GIC Care

GIY NGH BI THNG

n bo him s :___GM1914/09CK01PH_______________________________
Tn Ngi c bo him :

o Mnh Qun

Ngy sinh : 15/6/1988

Nam

M s th bo him GIC Care : 86172/0

M nhn vin / s CMND : 633/012625778

L : chng /v /con ca :_________________________________________________________________________________
ang lm vic ti : T chc Tm Nhn Th Gii ti Vit Nam
Chc danh : Tr L Hnh Chnh

Ngy bt u bo him ca

NBH : 29/8/2011
in thoi : 0936780660
1.

Email : Dao_Manh_Quan@wvi.org

M t tai nn / M t bnh tt

M t tai nn

M t bnh tt

Tai nn c lin quan n cng vic hay khng ?

Thi gian v a im xy ra tai nn :
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Din bin ca tai nn :
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Mc thng tt
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Thi gian iu tr
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Chn on v triu chng bnh :

+ n soi vo ht trc trng. Trc trng c 2 polyp ~
0.5-0.6cm khng cung
+ Hu mn c tr ni II
Thi gian nm vin / phu thut (nu c)
+ Ct Polyp qua ni soi : Ngy 14 thng 2 nm 2012
a im
Bnh Vin Bch Mai Khoa Thm D Chc Nng

2. Qu khch bao gi b nhng thng tt / bnh tng t cha ?

Khng

Nu c, xin vui lng cho bit chi tit (khi no, nguyn nhn, mc , v.v)
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3.

Xin hy gi km bng gc cc chng t y t, toa thuc v ha n thuc tng ng

a)

Khm Bnh

VND 30.000

b)

Soi trc trng

VND 70.000

c)

Ct Polyp ng tiu ha

VND 800.000

d)

Xt nghim sinh khit

VND 110.000

e)

n thuc

VND 576.000

Tng cng ton b chi ph

VND 1.686.000

4.Xin hy gi bn photo bng li xe v Giy ng k xe gng my / xe hi v bin bn Cng An (nu c) trong trng
hp b tai nn giao thng.

5.Xin hy gi bn tng trnh tai nn c xc nhn ca lnh o ni mnh lm vic (trong trng hp tai nn lao ng)
6. Xin hy gi giy chng t (trong trng hp cht)

7.Xin hy gi giy xc nhn quyn tha k hp php (trong trng hp cht) nu ngi c bo him khng ch nh
ngi tha k trong giy yu cu bo him.

8.Xin cho bit qu khch mun nhn tin bi thng di hnh thc no : (tin mt / chuyn khon)
Trong trng hp nhn tin mt xin cho bit :
H tn ngi th hng :____________________________________________________________________________
a ch :______________________________________________________ in thoi lin lc :___________________
S CMND hoc Passport :___________________________ngy cp:________________________________________
Ni cp:_________________________________________ngy ht hn (nu c):______________________________
Nhn tin mt ti Gras Savoye Willis Vietnam __________________________________________________________
Trong trng hp chuyn khon xin cho bit :
H tn ngi th hng : o Mnh Qun
a ch : Gii Phng, ng a , H Ni
S TK : 020704070005685

Ngn Hng : HD Bank Hon Kim

a ch Ngn Hng : 32 Trn Hng o, Hon Kim, H Ni

Ti tn l, o Mnh Qun cho php bt c bc s iu tr ti bnh vin hoc trung tm y t, phng khm a khoa nhng
ni m ti iu tr cung cp ton b chi tit v sc khe ca ti cho GIC v Gras Savoye Vietnam, l i din c y
quyn ca GIC . Bn photo ca vn bn ny cng s c hiu lc nh bn chnh.
Ti cng cam oan rng nhng li khai trn y ca ti l hon ton ng s tht v y nh nhng g ti c bit.

Xc nhn ca Cng ty

Ngi khai k tn

(K tn ng du)

H tn :__________________________________
Ngy : ________________________

Ngy :___________________________________