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1、 Medical Expense Claim Form (Bright Superb Health) 醫療費用索償表格(明智顯耀醫療計劃) Quality HealthCare Medical Services Limited (QHMS) is a service provider appointed to provide claims services for “Bright Superb Health”. Please contact QHMS Hotline for any claim enquiry. Tel : (852) 8101 8011 Fax : (852) 8200 83
2、77 Email : . Please mail your completed claim form and original medical receipts to QHMS Claims Department (Third Party Administration), Quality HealthCare Medical Services Limited, 3/F, Skyline Tower, 39 Wang Kwong Road, Kowloon Bay, Kowloon. 卓健醫療服務有限公司（卓健卓健醫療服務有限公司（卓健) 被委仼為處理明智顯耀醫療計劃索償事務之服務商。如有關任何
3、索償事項查詢，請致電卓健提供之專線。電話：(852) 8101 8011 傳真：（852） 8200 8377 電郵 : 請郵寄已填妥之索償表格及醫療收據正本至九龍宏光道請郵寄已填妥之索償表格及醫療收據正本至九龍宏光道 39 號宏天廣塲號宏天廣塲 3 樓卓健醫療服務有限公司卓健醫療理賠部樓卓健醫療服務有限公司卓健醫療理賠部 (TPA) 。 Consultants Information 顧問資料顧問資料 Consultant Name 顧問姓名 District/ Branch Code 區域/ 分行編號 Consultant Code 顧問編號 Contact Phone No. 聯絡電話
4、 Part 1 第一部份第一部份 - To be completed by Insured or Policy Owner if Insured is below 18 years old (Please attach hospital / medical expense receipts with this form) 請由受保人填寫，如受保人未滿 18 歲，則由保單持有人填寫(請連同住院/ 醫療費用單據一併交回) 1. Personal Particulars 個人資料個人資料 Name of Policy Owner 保單持有人姓名 Eng 英文 Family Name 姓 Given
5、Name 名 Chi 中文 Policy No. 保單編號 Name of Insured 受保人姓名 Eng 英文 Family Name 姓 Given Name 名 Chi 中文 HK Identity Card No. of Insured 受保人香港身份證號碼 Date of Birth 出生日期 Age 年齡 Sex M / F 性別 男 / 女 Country of Residence in the past 12 months of the Insured 受保人過去 12 個月之常居地 Daytime Contact Telephone No. 日間聯絡電話 E-mail A
6、ddress 電郵地址 Name of Current Employer 現任僱主名稱 Position Held 受僱職位 Address of Current Employer 現任僱主地址 Tel No. 公司電話 Remark 1 備註備註一一: Claim Status Notification and Claim Cheque (issued in Hong Kong Dollars) will be sent to your consultant unless you specified by ticking the following box. 如 無下列方格內填上剔號作出指示
7、，索償進度通知書及賠償支票 (以港幣支付) 將送予閣下顧問。 Send the Claim Status Notification, Claim Cheque and Claim Settlement Advice to my correspondence address as your record 索償索償進度進度通知通知書書、賠償支賠償支 票票及住院住院賠償通知賠償通知寄往本人的通訊地址 Remark 2 備註備註二二: Please tick the box if return the Original documents after processing claim 若理賠審結後需退
8、回正本文件正本文件，請方格內填上剔號 2. Consultation Information 求診資料求診資料 Please provide consultation information to facilitate the claim processing 請提供詳細求診資料以便處理索償 2.1 This consultation/ hospital confinement 是次求診住院 i. Reasons of this consultation (provide details as appropriate) 求診原因（請提供詳情） Due to illness/ accident.
9、 Please provide the diagnosis 由疾病/ 意外所致，請提供診斷 : For accident, please provide the circumstances of the incident如屬意外導致，請提供意外詳情 : ii. When did you first aware of the manifestation of such symptoms 您何時首次發現上述病徴 iii. Date of first consultation 初診日期 iv. Name of Hospital / Clinic / Doctor 醫院診所醫生名稱 v. Consul
10、tation period ： From to 求診日期 : 由 至 vi. Name of doctor(s) consulted for this illness / accident in the past： 您過去曾就是次疾病意外就診之醫生名稱： 2.2 Previous related consultation history 過去因該病求診紀錄 i. What was the sign / symptom in the first consultation 首次求診之病徴: ii. Date of first consultation 初診日期 iii. Subsequent co
11、nsultation dates of this sign / symptom 其後因該病徴覆診再診之日期 2.3 Please provide the name and address of your usual / family doctor ： 請列出閣下過去慣常求診的醫生家庭醫生之名稱及地址： 3. Others 其他資料其他資料 Do you have other insurance coverage? If so, please state 請問除本公司外，受保人有否投保於其他保險公司？如有，請列明: Name of Insurer 保險公司名稱 Type of Coverage
12、投保種類 Policy Number 保單編號 Policy Effective Date 保單生效日期 YY/MM/DD（年月日） YY/MM/DD（年月日） YY/MM/DD（年月日） YY/MM/DD（年月日） YY/MM/DD（年月日） YY/MM/DD（年月日） P.1/3 PERSONAL INFORMATION COLLECTION STATEMENT 個人資料收集聲明個人資料收集聲明 I/We understand and consent that, any personal data collected by Sun Life Hong Kong Limited (“Sun
13、Life”) (whether collected in this form or otherwise) may be used by Sun Life for the following purposes: (i) processing and evaluating this application and any other applications I/we make; (ii) administering and providing services in relation to this product and any other products I/we hold; (iii)
14、processing and investigating claims; (iv) conducting customer surveys; (v) researching and designing financial, insurance or pensions products for customer use; (vi) selecting and participating in reward, loyalty or privileges program and related service for me/us; (vii) contacting me/us for the abo
15、ve purposes; (viii) complying with all laws, regulations, regulatory guidance, court orders or obligation or requirement under an agreement, or other commitment, between Sun Life or any entity within the Sun Life Group and the regulator or government in any jurisdiction (in relation to money laundering, terrorist financing and tax evasion or otherwise) to which Sun Life and its related companies are subject to (of Hong Kong or any other countries); and (ix) purposes which are directly r
