FirstCare — Hospitalisation & Surgical and Dental Claim Form

摯關懷醫療計劃—住院及手術和牙科賠償表
Remarks 備註：
A) Documents required to be submitted with this form: 以下文件請連同此表格一併交回：
1. Attending Physician’s Report completed by the atteding Physician (To be obtained by the Claimant). 主診醫生填寫之賠償申請書（此報告需由申請人負責索取）。
2. Original Hospital receipt from the hospital. 住院收據正本。
3. Please submit a discharge summary if the Insured was admitted into a hospital(s) under the Hospital Authority. 若受保人入住政府醫院，請遞交出院紙。
B) Please note that if the above applied claim is approved, the claim payment will be reimbursed by autopay to the account specified on the application form.
賠償申請一經核准，賠償金額將會存入投保人在申請書上所指定的戶口內。

Part I 甲部
Name of Insured 投保人姓名 Membership no. 會員編號
Name of patient 病人姓名 Membership no. 會員編號
Occupation 職業 Date of birth 出生日期 I.D. card/passport no. 身分證/護照號碼
Please specify any other insurance with HSBC? 請註明在 豐有否投保其他保險？
Life Policy no. 人壽保險號碼 Non-Life Policy no. 非人壽保險號碼 Medical Policy no. 醫療保險號碼

A. Hospitalisation & Surgical — to be completed by the patient

住院及手術 — 由病人填寫
Applicable to inpatient or oupatient claim application (for those who have selected non-network doctor services)
本表格適用於住院或門診賠償申請（已選擇了非網絡醫生服務的人士）
(1) a) If hospitalisation was due to illness, please describe the symptoms and how long they have appeared
若因病而住院，請詳述病徵及該病徵已持續多久
b) Have you had any prior treatment for this or related conditions? 您是否曾經因同一病況而接受治療？
No 沒有 Yes 有 Doctor’s name 醫生姓名： Date 日期：
Address 地址：
(2) Are you making any other insurance claim as a result of this hospitalisation/surgery? 有關此次住院/手術，您有否申請其他保險賠償？
No 沒有 Yes 有 Name of insurance company 保險公司名稱： Policy no. 保單號碼：
(3) Was the hospitalisation/surgery a result of an accident? 此次住院/手術是否由意外引致？ No 不是 Yes 是
Date 日期： Time 時間： Place 地點：
Brief description 經過：
Was this accident reported to the police? 該意外有否報案？ Name of Witness 目擊証人姓名：
Yes 有 Police station and police reference number 報案警署名稱及檔案編號： No 沒有
(4) Do you want to have the certified true copy of the receipt returned to you after processing? 您是否需要退回核實正本之收據給您？ Yes 是 No 不是
B. Dental — you are entitled to dental benefits if you have chosen this benefit which is stated in your policy schedule.
牙科— 若申請人已選擇牙科保障（已列明於您的保障項目表內），可申請此項賠償。
Details of any accident 意外詳情 — to be completed by patient 由病人填寫
If any of the above treatments or services were necessitated as a result of an accident, please give brief details of the accident.
若因意外而需接受上述任何牙科治療或服務，請簡述意外情況。

To be completed by dentist 由牙醫填寫 Please mark teeth treated or area of oral treatment on following chart:
請在下圖標記出所治療的牙齒位置或其口腔治療的部位：
Date 日期 Particulars 項目 Charges 收費
LABIAL
1.
RIGHT ------------------------- LINGUAL ------------------------- LEFT
2.
3. LABIAL

Name of dentist (with qualification) 牙科醫生的姓名（資歷）/ Signature of dentist 牙科醫生簽名 Telephone 電話 / Date 日期
Personal Information Collection Statement 收集個人資料聲明
The information you provide to us is collected to enable us and any of our affiliated companies to carry on business and may be used for the purpose of: 1) any insurance, banking, provident fund scheme
or financial related products or services, 2) any sales or marketing, or any alterations, variations, cancellation or renewal of such products or services listed in 1 above; and 3) any claims or investigation
or analysis of such claims; and 4) exercising any right of subrogation, if applicable. Further, the information you provide to us may be transferred (in and outside the Hong Kong Special Administrative
Region) to the following organisations: 1) any of the company or companies within the HSBC Group for the purpose of insurance, banking or other businesses of the affiliated company concerned; 2)
any related company, or any other company carrying on insurance or reinsurance related business, or an intermediary, or a claim or investigation or other service provider providing services relevant to
insurance business, for any of the above or related purposes; 3) any association, federation or similar organisation of insurance companies (“Federation”) that exists or is formed from time to time for
any of the above or related purposes or to enable Federation to carry out its regulatory functions or such other functions that may be assigned to the Federation from time to time and are reasonably
required in the interest of the insurance industry or any member(s) of the Federation; 4) any members of the Federation by the Federation for any of the above or related purposes. Moreover, we are
hereby authorised to obtain access to and/or to verify any of your data with the information collected by the Federation from the insurance industry. You have the right to obtain access to and to request
correction of any personal information concerning yourself held by us, and to request, without charge, to opt out from receiving any direct marketing materials from us. Requests for such access and opt-
out can be made in writing to the Compliance Officer, 18/F, Tower 1, HSBC Centre, 1 Sham Mong Road, Kowloon, Hong Kong. 您提供的資料，為本公司及相關聯公司提供其業務所需，並可
能使用於下列目的： 1) 任何與保險、銀行、公積金計劃或財務有關的產品或服務， 2) 上述第一項該等產品或服務的任何銷售或推廣，或任何更改、變更、取消或續期；及 3) 任何
索償，或該等索償的調查或分析；及 4) 行使任何代位權，如適用。您提供的資料亦可能移轉（無論在香港特別行政區以內或以外）予： 1) 任何 豐集團的公司用作與保險、銀行或
相關聯公司之其他業務； 2) 任何有關的公司，或任何其他從事與保險或再保險業務有關的公司，或中介人或索償或調查或其他提供與保險業務有關的服務提供者，以達到任何上
述或有關目的； 3) 現存或不時成立的任何保險公司協會或聯會或類同組織（聯會），以達到任何上述或有關目的，或以便聯會執行其監管職能，或其他基於保險業或任何聯會會員
的利益而不時在合理要求下賦予聯會的職能； 4) 或透過聯會移轉予任何聯會的會員，以達到任何上述或有關目的。此外，本公司亦據此獲授權由聯會從保險業內收集的資料中查
閱及／或核對您任何資料。您有權要求查閱及更正由本公司持有有關您的個人資料，及免費要求不收取任何直接推廣資料。有關要求，可用書面寄香港九龍深旺道1號 豐中心1座
18樓，向本公司審核主任提出。
DECLARATION & AUTHORISATION 聲明及授權書
I hereby certify that the answers and statement given above are true and complete to the best of my knowledge and that I have withheld no material fact.
本人在此聲明以上提供的資料均屬正確無訛且並無缺漏。
I authorise any physician, hospital, clinic, insurance company or other individual organisation or government office that has any records or knowledge of me or my health, to disclose to HSBC Insurance
(Asia) Limited or its representative any information relevant to this claim. This authority shall remain valid notwithstanding my death or incapacity and a copy of this authorisation shall be as effective
and valid as the original.
本人授權任何知道本人健康情況及持有此等紀錄之醫生、醫院、診所、保險公司或其他私人、政府機構向 豐保險（亞洲）公司或其代表提供本人之有關資料。此授權書於本人死亡
或喪失能力後依然生效。本授權書之影印本亦屬有效。
INAH019R4 (0308) W

Date 日期 Signature of patient 病人簽署

The insured should sign on behalf of the patient who is under 18 years of age.如果病人是十八歲以下人士，請由投保人代為簽署。

