Form B - Application For Reimbursement/direct Payment Of Medical Expenses (Except Drugs Provided By The Hospital Authority) In Accordance With Csb Circular No. 2/2013
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11Restricted (Staff)
FORM B
Application for Reimbursement / Direct Payment of Medical Expenses
(except drugs provided by the Hospital Authority)
in accordance with CSB Circular No. 2/2013
(Applicants should read CSB Circular No. 2/2013 and
the Notes for Applicants at the end of this application form before completing the form)
IMPORTANT NOTES:
(1)
Applicants will not be reimbursed expenses on drugs which are available in the pharmacy of the
attending Hospital Authority facility; or for expenses on equipment / services available in the
Hospital Authority.
(2) This form is also applicable for reimbursement of medical expenses on drugs which form an
essential part of the medical treatment to the patient on medical grounds as prescribed by attending
doctors of Department of Health’s clinics but such drugs are not available in the pharmacy of the
attending Department of Health’s clinic. The attending Department of Health doctors should
follow the contents in the Note on Page 3 as appropriate in completing Part A of the application
form.
To : Director of Health (Attn : Medical Reimbursement Section, Finance and Supplies Division)
Unit 1107-1108, 11/F, 248 Queen’s Road East, Wan Chai, Hong Kong
Part A : To be completed by the attending Hospital Authority doctor
Name of patient:
or affix label with particulars of patient here
HKID Card No.:
Please tick one:
I certify that the patient concerned is a private patient. (If this box is ticked,
□
please proceed to (d) below)
I certify that the patient concerned is not a private patient.
□
(a) Diagnosis:
____________________________________________________________________________________
(b) Drugs / equipment / services required and cost / dosage of the items (if available):
________________________________________________________________________________________________
(Note: The attending doctor should also fill in the supplementary sheet for Continuous
Positive Airway Pressure machines and consumables, i.e. FORM B(1), if applicable.)
(c) Date / period of the treatment:
____________________________________________________________
Part A to be continued on Page 2
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