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 2
ADVERTISEMENT
1
2
3
4
5
6
7
8
9
10
11-2-
)
Part A (cont’d)
: To be completed by the attending Hospital Authority doctor
(Please refer to the attached note and tick as appropriate:)
I certify that (please tick both boxes for a fully supported application)
□
the drugs / equipment / services above are prescribed in accordance with the medical
necessity of the patient
AND
the drugs / equipment / services are either chargeable by or not available in the Hospital
□
Authority (see Note 4 on Page 3).
I am unable to certify because (please tick one or more below) :-
the drugs / equipment / services above are NOT prescribed in accordance with the
□
medical necessity of the patient;
AND / OR
the drugs / equipment / services above are available in the Hospital Authority (whether
□
chargeable by HA or not) but the patient intends to purchase / has already purchased
them from outside.
(d) Doctor’s particulars :
Hospital /
Department
Signature:
/ Clinic:
(with hospital / clinic chop)
Full name of attending
Hospital Authority /
Contact
doctor:
Tel. No.:
(in capital letters)
Post title:
Date:
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form D1181 - Application For Reimbursement Of Medical Expenses Privately Incurred - Australian Department Of Veterans' Affairs
Business
Form 19 - Application For Grant Or Renewal Of A Licence To Sell, Stock, Exhibit Or Offer For Sale, Or Distribute Drugs Other Than Those Specified In Schedule X
Business
Form Au-298 - Application For A Direct Payment Permit - New York State Department Of Taxation And Finance
Business
Related Categories
Parent category: Business