ទរងទមទរសណងរបសមន�រេពទយ ឬគ�នក
អគារករយាលយវឌឍនៈ ជានទ ១៨ អគារេលខ ៦៦ មហវថរពះមនវងស សង� តវត�ភ� ខណ� ដនេពញ រជធានភ�េពញ រពះរជាណាចរកកម�ជា | ទរសព��� ០២៣-៨៨៥-០៧៧ | [email protected]
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: