(Form AA

This form is used for claiming the social insurance benefit.
This form should be completed and signed by the attending physician
One form for each month, one form for hospitalization /outpatient andhome visit

Attending Physician’s Statement
Name of patient(Last,First)

Age(Date of Birth)

Sex(Male Female)

Name of Illness or Injury preferably with Number of International Classification of Diseases forthe use of Social Insurance (See the other side of this form)

Date of First Diagnosis :, 20Days of Diagnosis and Treatment :days

Type of Treatment

Hospitalization :From,20to20((Out patient or Home Visit :,20,20,20,20days))

Nature and Condition of Illness or Injury ( in brief)

Prescription, operation and any other treatments (in brief)

Was the treatment required as a result of an accidental injury ?

Yes

No

Itemized amounts paid to Hospital and / or Attending physician : Form B
B
Name and Address of Attending Physician

Name:

Address: HomePhone

Office

Phone

Date

LastFirst

Signature
Attending Physician
Reference Number of your Medical Record (if applicable)

Form B
B

Itemized Receipt(1)(2)(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
(13)
(14)
(15)

Fee for Initial Office Visit
Fee for Follow-up Office Visit
Fee for Home Visit
Fee for Hospital Visit
Hospitalization
Consultation
Operation
Professional Nursing
X-Ray Examinations
Laboratory Tests
Medicines
Surgical Dressing
Anesthetics
Operating Room Charge
The Others (Specify)(16)

Total()

$$
$
$
$
$
$
$
$
$
$
$
$
$
$
$

$
$

$

Important : Exclude the amount irrelevant to the treatment, i. e, payment for luxurious room charge.
:Name and Address of Attending physicianNameAddress

Date:

Last:

Superintendent of Hospital or ClinicFirstTitle

Home

PhoneOffice

Phone

SignatureTable of International Classification of Diseases for the use of social Insurance
0502
Certain infectious and parasitic diseases
0101
0102

Intestinal infectious diseases

Mental and behavioural disorders due to psychoactive substance use
0503

Tuberculosis

Schizophrenia, schizotypal and delusional disorders

0103

0504
Infections with a Predominantly sexual mode of transmission

0505

Viral infections characterized by skin and mucous membrane lesions

0506

0104

0105

Neurotic, stress-related and somatoform disorders

Viral hepatitis

0106
0107

Mood[affective] disorders

Mental retardation

0507

other viral diseases

Other psychoses and disorders of action

Mycoses

0108

Diseases of the nervous system
Sequelae of infectious and parasitic diseases

0109

0601

Parkinson’s disease

0602
0603
Neoplasms

Alzheimer’s disease
Epilepsy

0604

0201

Malignant neoplasm of stomach

0202

Malignant neoplasm of colon

0203

Cerebral palsy and other paralytic syndromes
0605

Disorders of autonomic nervous system

0606

Others Diseases of the nervous system

Malignant neoplasm of rectosigmoid junction and rectum
0204

Diseases of the eye and adnexa
Malignant neoplasm of liver and intrahepatic bile ducts

0205

0701

Conjunctivitis

0702

Cataract

Malignant neoplasm of trachea,bronchus and lung

0703

0206

Malignant neoplasm of breast

0704

0207

Malignant neoplasm of uterus

0208
0209

Disorders of refraction and accommodation
Other diseases of the eye and adnexa

malignant Lymphoma
Leukaemia

0210

Diseases of the ear and mastoid process
Other Malignant neoplasms

0211

0801
0802

Other benign neoplasms and other neoplasms

0803

Otitis externa
Other disorders of external ear
Otitis media

0804
Other diseases of middle ear and mastoid
Diseases of the blood and blood-forming organs and certain

0805

disorders involving the immune mechanism

0806

0301

Anaemias

0807

Disorders of vestibular function
Other diseases of inner ear
Other diseases of ear

0302
Other diseases of blood and blood-forming organs and certain
disorders of the immune mechanism

Diseases of the circulatory system
0901

Hypertensive diseases

0902

Ischaemic heart diseases

0903
Endocrine, nutritional and metabolic diseases
0401
0402

Disorders of thyroid gland
Diabetes mellitus

0403
Other diseases of endocrine, nutrition and metabolism

0904
0905

Mental and behavioural disorders

Occulusion of percerebral and cerebral arteries

0907

Cerebral arteriosclerosis

0908

Other cerebrobascular diseases
Atherosclerosis

0910

Haemorrhoids

0911

Hypotension

0912
Vascular dementia and Unspecified dementia

Intracerebral hemorrhage

0906

0909

0501

Other froms of heart disease
Subarachnoid hemorrhage

Other disorders of circulatory system

Diseases of the respiratory system

1402

1001

Acute nasopharyngitis [ common cold]

1403

1002

Acute pharyngitis and tonsillitis

1404

1003
1004

Other acute upper respiratory infecitions
Pneumonia

Urolithiasis
Other diseases of urinary system

1405

Hyperplasia of prostate

1406

1005

Acute bronchitis and bronchiolitis

1006

Renal failure

Other diseases of male genital organs

1407

Vasomotor and allergic rhinitis

1007

Chronic sinusitis

Menopausal and postmenopausal disorders
1408

1008

Other disorders of breast and female genital organs
Bronchitis, not specified as acute or chronic

1009
1010

Chronic obstructive pulmonary disease
AsthmaPregnancy, childbirth and the puerperium

1011

Other diseases of respiratory system

1501

Pregnancy with abortive outcome

1502
Diseases of the digestive system
1101

Oedema, proteinuria and hypertensive disoders in pregnancy,Dental caries

1102

Childbirth and the puerperium
Gingivitis and periodontal diseases

1103

1503*
1504

Other disorders of teeth and supporting structures
1104

Others Pregnancy, childbirth and the puerperium

Gastric and duodenal ulcer

1105

Gastritis and duodenitis

1106

Alcoholic liver disease

1107

Certain conditions originating in the perinatal period
1601

Chronic hepatitis, not elsewhere classified
1108

Disorders related to length of gestation and fetal growth1602

Liver cirrhosis not elsewhere classified
1109

Others Certain conditions originating in the perinatal period

Other disorders of liver

1110
1111

Single spontaneous delivery

Cholelithiasis and cholecystitis
Diseases of pancreas

1112

Congenital malformations, deformations and chromosomal

Other diseases of digestive systemabnormalities
1701

Congenital anomalies of heart

1702
Diseases of the skin and subcutaneous tissue

Others Congenital malformations, deformations and chromosomal

1201

abnormalities
Infections of the skin and subcutaneous tissue1202

Dermatitis and eczema

1203

Symptoms, signs and abnormal clinical and laboratory findings, notOthers Diseases of the skin and subcutaneous tissue

Elsewhere classified
1800
Symptoms, signs and abnormal clinical and laboratory findings, notDiseases of the musculoskeletal system and connective tissue
1301
1302

Elsewhere classified

Inflammatory polyarthropathies
Arthrosis

1303

Spondylopathies

Injury, poisoning and certain other consequences of external causes

1304

Intervertebral disc disorders

1901

1305

Cervicobrachial

1902

1306
1307
1308
1309

Low back pain and sciatica
Other dorsopathies
Shoulder lesions

Intracranial damage and internal organ damage1903

Burns and corrosions

1904

Disorders of bone density and structure

1310

Poisoning

1905
Others Injury, poisoning and certain other consequences of external

Other diseases of skeletal muscles and connective tissues
Diseases of the genitourinary system
1401

Fracture

Glomerular diseases

causes1503
Important : No.1503 with asterisk is not covered by the social insurance.