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 4
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11-4-
Part B : To be completed by the applicant
(Please tick the appropriate box)
I wish to apply for
□
reimbursement (please see Note 1 on Page 6)
□
direct payment from Department of Health to Hospital Authority (please
see Note 2 on Page 6)
□
direct payment from Department of Health to suppliers (please see Note
1(d) on page 6)
of expenses for the drugs / equipment / services set out below -
(a) Name and cost of the drugs / equipment / services:
(b) Name of the Hospital Authority / Department of Health
hospital / clinic attended:
(c) Particulars of the patient -
(i) Name:
(ii) HKID Card No.:
(iii) Date of birth:
(d) I confirm that the drugs / equipment / services listed in (a) above have been received.
(e) I hereby authorise the Department of Health to ask the Hospital Authority / clinics of
Department of Health for further information on my or the patient’s (if he or she is a
dependant of the applicant and is below the age of 18 or a dependant aged 18 or above but
with mental infirmity) health condition where the Director considers necessary.
(f) I have read CSB Circular No. 2/2013 and the Notes for Applicants at the end of this form.
I understand and accept the terms and conditions governing the grant of reimbursement and /
or direct payment of medical expenses set out in the CSB Circular and the Notes for
Applicants of this form.
[(g) below is only applicable to pensioners]
(g) I declare that on the date when the medical expenses above are / were incurred, I am / was in
receipt of a pension or an annual allowance. In the event that the medical expenses have
not yet been incurred and that my pension or an annual allowance has been suspended under
the pensions legislation before the medical expenses are incurred, I will immediately notify
the Department of Health and will provide such details as may be required.
I understand that I will be liable to criminal prosecution if I wilfully furnish false or incomplete
information in connection with this application.
Contact
Signature:
telephone no.:
Name of the applicant:
Department:
HKID Card No.:
Date:
For pensioners only -
(i) Correspondence address:
(ii) E-mail address / Fax
(optional):
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