate answers)

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) ( /

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 \

NONE OF THE ABOVE

Date Illness / Disorder / Complaint

(HIV)

Details of treatment / hospitalization Name of attending Physician or Surgeon / Hospital

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

Day(s) Month(s) Year(s) , or since

Name of Patient : HKID / Birth Certificate No. of Patient :

/

Discharge Date :Admission Date :

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

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?

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

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

C. Professional Comment :

2. Has the patient ever had the same or similar symptom(s) before? ?

No Yes Please state when and describe details

(Please use any separate sheet with the signature of attending Physician or Surgeon on it if more space is needed) ( )

Date of operation : Name of Surgeon

Final diagnosis : When was it made? Operation performed

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.

Reason of referralName of referred Physician 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?

/

Yes Please state the date, time and reasonNo

Name of attending Physician / Surgeon /

Signature & Chop of attending Physician / Surgeon or Hospital Stamp

/

Date : Date :

Address & Telephone

EB1/FR00021B/P01 (11/07)

PART II - To be completed by Attending Physician / Surgeon

Please fill in question 2