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1、 適治適治華華 乳癌藥物資助計劃乳癌藥物資助計劃 資助申請表格資助申請表格 Breast Cancer Drug Financial Assistance Program XGEVA Reimbursement Claim Form 申請人資料Applicants Name :_ 檔案編號File No. _ 姓名Name (英文English) _ (中文Chinese) _ 香港身份證號碼ID Number _ 聯絡電話Contact Phone Number住宅(home)_ 手提(mobile) _ 已注射的適治華Number of XGEVA taken _針/ vials 注射日期
2、Consumption period 由from _ 至to _ 申請可郵寄或親身遞交至 香港北角木星街9號永昇中心22樓 香港乳癌基金會 (信封面請註明乳癌藥物資助計劃 - 適治適治華華) Submission can be sent by post or delivered in person to: Hong Kong Breast Cancer Foundation 22/F., Jupiter Tower, 9 Jupiter Street, North Point, Hong Kong (Please mark “Breast Cancer Drug Financial Assis
3、tance Program- XGEVA” on the envelope) 申請需包括以下所有文件Please make sure you have enclosed all of the following 藥費單據正本 Original copy of official medication receipt 經私家醫生或私家醫院醫生診症的病人，須於每次求診後提交由醫生填寫的 乳癌藥物資助計劃 轉介信 Patients receiving treatment at either private clinics or private hospitals should also submit doctors referral form 申請人簽名Applicants Signature_ 日期Date_ 所有遞交之正本文件均不會獲發還。本表格可影印使用或從本會網址www.hkbcf.org下載 All original copies of documents will not be returned.You can copy this form for subsequent usage or download the form from www.hkbcf.org
