-9-
Annex
Application for Direct Payment / Reimbursement of Medical Expenses
(Except Drugs Provided by the Hospital Authority (HA))
(i) Direct Payment from
(ii) Reimbursement for other
(iii) Reimbursement for
Department of Health
chargeable equipment /
drugs / equipment / services
for specified
services provided by /
not available in HA
equipment/services
through HA
1
provided by HA
1. Obtain payment slip
1. - Obtain referral letter or
1. Obtain payment slip
from doctor
prescription from
from doctor
doctor
- Retain photocopy of
drug prescription
2. - Present payment slip
2. -
Present payment slip
2. - Procure drug /
and completed
to Shroff
equipment / service
2
FORM B to Shroff
outside HA
- Settle payment
(No need to make
any payment)
- Settle payment
- Obtain receipt from
Shroff
- Obtain receipt from
- Retain original receipt
Shroff
- Receive equipment/
service in HA facility
3. Serving civil servants
3. Retired civil servants
3. Receive equipment /
Submit completed
Submit completed FORM
service in HA facility
FORM B, original
B, original receipt(s), and
photocopy of drug
receipt(s) and photocopy
of drug prescription(s) (if
prescription(s) (if
applicable) via Head of
applicable) to Department
of Health direct
Department to Department
of Health
Notes:
Copy of FORM B is attached to CSB Circular No. 2/2013, and is also available at
CSB’s website ( ).
A limited
supply of forms is also available from the shroff of major HA hospitals.
Please submit FORM B through the Medical Records Office at the HA hospital for the
attending doctor’s assistance in completing Part A therein as necessary.
1
Including (a) percutaneous transluminal coronary angioplasty (PTCA) procedures; (b) intraocular lens operation; (c)
non-PTCA consumables for interventional cardiology; and (d) positron emission tomography (PET) service.
2
Civil service eligible persons should submit FORM B to Shroff before the equipment / service is provided, unless
otherwise advised by the attending HA facility concerned.