PDF《Hospital Authority》

Hospital Authority 医院管理局 医院管理局 医院管理局 医院管理局 Kwong Wah Hospital 广华医院 广华医院 广华医院 广华医院 Medical Report and Patient Information Application Form 医事报告及病人资料申请表 医事报告及病人资料申请表 医事报告及病人资料申请表 医事报告及病人资料申请表 1.

Particulars of Patient : 病人资料 (a) Name : (English) ( ) 姓名 Surname 姓氏 Forename 名字 (英文) Chinese (中文姓名) (b) Sex: Male Female Age : ______ 性别 男女年龄 Date of Birth 出生日期 (c) Nature of Identify Document and Number : 身份证明文件类别及号码 (d) Address : 地址: (e) Daytime Telephone No : 日间联络电话号码 (f) Any other contact number(s) : 其他联络电话号码 # Please attach a true copy of Patient'

s HKID Card/Passport or produce in person the original for our verification. Please attach a copy of the Patient'

s birth certificate if under

18 years of age or produce in person the original. 请附上病人的香港身份证/护照真确副本或亲身出示正本以供本院查核.如病人年龄未满十八 岁,请附上其出生证明书真确副本或亲身出示正本. 2. Information Request from the Hospital : 向医院索取的资料 (a) Specialty : 专科 (b) Period : from to 期间 由至For Office Use Only ID BC Fee Cheque Form Consent Please tick the appropriate box 请在适当空格上加上「√」号Checked by Date rec'

d -

1 - (c) Purpose of Report 医事报告之用途 [For hospital reference only] [只供医院参考之用] a general medical report for : 一般性质的医事报告以供 future medical purpose 日后医疗用途 insurance claim (insurance claim form attached or no attached) 申索保险赔偿 (保险赔偿表格 附上 或 没有附上) employee compensation claims 申索工伤赔偿 legal proceedings/concerned parties : third party/private company/others : 法律申诉程序/有关人仕: 第三者/私人公司/其他 : rehousing application 申请公屋徙置 to Immigration Department for family reunion 向入境事务处申请家人来港团聚 application for reimbursement/direct payment of medical expenses (for civil servants, pensioners and others eligible persons) 申请发还/直接支付医疗费用(公务员、退休公务员及其他合资格人士适用) other, please specify 其他(请注明) 3. Person to whom the Medical Report is to be sent 医事报告的接收人 The Patient and/or the Patient'

s parent/guardian by signing this Form consents to the relevant HA hospital disclosing and sending the medical report to the following person: 病人及/或其父/母/监护人签署此表格代表病人及/或其父/母/监护人同意有关之医院管理局 医院向下述人士透露及发出其医事报告 Name : (English) ( ) 姓名 Surname 姓氏 Forename 名字 (英文) Chinese (中文姓名) Address : 地址: Tel No. (电话号码): H.K.I.D. / Passport No. (if applicable) : 香港身份证/护照号码(如适用) # Please attach a true copy of the HKID Card/Passport of the individual to whom this Medical Report is to be sent if not the patient himself or produce in person the original HKID Card/Passport of both the relevant person &

the applicant when submitting the request. This does not apply if the recipient is a limited company such as an insurance company. 如果此医事报告非由本人接收,申请时请附上接收人的香港身份证/护照真确副本或请亲身 出示有关人士及申请者香港身份证/护照正本.如若接收人为一有限公司(如保险公司), 则此栏不适用. Please tick the appropriate box (请在适当空格上加上「√」号) -