医疗理赔申请书ClaimApplicationFormforMedical.pdf

平安健康保险股份有限公司 PING AN HEALTH INSURANCE COMPANY OF CHINA LTD. 医疗理赔申请书 单证代码Document code: 000000NK1302 Claim Application Form for Medical Expenses 小条码Bar code: 该理赔申请书适用于住院/ 门诊医疗费用、住院津贴、重疾理赔申请。 This document is an application form for claim settlement of all inpatient and outpatient medical expenses, inpatient allowance and claims for Critical Illness policies. 您需要做的: What you should do: 步骤一：请您用正楷填写此表格 Step 1: Fill in this Claim Application Form using block letters. 步骤二：请附加如下理赔申请材料： Step 2: Attach the following materials to this Claim Application Form: 1. 被保险人的身份证明复印件 （与投保时一致）▲ 1. A copy of the identity certificate the insured used for enrolment 2. 医疗费用收据（发票）原件* 2. The original official receipts (“fapiao”) received from your doctor or 3. 费用明细清单复印件** hospital* 4. 医疗资料复印件，包含但不限于： 3. A copy of the itemized medical bills received from your doctor or  出院小结（住院理赔）  门诊病历资料 hospital**  与之相关的检查结果，如X 线检查、病理检查等。 4. Copies of all medical documentation given to you by your doctor or 5. 如账户信息第一次使用，请提供账户信息复印件 hospital. These include, but are not limited to: