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Important information:

Please complete the claim form in BLOCK CAPITALS and submit it to Us within six months of the initial Treatment date (unless this is not reasonably possible).

For all Out-Patient Treatment and if the total amount You are claiming (per Insured Person, per Medical Condition, per Period of Cover) for In-Patient or

Day-Patient Treatment is less than USD 500 You only need to complete Sections 1 and 2 and include a copy of Your receipt when You send Us Your claim

form. You can scan Your claim form and receipt and email it to [email protected] or fax it to +852 2279 7330. Please keep a copy of the

original documents in case they should be required by Us.

If the total amount You are claiming now or have claimed for Day-Patient and In-Patient (per Insured Person, per Medical Condition, per Period of Cover)

is over USD 500, please ensure Section 3 is completed by the treating Medical Practitioner. We must also see receipts, diagnostic reports and discharge

Section 2: Payment details

Please pay: Planholder Provider

Please choose payment type: Bank transfer

Bank transfer – please complete all details to enable bank transfer payments.*

Account/payee name:

Payment currency:

Bank name: Bank code: Branch code:

Branch address:

IBAN or account no.

Routing code:

Email address: Telephone number:

Reason for doctor visit/diagnosis:

– specify symptoms or medical problem e.g. abdominal pain/rash on foot/eye infection

Country where Treatment took place: Treatment date (dd/mm/yyyy): / /

Currency claim incurred in: Currency you would like your claim reimbursed in:

Total claimed amount:

Type of service: Out-Patient

Day-Patient In-Patient Dental Maternity Optical Routine check-up

Attending physician: Dentist Medical Practitioner Specialist Other Please specify:

Is this claim due to Accident/injury? Yes No

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We have no control.

I have read the declaration in Section 4 on the next page

I agree to the declaration, give my authorisation and understand that any claim for Benefit is in accordance with the terms and conditions of Our Plan.

I will enclose Section 4 if authorisation has been limited by me where available.

Patient’s signature (Insured/main applicant): Date (dd/mm/yyyy):

/ /

Section 3: Medical information, Day-Patient and In-Patient claims over USD 500

(to be completed by the doctor responsible for the patient’s Treatment)

Medical Condition:

Diagnosis ICD10 code (if applicable):

Name:

Address:

Admission date (dd/mm/yyyy): / / Discharge date (dd/mm/yyyy): / /

Medical Practitioner Declaration:

I declare that I am the patient’s Medical Practitioner, and that the particulars given are, to the best of my knowledge, true and correct.

Print name:

Official stamp:

Signature:

Date (dd/mm/yyyy): / /

If Your Plan includes a cash Benefit: If the patient stayed in Hospital overnight without charge please include confirmation from the Hospital including the

Page 3 of 3WC AP 28023 05/2020

Insurance Agent Registration Number: 10974559.

Section 4: Declaration and authorisation

Data Privacy

We and Your Underwriters will collect certain information about You in the course of considering Your claim. This information will be processed for the

purposes of administering claims. Your information may be passed to Underwriters, Medical Practitioners, Medical Assistance Companies and Claims

Administrators for these purposes, including those located outside the HKSAR. The same duty of confidentiality is required of any third parties to whom the

administration of Your Plan may be subcontracted, including those located outside the HKSAR. Your name and contact details will not be disclosed to other

organisations (except as stated above).

It may be necessary to obtain a medical report from Your usual Doctor/Medical Practitioner for this claim. If We need to do this, Yo u have specific rights

and they are set out below. If You wish:

3. Having seen the report, Yo u can refuse Your consent – again this may affect Our ability to deal with Your claim.

4. You may ask the Doctor to change the report if You disagree with it. If (s)he refuses, You can require him/her to attach a statement of Your views to

the report.

5. You may also ask the Doctor to let You see all reports supplied to Us within the last six months.

Important note: Y

Your Doctor may refuse to let Yo

intentions in respect of You , or it may reveal the identity of another person who has supplied information about You who is not a health professional but is

involved in Your care.

You may opt out of future marketing by contacting Us at any time. A list of Now Health group companies, their contact details and Our Data Privacy Policy

is available at www.now-health.com.

Declaration

I hereby declare that I am the patient/patient’s guardian* (if the patient is under 16 years of age) (*please cross out if not applicable).

I wish to claim Benefit and declare the information I have given is, to the best of my knowledge, true, correct and complete even if it is not in my own handwriting.

I understand it is unlawful for me to knowingly provide false, incomplete or misleading facts or information (misrepresentations) to Now Health

International for the purpose of defrauding or attempting to defraud Now Health International or the Underwriters. Penalties may include imprisonment,

fines, denial of coverage, loss of or increase in premium, loss of Benefits and legal damages.

I agree to the data protection declaration above and understand that cover is provided in accordance with the terms and conditions of the Now Health

When completed and signed by the patient and Medical Practitioner (when appropriate), please return this form and the accompanying invoices and

payment receipts to: Now Health International (Asia Pacific) Limited, Units 1501-3, 15/F, AIA Tower, 183 Electric Road, North Point, Hong Kong.