01-02-2017-direct billing form - safetynet...vattanac capital, level 18, no.66 monivong blvd,...

ទរងទមទរសណងរបសមន�រេពទយ ឬគ�នក

អគារករយាលយវឌឍនៈ ជានទ ១៨ អគារេលខ ៦៦ មហវថរពះមនវងស សង� តវត�ភ� ខណ� ដនេពញ រជធានភ�េពញ រពះរជាណាចរកកម�ជា | ទរសព��� ០២៣-៨៨៥-០៧៧ | safetynet@forteinsurance.com

021/FHPDBC/V1/2016

DIRECT BILLING CLAIM FORM

េឈ� ះេពញរបសអ�កជង

ពតមានអ�កជង / Patient Information

ពពមានេពទយ / Medical Information

ពតមានចននទករបាក នង េសចក�របកស / Financial Information and Declaration

េលខសមាជក

ៃថ�ែខឆា� កេណើ ត

ស�� តអញ / Chief complain:

T (សតណ� ភាព).................. C BP (សមា� ធឈម)............... mmHg O sat (ករមតអកសែសនក�ងឈម) ......... %

HR (ចង� កេបះដង).............. beats/mn RR (ចង� កដេង�ើម)............... /mn BS (ករមតជាតស�រក�ងឈម) ............ mg/dl

របវត�ៃនជងបច�បបន� / History of present illness:

កលបរេច�ទ / Date:

ហត�េលខេវជ�បណ� ត នងរតមន�រេពទយ ឬគ�នក

Signature of Doctor and Stamp of Hospital or Clinic

កលបរេច�ទ / Date:

ហត�េលខរបសអ�កជង ឬអ�កែថទអ�កជង

Signature of Patient or Patient’s Guardian

េរគវនច�យ / Diagnosis:

ករវះកត (របសនេបើមាន) / Surgical procedure, if any:

េលខទនាកទនង

េលខអត�ស�� ណបណ�

េភទ/ Full Name of Patient:

/ Membership Number:

/ Contact Number:

/ National ID Number:

/ Sex:

/ Date of Birth: DD / MM / YYYY

Vattanac Capital, Level 18, No.66 Monivong Blvd, Sangkat Wat Phnom, Khan Daun Penh, Phnom Penh City, Kingdom of Cambodia | 023-885-077

ចននទករបាកសរបែដលរត�វបានទមទរ៖ Total Amount Claimed:

ចននទករបាកែដលបានទទលពអ�កជង៖Amount Received from Patient:

US$ US$

េសចក�របកសរបសេវជ�បណ� តពយោបាល ឬេវជ�បណ� តវះកតDeclaration of Physician / Surgeon

េឈ� ះេពញ / Full Name:

េសចក�របកសរបសអ�កជង ឬអ�កែថទអ�កជងDeclaration of Patient / Patient’s Guardian

េឈ� ះេពញ / Full Name:

អយ / Age:

DD / MM / YYYY DD / MM / YYYY

o o

2

ស�� ជវត / Vital signs: