GROUP MEDICAL INSURANCE Hospital & Surgical Claim Form Claim Instructions patient 1. 2. 3. 4. 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 PartII: To be completed by attending physician / surgeon (any cost incurred is to be borne by the Employee / Member) Submit this 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 form and all relevant receipt(s) 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, name of , 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 insufficient. 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 1. 2. 90 90 3. 4. - 25 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 To From Yes Yes No A 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. I understand 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 submitted previously 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 be made to the Prudential's principal office in Hong Kong. r Yes No Date Signature of Member