HSBC Insurance (Asia) Limited 18/F, Tower 1, HSBC Centre, 1 Sham Mong Road, Kowloon, Hong Kong
豐保險（亞洲）有限公司 香港九龍深旺道1號 豐中心1座18樓
Page 頁次 1/2
Part II — to be completed by the attending physician/surgeon at the claimant’s own expenses (applicable to Hospitalisation & Surgical Claims only)
乙部 — 由主診醫生填寫，所需費用由索償人自行承擔（只適用於住院及手術賠償）

Patient Name (in full) 病人姓名：

Name of Hospital 醫院名稱： Date of Admission 入院日期：

1. Preliminary information of this patient 病人的初步資料：

(a) Clinical diagnosis 臨床診斷：

(b) Treatment Plan 治療計劃： (i) any therapeutic medication/treatment? 是否需要接受藥物或其他治療﹖ Yes 是 No否

(ii) any operation? 是否需要接受手術? Yes 是 No否

If yes, specify name 倘若需要，請提供手術名稱
(c) Date on which the patient first consulted you for this medical condition (s)/injury 病人因該傷病首次向你求診的日期

(d) Symptoms and complaints for this hospitalisation/treatment 此次住院/手術的症狀及主要病因

(e) According to the medical history given by the patient, how long had he/she been experiencing these symptoms before the above first consultation? 根據病人所提供的病歷
記錄，病人在首次求診前已經歷了該病徵有多久？

2. Additional information of this patient 病人的詳細資料：

(a) Final Diagnosis 最後的診斷：

(b) Date and Name of Operation(s) performed 手術的名稱及日期：

(c) Underlying cause of this medical condition for the hospitalisation 此次入院症狀的基本原因：

(d) Has the patient been treated by other doctor(s) for similar or related illness in the past? 病人曾否因類似或有關症狀接受其他醫生的治療？ Yes 是 No否
If yes, please specify treatment date and name and address of the doctor(s) 倘若病人曾接受其他醫生的治療，請提供該醫生的姓名及地址及治療日期

(e) If the patient was referred to you by another doctor, please provide the referring doctor’s name and address. 如果該病人是由其他醫生轉介，請提供該醫生的姓名及地址。

(f) If you have consulted other specialist during this hospitalisation, please provide the following 倘若於住院期間你曾因上述傷病諮詢其他專科醫生，請提供以下資料：

Consulted Specialist’s Name 該專科醫生的姓名：

Reason 原因：
(g) Brief medical summary to show treatments, investigations, results and/or any complications (histo-pathologic report to be attached) 請扼要地列舉病人於住院期間曾接
受的治療、檢查、有關的結果及曾出現的併發症（連同病理報告副本）

(h) Was the condition due to or associated with the following (please circle the right answer)? 上述的傷病是否由於下列病症所引致（請選擇有關病症）？
Sexually transmitted disease, pregnancy, infertility, sterilization, refractive error or correction of eyesight, cosmetic surgery, mental illness, emotional disorder, congenital
condition or none of the above. 性病、懷孕、不育、絕育、視力不正常、美容手術、精神病、情緒失調、先天缺陷或其他。

I hereby certify that all information given above is accurate and true to the best of my knowledge. 本人現聲明上述所填報資料是據我所知及正確無訛。

Name of attending doctor (in full and in block letter) 主診醫生的姓名 Address & Telephone No. 地址及電話號碼
INAH019R4 (0308) W

Signature of attending doctor with Practice/Hospital Stamp Date (DD/MM/YY)

主診醫生的簽名及其或醫院的印章 日期

FirstCare — Hospitalisation & Surgical and Dental Claim Form 摯關懷醫療計劃—住院及手術和牙科賠償表

The 2nd page of this claim form is endorsed by the Hong Kong Medical Association and
the Medical Insurance Association of the Hong Kong Federation of Insurers Page 頁次 2/2