MSH China 非直付理赔申请书–A部分 就诊人信息（英文版）（2页）.pdf
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For a claim to be valid, the following two pages
(Part A and B) must be completed and submitted
to MSH CHINA ENTERPRISE SERVICES CO., LTD.
(hereinafter "Service Center") which is the
appointed Service Provider appointed by your
insurance company within 180 days after the date of service.
Patient Information
Member ID* :
DOB* : MM/ DD/ YY
Name* :
Gender:
□ Male □ Female
Tel. :
ID/Passport No:
Address :
Email :
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