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 9
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11FORM B(1)
Hospital Authority
Patient’s Identification
( or affix a label with particulars of
Hospital
patient here)
Continuous Positive Airway Pressure (CPAP) Machines / Consumables
Reimbursement Form
(Supplementary form for CPAP Machines / Consumables Only)
Diagnosis
□
Obstructive Sleep Apnoea
□
Others (specify
)
Equipment
□
Basic CPAP machine
Basic consumables
Mask
□
□
□
Tubing
□
Filter
□
Headgear / straps for fixing mask
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Humidifier
Other non-basic items (including machine and consumables). Please
□
specify the item(s) with model no, if any.
Specify
Justification
Specify
Justification
Specify
Justification
I hereby certify that the ticked items are prescribed in accordance with the medical necessity
of the patient.
Signature:
Hospital / Department / Clinic:
Name of attending Hospital
Authority doctor
:
Date:
Please tick the appropriate box(es)
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