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.

Attending Physic ia n's Sta tement
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
FromHospitalization

/////
/

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
NameLast()

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 Dressing
Anesthetics
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
Name

Last(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 be
filled 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
FillingInlay
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