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I. 保单持有人／受保人（病人）资料 

Details of Policy Holder/Insured Person(Patient)

由保单持有人或受保人（病人）填写 

To be completed 

by the Policy Holder or the Insured Person(Patient)

保单持有人姓名 

保单号码 

受保人号码（如适用）

Name of Policy Holder Policy No. Insured Person No.

 (ifapplicable)

受保人（病人）姓名 

聯络电话 

香港身份证号码

Name of Insured Person

(Patient)

Contact Telephone No. H.K.I.D. No.

II. 治疗详情及评估 

Treatment Details and Assessment

治疗详情由医生填写

Treatment Details to be completed by Doctor

诊断 Diagnosis

入院日期 Date of Admission

医院名称 Name of Hospital

病房级别 Level of Accommodation

预计入住的病房级别 

Intended Level ofAccommodation

私家房 Private

半私家房 Semi-private

普通房 Ward 

日间／诊所手术 Day Case/Clinical