Giy yu cu gii quyt quyn li bo him

I. Thng tin v ri ro H v tn ngi gp ri ro: Tn gi khc (nu c) Ng y thng nm sinh S CMTND/H chi u Cc a ch Ngi gp ri ro tng c tr 1. 2. 3. S Hp ng (lit k tt c hp ng lin quan) 1. 2. 3. T nm Ri ro: T vong Nm vin Ng y xy ra ri ro 4. 5. 6. Phu thut Thng tt Khc

Ni xy ra ri ro: Nguyn nhn xy ra ri ro: ........ Ngh nghip sau cng Ni l m vic sau cng Cc ngh nghip, ni l m vic khc (nu c ngh ghi r tn T chc/Cng ty, a ch, Ngi lin h, in thoi ):

1. Ngi gp ri ro c tham gia bo him y t (BHYT) hay khng? C Khng S th BHYT: Thi hn: T ng y Ni ng k khm cha bnh: 2. Ngi gp ri ro tng b triu chng no di y khng? Nn ra mu Ni hch au u/chng mt au bng, d d y

n ng y

au, co tht vng tim

Tiu ra mu i ngo i ra mu Chy mu cam Ho ra mu, ho m Khc. 3. Ngi gp ri ro c ang hoc tng s dng loi thuc no khng (k cc thuc ng y, thuc tim)? C Khng (Nu c xin cho bit chi tit: Loi thuc? Liu lng s dng? L do s dng? Bc s ch nh dng thuc?)

4. Ln u tin ngi gp ri ro pht hin bnh l khi no? Ng ythng.nm. Triu chng bnh: Chn on ca bc s: Tn, a ch ca Bc s /Bnh vin chn on: 5. Qu trnh khm, iu tr bnh sau khi pht hin nh th no? Ng y thng nm Tn Bc s/Bnh vin a ch Chn on ca Bc s/Bnh vin

6. Ngo i cc ln khm, iu tr bnh trn, trong 10 nm gn y, Ngi gp ri ro bao gi phi nm vin, phu thut hoc i khm, l m xt nghim (siu m, ni soi, chp CT, chp X quang, khm sc khe) khng? C Khng (Nu c xin cho bit chi tit) Ng y thng nm Bnh vin/c s y t L do khm hoc iu tr Chn on ca bc s/Bnh vin

7. Ch k khai mc ny nu ri ro xy ra do tai nn Thi gian xy ra tai nn: a im xy ra tai nn: M t chi tit tai nn: 1. 2. 3. Ngi s cu/cp cu 1. 2. Ni cp cu (nu c) Tn C quan th l h s tai nn (nu c): 8. Ch in mc ny trong trng hp ri ro l t vong Ngi t vong c c khm nghim t thi khng? C Ngi t vong c c gii phu php y khng? C a ch/in thoi a ch/in thoi Ngi pht hin/chng kin a ch/in thoi

Khng Khng

Mi thng tin chi tit xin vui lng lin h vi Cng ty Bo Vit Nhn thHi Dng - T: 0320.3890.507

9. Ch in mc ny nu Ngi gp ri ro c tham gia bo him ti cc Cng ty Bo Him khc Tn Cng ty Bo him Ng y tham gia S hp ng

S tin bo him

II. Phng thc thanh ton Tin mt Ti tr s Cng ty - Ch t i khon : - S t i khon : Chuyn khon - Ngn h ng : - Chi nhnh :

Ti vn phng i dinca Cng ty

III. Thng tin V ngi yu cu Gii quyt quyn li bo him (GQQLBH) H v tn Ng y sinh: Gii tnh Nam N S CMND a ch: in thoi Quan h vi ngi gp ri ro: Danh ngha ca Ngi yu cu GQQLBH l g? Ngi gp ri ro Ngi th hng duy nht c ch nh trong Hp ng Ngi tham gia bo him (bn mua bo him) trong Hp ng An Sinh Gio Dc Ngi c y quyn GQQLBH Khc. Quan h vi Ngi yu cu GQQLBH H v tn ngi t vn bo him (TVV) Quan h vi ngi gp ri ro. IV. Giy t km theo gm c:
Loi giy t S lng Loi giy t S lng Loi giy t S lng

Hp ng bo him gc Giy chng t Giy u quyn GQQLBH S h khu (bn sao) CMTND (bn sao) Giy y quyn sao bnh n Th BHYT (bn sao) Phim chp X-Quang Khc

H s bnh n (bn sao) Giy ra vin/Th ra vin Phiu m/Giy CN phu thut S khm bnh/S Y b Bin lai/Ha n thu tin/thanh ton vin ph Phiu siu m Phiu chp X-Quang Phiu in tim

Bin bn tai nn (bn sao) Bin bn gii quyt tai nn Vn bn ca c quan Cng an lin quan n tai nn Vn bn ca Ta n lin quan n tai nn Giy php li xe (bn sao) Phiu ni soi Phiu xt nghim mu Phiu xt nghim nc tiu

Lu : Trong trng hp Ngi gp ri ro tng khm bnh, nm vin, phu thut, ngh cung cp ton b giy t y t c lin quan. Vic cung cp y , trung thc cc giy t v thng tin theo yu cu ca Bo Vit Nhn th s gip cng tc GQQLBH c thun li v nhanh chng. Thi hn 30 ngy gii quyt h s ch c tnh k t ngy Bo Vit Nhn th nhn c y h s v cc thng tin theo yu cu. Vic cung cp thng tin sai s tht c th dn n hnh v vi phm php lut dn s, php lut kinh doanh bo him; trong trng hp ny, Bo Vit Nhn th c quyn khi kin yu cu nhng ngi cung cp thng tin sai s tht bi thng thit hi lin quan n cc hp ng bo him ni trn. Cam kt v U quyn: Ti (Ngi yu cu GQQLBH) xin cam oan nhng ni dung k khai trong Giy yu cu n y hay bt c cc thng tin n o khc m ti cung cp cho Bo Vit Nhn th trong qu trnh yu cu GQQLBH l y v ng s tht. Ti y quyn cho cc t chc, c nhn c thng tin v sc khe, bnh s hay qu trnh iu tr ca Ngi gp ri ro (theo Giy yu cu n y) c php cung cp cho Bo Vit Nhn th hoc ngi i din ca Bo Vit Nhn th bt k thng tin n o m Bo Vit Nhn th yu cu./. ...., ngy .. thng nm.. Phn d nh ring cho Cng ty Bo him Ngi yu cu gii quyt quyn li bo him Thng tin trn GYCGQQLBH c k Ngy tip nhn h s: (k, ghi r h tn) khai y ? Cn b tip nhn h s
(k, ghi r h tn)

Khng

Khch hng c c KTSK khi tham gia BH?

H v tn:

H v tn:

Khng

Mi thng tin chi tit xin vui lng lin h vi Cng ty Bo Vit Nhn thHi Dng - T: 0320.3890.507

Mi thng tin chi tit xin vui lng lin h vi Cng ty Bo Vit Nhn thHi Dng - T: 0320.3890.507