20TransHR20医疗保险索赔申请单

20TransHR2020TransHR20医疗保险索赔申请单医疗保险索赔申请单 附录E 医疗保险索赔申请单MEDICAL INSURANCECLAIM FORM公司名称卓越亚马逊公司Name ofyour pany员工编号Employee No员工姓名Name ofEmployee家属姓名Name ofDependent异地就诊是 否 patient outY N of workingcity工作城市Working City部门Department联系电话Telephone电邮zjzj amazon Email家属医疗费收据原件是否需退回Return theOriginal Medical Receipt是 否 Y N 若需退原件请同时提供退回单据 的复印件 我们将尽快退回 PLS providecopy ifyou requirethe original medical receiptto bereturned sothat wecan returnthe originalcopy toyou assoon aspossible 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 envelopewith youraddress postcode name can help you receive the originalmedical receipt more quickly 就诊日期Medical ConsultationDate费用类别Sort of Medical Expenses收据数量Number ofMedical receipt s 收据金额Amount ofReceipt备注Remarks门诊Outpatient 住院Hospitalization 生 育Child Delivery 其他Others 门诊Outpatient 住院Hospitalization 生育Child Delivery 其他Others 门诊Outpatient 住院Hospitalization 生育Child Delivery 其他Others 门诊Outpatient 住院Hospitalization 生育Child Delivery 其他Others 门诊Outpatient 住院Hospitalization 生育Child Delivery 其他Others 门诊Outpatient 住院Hospitalization 生育Child Delivery 其他Others 门诊Outpatient 住院Hospitalization 生育Child Delivery 其他Others 合计Total员工签名 中文 提交日期Sign ature ofEmployee CHN Date员工留存联Hold byEmployee员工编号Employee No员工姓名Name ofEmployee家属姓名Name ofDependant索赔收据数量Invoice Number索赔收据总金额Total AmountofMedical Receipt提交日期Date备注Remarks 2 索赔须知Important Notesfor MedicalClaims1 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 Plea se fillin theeach blank with informationclearly pletely andcorrectly In orderto speedup yourclaim 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 fillin Employee Code separate employees application fromdependants 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 fillin thenumber and the amount of each MedicalReceiptseparately aordingto themedical consultationdates Fill inthe Total blankwithtotal numberand theamountofeachMedicalReceipt 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 theMedicalReceipt s with relevantdiagnostic documentson theback ofthis claimform aordingto themedical consultationdate Please donot stickthe 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 documentswhen claiming Outpatient Original MedicalReceipt s and detailsof medicine the employeein Beijingneed toprovidetheoriginal prescription s Copy ofmedical record Copy ofMedical Examinationand laboratoryReport s Hospitalization Original MedicalReceipt s Original Detailsof hospitalizationexpense s Original Certificateof diagnosisissued bythe hospital6 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 youroriginal reception s or invoice s had alreadyprovide tothe thirdparty forreimbursement you canClaim toChina lifeby originalcertification ofindemnity proofand copiesof documentsmentioned 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 originalreceipt s are neededto bereturned for dependentsONLY please providethe copyof billandtheorigin