01-02-2017-Direct Billing Form - SafetyNet...Vattanac Capital, Level 18, No.66 Monivong Blvd,...
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ទំរង់មរសំណងរបស់មន� ី រេពទ ឬគ� ី ន ី ក អររ ិ ល័យវឌនៈ ន់ទ ី ១៨ អរេលខ ៦៦ មវិថីពះមុន ី វង ស� ត់វត�ភ�ំ ខណ � ដូនេពញ ជន ី ភ�ំេពញ ពះចកកម� ុ | ទូរស័ព� ០២៣-៨៨៥-០៧៧ | [email protected] 021/FHPDBC/V1/2016 DIRECT BILLING CLAIM FORM េ�ះេពញរបស់អ�កជំងឺ ព័ត៌នអ�កជំងឺ / Patient Information ព័ព៌នេពទ / Medical Information ព័ត៌នចំនួនទ ឹ កក់ ន ិ ង េសចក� ី បស / Financial Information and Declaration េលខសជិក ៃថ�ែខ � ំកំេណ ើ ត ស� � តំអូញ / Chief complain: T (ស ី តុណ�ព).................. C BP (ស� ធម)............... mmHg O sat (កម ិ តអុកស ី ុ ែសនក� ុ ងម) ......... % HR (ច� ក់េបះដូង).............. beats/mn RR (ច� ក់ដេង� ើម)............... /mn BS (កម ិ តត ិ ស�រក� ុ ងម) ............ mg/dl បវត� ិ ៃនជំងឺបច� ុ បន� / History of present illness: លបរ ិ េច�ទ / Date: ហត�េលេវជ�បណ � ិ ត ន ិ ងមន� ី រេពទ ឬគ� ី ន ី ក Signature of Doctor and Stamp of Hospital or Clinic លបរ ិ េច�ទ / Date: ហត�េលរបស់អ�កជំងឺ ឬអ�កែថំអ�កជំងឺ Signature of Patient or Patient’s Guardian េគវ ិន ិ ច័ �យ / Diagnosis: រវះត់ (បស ិ នេប ើ ន) / Surgical procedure, if any: េលខទំក់ទំនង េលខអត�ស� � ណប័ណ � េភទ / Full Name of Patient: / Membership Number: / Contact Number: / National ID Number: / Sex: / Date of Birth: DD / MM / YYYY Vattanac Capital, Level 18, No.66 Monivong Blvd, Sangkat Wat Phnom, Khan Daun Penh, Phnom Penh City, Kingdom of Cambodia | 023-885-077 ចំនួនទ ឹ កក់សរុបែដលត�វនមរ៖ Total Amount Claimed: ចំនួនទ ឹ កក់ែដលនទទួលព ី អ�កជំងឺ៖ Amount Received from Patient: US$ US$ េសចក� ី បសរបស់េវជ�បណ � ិ តពល ឬេវជ�បណ � ិ តវះត់ Declaration of Physician / Surgeon េ�ះេពញ / Full Name: េសចក� ី បសរបស់អ�កជំងឺ ឬអ�កែថំអ�កជំងឺ Declaration of Patient / Patient’s Guardian េ�ះេពញ / Full Name: យុ / Age: DD / MM / YYYY DD / MM / YYYY o o 2 ស� � ជីវិត / Vital signs:
Transcript of 01-02-2017-Direct Billing Form - SafetyNet...Vattanac Capital, Level 18, No.66 Monivong Blvd,...
ទរងទមទរសណងរបសមន�រេពទយ ឬគ�នក
អគារករយាលយវឌឍនៈ ជានទ ១៨ អគារេលខ ៦៦ មហវថរពះមនវងស សង� តវត�ភ� ខណ� ដនេពញ រជធានភ�េពញ រពះរជាណាចរកកម�ជា | ទរសព��� ០២៣-៨៨៥-០៧៧ | [email protected]
021/FHPDBC/V1/2016
DIRECT BILLING CLAIM FORM
េឈ� ះេពញរបសអ�កជង
ពតមានអ�កជង / Patient Information
ពពមានេពទយ / Medical Information
ពតមានចននទករបាក នង េសចក�របកស / Financial Information and Declaration
េលខសមាជក
ៃថ�ែខឆា� កេណើ ត
ស�� តអញ / Chief complain:
T (សតណ� ភាព).................. C BP (សមា� ធឈម)............... mmHg O sat (ករមតអកសែសនក�ងឈម) ......... %
HR (ចង� កេបះដង).............. beats/mn RR (ចង� កដេង�ើម)............... /mn BS (ករមតជាតស�រក�ងឈម) ............ mg/dl
របវត�ៃនជងបច�បបន� / History of present illness:
កលបរេច�ទ / Date:
ហត�េលខេវជ�បណ� ត នងរតមន�រេពទយ ឬគ�នក
Signature of Doctor and Stamp of Hospital or Clinic
កលបរេច�ទ / Date:
ហត�េលខរបសអ�កជង ឬអ�កែថទអ�កជង
Signature of Patient or Patient’s Guardian
េរគវនច�យ / Diagnosis:
ករវះកត (របសនេបើមាន) / Surgical procedure, if any:
េលខទនាកទនង
េលខអត�ស�� ណបណ�
េភទ/ Full Name of Patient:
/ Membership Number:
/ Contact Number:
/ National ID Number:
/ Sex:
/ Date of Birth: DD / MM / YYYY
Vattanac Capital, Level 18, No.66 Monivong Blvd, Sangkat Wat Phnom, Khan Daun Penh, Phnom Penh City, Kingdom of Cambodia | 023-885-077
ចននទករបាកសរបែដលរត�វបានទមទរ៖ Total Amount Claimed:
ចននទករបាកែដលបានទទលពអ�កជង៖Amount Received from Patient:
US$ US$
េសចក�របកសរបសេវជ�បណ� តពយោបាល ឬេវជ�បណ� តវះកតDeclaration of Physician / Surgeon
េឈ� ះេពញ / Full Name:
េសចក�របកសរបសអ�កជង ឬអ�កែថទអ�កជងDeclaration of Patient / Patient’s Guardian
េឈ� ះេពញ / Full Name:
អយ / Age:
DD / MM / YYYY DD / MM / YYYY
o o
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ស�� ជវត / Vital signs:
