預先批核表格 Pre-approval Claim Form

醫療費用預先批核服務簡易指南

Simple guide for Medical Expense Pre-approval Service

1 請填妥預先批核表格，並於入院或接受醫療程序前最少 5 個工作天由你於 Bowtie 網上平台上載，或由醫院直

接遞交你的預先批核表格。
Fill out and upload the Pre-approval Form to us prior to admission or medical procedure at the Bowtie
online portal or submitted by hospital directly to process the application, and reserve at least 5
working days for us to process the application.

2 預先批核一經完成，我們會以電郵及手機短訊(如適用) 通知你有關結果，並可於 Bowtie 網上平台查詢有關結

果詳請。
Once the pre-approval application is reviewed, you will be informed of the result via email & SMS (If
applicable), and you can check the details of the application at Bowtie online portal.

3 「免找數服務」一經安排，我們/第三方服務供應商會向有關醫院發出「付款保證書」。當你於醫院登 記時，
你可以通知醫院 Bowtie 已為病人發出「付款保證書」 ，並 提供 ( 1 ) 受 保人身份證明文件 ( 2 )入院 /治 療 日期

( 3 ) 付款保證書編號 以作核 實 。
Once “Cashless Settlement ” has been successfully set-up, we/our T hird Party Administrator will send a
“Letter of Guarantee” (LOG) to the concerned hospital. Upon registration at hospital, please notify the
hospital that the LO G has been arranged by Bowtie, also present ( 1 ) insured 's identi fi cation
document ( 2 ) date of admission/treatment ( 3 ) reference number of the LO G for veri fi cation purpose.

4 完成 治療後，醫院會直接向我們遞交醫療單據，我們會替你直接繳付有關已獲批核的醫療開支。如有關 醫療開
支高於合資格保障應支付的賠償額，你需要在出院時於醫院繳交差額費用 。如需索償差額費用 ，你可保留收
據並於 Bowtie 網上平台進行申請。倘若理賠程序時發現住院/治療中有醫療開支屬保單的不受保範圍，我們有
權向你收取有關費用。
The hospital will send us the bills and we will settle the approved medical expense on behalf of you. If
the medical ex pense exceeds the payable amount under eligible benefi t upon claim assessment, you
will have to pay the shortfall amount when you are discharged from the hospital. You can also submit
the receipt with the shortfall amount to Bowtie for additional claim procedure. In case of any
x
uncovered medical e penses in the policy during claims assessment, we reserve the right to claw back
the amount from you.

5 需要協助? 請聯絡
For en q uiry, please contact

賠償部熱線 Claims H otline : 3 001 5 670

賠償部電郵 Claims D epar t men t Email : claim @b owtie.com .hk

客戶服務熱線 Customer Service H otline : 3 008 8123
客戶服務電郵 Customer Service Email : cs @b owtie.com .hk
PA001 / 202207 Page 1
預先批核表格 Pre-approval Claim Form

條款及細則 Terms and Condition

1. 醫療費用預先批核服務或「免找數服務」為一項就受保人於治療 / 住院期間所衍生的受保開支而設的行政安排，
而並非保單保障內容， 我們有權隨時撤銷此項服務而毋須另行通知，並保留絕對決定權。
The “Cashless Settlement” service is not a contractual service but an administrative arrangement offered
in our absolute discretion in respect of covered expenses incurred by the Insured during the treatment/
hospitalization. It is subject to termination by Bowtie at any time without prior notice.

2. 如因保單下的不受保事項而引發之治療或住院，均不會獲發「付款保證書」。

If the treatment or hospitalization is due to illness or disability classified under any exclusion or
whatsoever of the concerned policies, no Letter of Guarantee will be issued.

3. 預先批核 結果通知的實際發出日期須視乎受保人及 / 或醫院遞交齊備文件所需日數而有所不同。

The actual date of notification on the pre - approval result may differ, subject to the re q uired days for the
submission of all re q uired documents by the Insured and/or hospital.

4. 預先批核並不 代表 Bowtie 同意就受保障計劃支付任何保障，所有賠償決定受醫療賬單、保單條款及細則及保單下

的不保事項 約束 。如 最終 醫療 帳 單 包含 不 在 受保障 範圍 內的費用，或醫療 帳 單 超出 有 關 保障 限額 的費用時，受保
人 需要在出 院時支付 相關 費用，我們 亦 有權 向你收取 有 關 費用。
Obtaining a pre-approval shall not be deemed as an agreement to pay for any payment on behalf of
the Insured, all claims settlement will be subjected to the final bill, the policy terms & conditions and the
exclusions set out in the policy terms & conditions. If the final bill includes excluded items under the
Insured ’s policies or the final bill exceeds the Insured ’s eligible benefit limit under his/her policy ( ies ) , the
Insured shall pay for such expenses/shortfall upon discharge from hospital, we also reserve the right to
k
claw bac the amount from you.

