AStarting date of medication

YearMonthMonthDay

DayPatient
Name of patient
Address
Date of birthYear

To:I (patient who has received treatment) authorize
or its staff, and its
subcontractors to refer and obtain any and all factual information related to an overseas
medical treatment benefit claim(s) filed or to be filed including date of the treatment,
place, and any treatment records and information from the medical organization in orderto verify by submitting the related application forms.
Also, I agree to submit a photocopy of my passport if it is necessary along verification
process written above.

Signature

Insured person who has received treatment shall sign one s signature. However, in thefollowing case, guardian (insured person is under age), guardian of adult (insured person
is adult ward), heir (insured person is dead) shall sign one s signature.

Signature
Address
Date Year

Month(Relation to the insured) SelfDay
GuardianThis agreement of authorization expires

HeirOthermonth after the signed date.

Also, we might ask you to fill out the formatted documents if countries or regions, andmedical institutions required submitting their format of agreement of authorization orauthorization letter.

Request to Attending Physic ian
1 . Please fill in this form so that the patient may claim the health insurance benefit.
2 . This form should be completed and signed by the attending physician.
3 . One form for each month and one form for hospitalization/ outpatient (home visit) should befilled out.

Attending Physic ian's Statement
Form AA
1 . Name of Patient(Last, First)

Age(Date of birth)
()

Sex.

( MaleFemale ).

2 . Name of Illness or Injury preferably with the number of International Classification of Diseases
for the use of Health Insurance. (Please refer to the table attached to this form. )
( No.

)

3 . Date of first Diagnosis.

.

4 . Days of Diagnosis and Treatment
days
5 . Type of Treatment
From

Hospitalization//////

Outpatient or Home Visit

to////.
.

//((//days))//

6 . Nature and Condition of Illness or Injury(in brief)

7 . Prescription, Operation and any other Treatments(in brief)

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

Yes

No

9 . Itemized amounts paid to Hospital and / or Attending Physician : Fill in Form B
B
10 . Name and Address of Attending Physician
Name

Last()

Address

Home(First().

Title()

Phone()

Office(Date().

)
)

Phone
Signature()

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

A
2.

6.

7.

Request to Attending Physic ia n
1 . Please fill in this form so that the patient may claim the health insurance benefit.
2 . This form should be completed and signed by the attending physician.
3 . One form for each month and one form for hospitalization/ outpatient (home visit) should be
filled out.

Itemized Rec eipt
Form BB
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
X
Laboratory Tests*

$$
$
$$
$
$$
$
* Please fill in thecontent of theLaboratory Tests.
*$$$$
Medicines**** Please fill in the nameand the amount of theprescription of anindividual medicine.
**$$$
$
$
$
$
$

Surgical DressingAnesthetics
Operating room Charge
The Others(Specify)

()
$$
$$
$

Total

Unit isImportant : Exclude the amount irrelevant to the treatment. i. e, payment for a luxurious room charge.
:Name and Address of Attending Physician
NameLast( )Address

Home(First()

Title()

Phone(Office(Date()).

.

)
)

Phone
Signature()

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

Request to Attending Physic ia n
1 . Please fill in this form so that the patient may claim the health insurance benefit.
2 . This form should be completed and signed by the attending physician.

Form C

3 . One form for each month and one form for hospitalization/ outpatient (home visit) should befilled out.

Attending Dentist's Sta tement
1 . Name of Patient(Last, First)

Age(Date of birth)()

2 . Date of first Diagnosis.

Sex.

(MaleFemale).

3 . Days of Diagnosis and Treatment
days.

Primary tooth

Permanent tooth(Upper)(Lower)Type of Treatment

Dental Treatment

Localization of Teeth Examined

Date
MO. DA. YR.

Fee

Iinitial Office VisitX

Ray Examination

Dental Pulp Extirpation
Operation
Extraction
Filling
Inlay
Metal Crown
Post Crown
Jacket Crown
Bridge Work
Plate DenturePartial Denture
Complete Denture
Treatment of Pyorrhea Alveolaris
Medicine
The Others

Total
Name and Address of Attending Physician
Name

Last()

Address Home(First().

Title(Phone()

Office(Date()).

)
)

Phone
Signature()

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

C
Permanent tooth(Upper)(Lower)Primary tooth