PDF《ST. TERESA'S HOSPITAL》

1 Medical Records Department/2017 [请在适当方格填上?号] (Please ? in the appropriate box)] Part A.

病人个人资料 Particulars of Patient 英文姓名(English Name)中文姓名(Chinese Name) 性别(Sex): ? 男(Male) ? 女(Female) 年龄(Age)出生日期(Date of Birth) 香港身份证号码 / 国家护照号码(HKID/Passport No. 地址(Address) SMS 短讯 / 手提电话号码(Contact No. 电邮地址(E-mail address) 所需资料查阅的期间(For the period) Section B(i) to B (ii) to be completed if this request if made by a person other than the patient Part B (i) 申请人资料 Particulars and Capacity of the Applicant (如病人为申请人本人则不需填写 if applicant is the patient then not necessary to fill in this Part) 英文姓名(English Name)中文姓名(Chinese Name) 性别(Sex):? 男(Male) ? 女(Female) 年龄(Age)出生日期(Date of Birth) 香港身份证号码 / 国家护照号码(HKID/Passport No. 地址(Address) SMS 短讯 / 手提电话号码(Contact No. 电邮地址(E-mail address) 圣德肋撒医院ST. TERESA'

S HOSPITAL 医疗报告申请表格 Medical Report Application Form

2 Medical Records Department/2017 Part B (ii) 授权 Authority 本人经以下途径已取得病人授权作此申请: (请在适当的方格填上 ? 号) I am authorised to make this request by reason of the following: (Please tick ? the appropriate box) ? 本人已取得病人书面授权代为作出此申请(请连同病人的授权同意书之副本以及身份证副本一起提 交) . I am authorised in writing by the patient to make this request on his/her behalf (please enclose a copy of the written authorisation and Hong Kong Identity card copy). ? 病人是未成年人士(十八岁以下)而本人为病人的父母或合法监护人(请连同病人的出生证明书或法定管 养权证明书之副本一起提交). The patient is a minor (below the age of 18) and I have parental responsibility over the patient (please enclose copy of the patient'

s birth certificate or legal custody paper). ? 病人无能力处理本身事务而本人已经被法庭委任处理其事务(请连同有关法庭命令之副本一起提交). The patient is incapable of managing his/her own affairs and I have been appointed by a court to manage those affairs (please enclose a copy of the relevant Court Order). ? 根窠】堤趵

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2 条,病人是精神上无行为能力而本人已被法庭委任为其监护人(请连同 有关监护令之副本一起提交). The patient is mentally incapacitated within the meaning of section

2 of the Mental Health Ordinance (Cap. 136) and I have been appointed to be his/her guardian (please enclose a copy of the relevant Guardianship Order). Part C. 申请原因 Reason for Application ? 保险索偿(Insurance Claims) ? 工伤索偿(Employee Compensation Claims) ? 法律申诉(Legal Proceeding) ? 医疗参考(Clinical Follow-up) ? 个人记录(Personal Record) ? 其他-请注明 (Others-Please specify)

3 Medical Records Department/2017 Part E. 进一步资料及付款 Further Information and Payment 本人明白在处理有关申请之前,本人须先提供: I understand that before complying with this request, you require me to provide: (a) 本人身份证明文件 (proof of my identity);

(b) 如本人代表病人作出申请,病人之身份证明文件和病人已签署之授权文件须一并提供(请见 B(ii)) (proof of the patient'

s identity if I am making this request on behalf of the patient and further proof of authority for making this application specified in section B (ii) above);