Looking for a Medicaid Reimbursement Form Templates? Download it for free!

Form B - Application For Reimbursement/direct Payment Of Medical Expenses (Except Drugs Provided By The Hospital Authority) In Accordance With Csb Circular No. 2/2013 Page 11

-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

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

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.

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.

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.

Form B - Application For Reimbursement/direct Payment Of Medical Expenses (Except Drugs Provided By The Hospital Authority) In Accordance With Csb Circular No. 2/2013 Page 11

Related Articles

Related forms

Related Categories