Date Signature

Type of Treatment

Days of Diagnosis and Treatment

Name of Illness or Injury preferablywith the number of InternationalClassification of Diseases for the useof Health Insurance.(Please refer tothe table attached to this form.)

Office Address

Office Phone( )

Form A Please fill in this form so that the patient may claim the health insurance benefit.

This form should be completed and signed by the attending physician.

One form for each month and one form for hospitalization/outpatient(home visit) should be filled out.

1

Age (Date of birth)

Request to Attending Physician

Attending Physician's Statement

Name of Patient (Last,First) Sex (Male Female)

Date of first Diagnosisdays

Outpatient or Home Visit

HospitalizationFrom

Attending Physician( )

Reference Number of your Medical Record(if applicable)

to

Name Last( ) First( ) Title( )

Nature and Condition of Illness orInjury(in brief)

Prescription,Operation and anyotherTreatments(in brief)

Was the treatment required as a resultof an accidental injury? Yes No

Name and Address of Attending Physician

Itemized amounts paid to Hospitaland/or AttendingPhysician Fill in Form B

The Others(Specify)

Form B Request to Attending PhysicianPlease fill in this form so that the patient may claim the health insurance benefit.

This form should be completed and signed by the attending physician.

One form for each month and one form for hospitalization/outpatient(home visit) should be filled out.

1

Itemized Receipt Name of Patient (Last,First) Age (Date of birth) Sex (Male Female)

Fee for Home Visit

Fee for Initial Office Visit

Fee for Follow-up Office Visit

Important Exclude the amount irrelevant to the treatment.i.e,payment for a luxurious room charge.

Phone( )

Signature

Consultation

Operating room Charge

X-Ray Examinations

Laboratory Tests*

Hospitalization

Professional Nursing

*Please fill in the content of theLaboratory Tests.*

Medicines**

Surgical Dressing

**Please fill in the name and theamount of the prescription of anindividual medicine.**

Operation

Fee for Hospital Visit

Date

Reference Number of your Medical Record(if applicable)

Name

Office Address

Office

Last( ) First( ) Title( )

Attending Physician( )

Anesthetics

Name and Address of Attending Physician

Total