5. 免找數服務或 由第三方服務供應商提供，Bowtie 對於上述服務之質素及其供應並不作出任何的陳述、保證或承

諾，亦不會承擔服務供應商所提供 的服務所引致的責任及法律責任。
The Cashless Settlement service may be provided by third - party service providers. Bowtie ma kes no
representation, warranty or underta k ing as to the q uality and availability of the services and shall not
accept any responsibility or liability for the services provided by the service providers.

PA001 / 202207 Page 2

預先批核表格 Pre-approval Claim Form
此申請表格適用於個人及團體醫療保險計劃 

This form is applicable to both individual and group medical insurance

日期
Date DD /MM /YY

Part 1. 授權 (*由保單持有人 / 受保人簽署) Authorization (*To be signed by Policyholder / Insured)

本人謹此代表本人/受保人授權任何僱主、註冊西醫、醫院、診所、保險公司、銀行、政府機構、或其他機構、組織或人士、凡知道或持有任何有關本
人/受保人之記錄者， 詳情或醫療資料，及/或曾診驗或可能將會診驗本人/受保人者，均可將該等資料提供給保泰人壽保險有限公司。此授權對本人之
繼承人及受讓人具有約束力；即使死亡或無行為能力時，此授權仍具效力。本授權書的影印本與正本均有同等效力。
I HEREBY AUTHORIZE on behalf of myself/the insured any employer, registered practitioner, hospital, clinic, insurance company, bank,
government institution, or other organization, institution or person, that has any records , knowledge or medical information of me/the
insured and who has attended or may hereafter attend myself/the insured to disclose such information to Bowtie Life Insurance
Company Limited. This authorization shall bind my successors and assignees and remains valid notwithstanding death or incapacity.
A photocopy of this authorization shall be as valid as the original.
*提示 Note:

1. 如屬團體醫療保單 - 須由受保僱員/會員填寫及簽署。For group medical policy - To be completed and signed by the Employee/ Member.

2. 若受保人未滿18歲 - 須由保單持有人填寫及簽署。If the Insured is under age 18 - To be completed and signed by the Policyholder.

保單持有人姓名 身份證號碼 簽署 簽署日期

Name of Policyholder : ID Number : Signature : Sign Date :

受保人姓名 身份證號碼 簽署 簽署日期

Name of Insured : ID Number : Signature : Sign Date :

Part 2. 病人資料 Patient Information

保單號碼 病人姓名

Policy Number Name of Patient

身份證號碼 聯絡電話

Identity card / HKID card Contact Number

Part 3. 病歷 (由主診醫生 / 手術醫生填寫) Clinical History (To be completed by the attending physician / surgeon)

是，自
1. 閣下是否病人的慣常醫生?
DD /MM /YY
Yes, Since
Are you the patient’s usual doctor?

No

2. 病人因此疾病或意外首次求診的日期

Date of first consultation for this condition or related illness /

DD /MM /YY
accident

PA001 / 202207 Page 3

 3. 此次住院 / 手術的主要病徵
Chief complaints / symptoms of the patient relating to this
hospitalization / surgery

4. 病徵的出現日期 / 意外發生日期 DD /MM /YY

Date of symptoms first appeared / accident occurred

5.(a) 最後診斷
Final Diagnosis

5.(b) 診斷日期 DD /MM /YY

Date of Diagnosis

6. 引起診斷結果的主因
Underlying cause for the diagnosis

7. 如病人由其他醫生轉介，請提供轉介醫生的姓名和地址
If the patient was referred by another doctor, please provide
the referring doctor’s name and address.

8. 病人曾否因同類或相關疾病接受治療或住院? 是，請說明詳情
Had the patient previously been treated or hospitalized for Yes, Please provide details
the same / related disorder?) 就診日期
Consultation Date
DD /MM /YY
疾病
Disease / Disorder

醫生 / 醫院名稱
Name of Physician /

Hospital

治療 / 住院詳情
Details of treatment / 

hospitalization

否
N o

/
PA001 202207 Page 4
 9. 病人是否因其他原因，直接或間接引致或加劇有關之受傷/病症?
Was the patient’s injury / illness directly or indirectly due to aggravated by other factors?

是 - 請在下列適當位置劃上剔號並提供詳情 (如適用)
Yes - Please tick where it is appropriate and give details (If applicable)

倚賴或過量服用藥物 / 酒精 / 毒品 節育 / 恢復生育 / 結紮 / 變性 / 不育 / 性機能失常

Dependence or overdose of drugs, alcohol or narcotics Birth control / Reversal of birth control / Sterillsation / Sex
reassignment / Infertility / Sexual dysfunction

懷孕 / 分娩 / 墮胎 / 流產 自殺 / 自殘身體
Pregnancy / Childbirth / Abortion / Miscarriage Attempted suicide / Self-inflicted

美容 / 整容 先天性疾病
Beautification / Cosmetic Purpose Congenital condition
疾病
矯正視力 / 屈光不正 Disease / Disorder
Correcting visual acuity / refractive errors
發病日期
DD /MM /YY
性病 / 經由性接觸傳染的疾病
Date of manifestation
Venereal disease / Sexually Transmitted Disease 確診日期
DD /MM /YY
Date of diagnosis

人體免疫力缺乏病毒 其他
Human Immunodeficiency Virus Others
詳情
Details

否
No

10. 病人過往有否下列的病歷 / 習慣 ?
Did the patient have the following past medical history / habit ?

