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 Page 5
ADVERTISEMENT
1
2
3
4
5
6
7
8
9
10
11-5-
Part C : To be completed by the patient who is a dependant and aged 18 or above (except for
those with mental infirmity)
I hereby authorise the Department of Health to ask the Hospital Authority / clinics of Department
of Health for further information on my health condition where the Director considers necessary.
Signature:
Name of the patient:
Date:
Part D : To be completed by the applicant’s bureau/department (for reimbursement
applications submitted by serving officers only)
[Remarks: Serving officers are not required to submit this form to their bureuau/department
for filling Part D if they apply for items under the direct payment arrangement from
Department of Health to Hospital Authority (see Notes 2 and 3 on Page 6).]
I confirm that the patient is
a Government servant
□
□
a dependant of a Government servant
others (please specify: _________________________)
□
eligible for free medical services as defined under CSR 900(3).
Signature:
Department:
Name of certifying officer:
Date:
Contact telephone no:
Our file ref:
Contact fax no:
Your file ref:
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form D1181 - Application For Reimbursement Of Medical Expenses Privately Incurred - Australian Department Of Veterans' Affairs
Business
Form 19 - Application For Grant Or Renewal Of A Licence To Sell, Stock, Exhibit Or Offer For Sale, Or Distribute Drugs Other Than Those Specified In Schedule X
Business
Form Au-298 - Application For A Direct Payment Permit - New York State Department Of Taxation And Finance
Business
Related Categories
Parent category: Business