医疗保险索赔申请单-电子版
医疗保险索赔申请单
MEDICAL INSURANCE CLAIM FORM
员工签名（中文）：提交日期：Signature of Employee（CHN）Date
索赔须知
1．请尽可能清楚、完整、正确地填写索赔申请单上每一栏，以便您的索赔申请能准确、迅速地在保险公司得到赔付.
Please fill in the each blank with information clearly, completely and correctly; In order to speed up your claim application, please notice.
2．请您一定填写员工编号；员工与家属请分开填写索赔申请单.
Please fill in …Employee Code?;separate employees? application from dependants?.
3．每日就诊费用请分栏填写;合计栏请填写本次索赔的所有收据数量与金额.
Please fill in the number and the amount of each Medical Receipt separately according to the medical consultation dates.
Fill in the “Total” blank with total number and the amount of each Medical Receipt.
4．每日就诊的病历资料与对应的医疗收据放在一起，并按顺序钉附在索赔申请单后，请勿粘贴。
Stapling the Medical Receipt(s) with relevant diagnostic documents on the back of this claim form according to the medical consultation dates，Please do not stick the paper.
5．索赔时请提供以下单据：
门诊：收据原件以及药品明细清单（北京地区员工需提供处方原件）、病历复印件、检查/化验报告单复印件
住院：收据原件、医疗费用明细清单原件、诊断证明/出院小结原件
Please provide these documents when claiming:
Outpatient: Original Medical Receipt(s) and details of medicine (the employee in Beijing need to provide the original prescription(s))、Copy of medical record、Copy of Medical
Examination and laboratory Report(s)
Hospitalization: Original Medical Receipt(s)、Original Details of hospitalization espense(s)、Original certificate of diagnosis issued by the hospital
6．如果收据原件已提交第三方索赔，可提供第三方返回的费用分割单原件及上述资料的复印件索赔。
If your original reception(s) or invoice(s) had already provide to the third party for reimbursement, you can claim to Chinalife by original certification of indemnity proof and copies of documents mentioned above.
7．若需要退回收据原件(仅限家属)向第三方索赔，请同时提供退回单据的复印件。
If original receipt(s) are needed to be returned (for dependents ONL Y), please provide the copy of bill and the original one .
8. 如果您可以提供一份注明地址、邮编、姓名的回邮信封，可以尽快拿到退回的原始收据.
An envelope with your address、postcode、name can help you receive the original medical receipt more quickly.
010-********、159******** huangxuan@https://www.wendangku.net/doc/9814266682.html,