是 - 請在下列適當位置劃上剔號並提供詳情 (如適用)
Yes - Please tick where it is appropriate and give details (If applicable)

心臟病 糖尿病 曾接受手術 吸煙習慣

Cardiac problem Diabetes Mellitus Previous operation Smoking habit

高血壓 乙型肝炎 濫用藥物 飲酒習慣

Hypertension Hepatitis B Drug addiction Drinking habit

其他嚴重、慢性或先天性疾病
Other major, chronic or congenital illness
詳情
Details
診斷日期
DD /MM /YY
Diagnosis date

醫生名稱
Name of Physician
病歷之現況 完全康復 治療中
Current condition of the
 Fully Recoverd
above medical history On Treatment

吸煙 / 飲酒習慣開始於 DD /MM /YY

Smoking / drinking habit since
否
No

PA001 / 202207 Page 5

 Part 4. 治療計劃 Treatment Plan

預計入院 / 治療日期 預計住院時間

DD /MM /YY 日 Days
Expected Date of Admission Estimated length of stay

醫院名稱

Name of Hospital

建議之醫療 / 手術程序 建議之檢驗名稱

Medical / Surgical Procedure Required Investigation Required

私家房 半私家房 標準房 日間病房 其他

住房類別

Private Semi-Private Ward Day Care Others:

Ward Type
請提供原因 Please specify reason

預計費用

Estimated Fee

住宿費用
$ 日 Days
Room Charges

每日醫生巡房費
$ 日 Days
’
Daily Doctor s Round Fee

(如多於一位醫生，請列出明細及原因。If more than one doctor, please provide the breakdown

an d justification. )

手術費
$
Surgical Fee

(如多於一位醫生，請列出明細及原因。If more than one doctor, please provide the breakdown

an d justification. )

麻醉師費
’
Anaesthetist s Fee $

手術 室費
Operating Theatre Charges $

手術 儀器及物料等費用
Operating Equipment and Material Fee $

其他醫院費用
Other Hospital Charges $

預計 總費用
Total Estimated Fee $

A001 / 202207
P Pa ge 6
 Part 5. 醫生資料 Physician Details

本人謹此聲明曾為病人作出治療，以上之所陳述乃本人對病人健康狀況之意見。

I hereby certified that I did personally treat the patient and the facts as given above represent my opinion of his / her condition.

主診醫生姓名 資歷

Name of Attending Physician Qualification

地址 聯絡電話

Address Telephone No.

主診醫生簽署及蓋印 日期

Signature and stamp of Attending Physician Date DD /MM /YY

PA001 / 202207 Page 7

本人 / 受保人聲明及同意下列各點 : (甲) 本賠償申請表格上所載的聲明及答案，以及經本人 / 受保人所簽署之醫療問卷或所遞之其他文件，均屬真確無
訛，詳細完整。 (乙) 倘本人 / 受保人未能提供此申請所需資料，可導致保泰人壽保險有限公司 (保泰) 未能處理此賠償申請。

I / The insured hereby declare and agree that: (a) all the foregoing statements and answers in this claim form together with those in any
required medical questionnaire or other document signed or submitted by me/the insured in connection with this claim are full, complete and
true. (b) Bowtie Life Insurance Company Limited (Bowtie) may be unable to process this claim if I/the insured fail to provide any information
related to this claim.

個人資料收集聲明

收集目的 

保泰人壽保險有限公司 (「保泰」) 可以將從你所收集的個人資料作以下目的，而保泰亦需要你的個人資料以達致該目的： 

1. 處理及評估申請/資料遞交； 

2. 確認和核實身份； 

3. 管理你所持有的保泰產品， 並提供相關服務； 

4. 處理及調查你所持有的保泰產品的索償個案； 

5. 進行客户調查； 

6. 為客戶研究，設計及/或優化的保泰產品與服務； 

7. 為你甄選及參與獎賞、忠實或特選客戶計劃，並提供予你有關的服務； 

8. 因上述目的與你聯絡； 

9. 為遵守所有保泰及其關連公司所受限制的 (香港或其他國家) 法例、 法規、 法規指引、法庭命令或保泰及其關連公司與任何管轄區域的監管機構或政府
之間的協議項目下的義務或其他承諾 (其相關於洗黑錢、恐怖分子資金籌集、逃税或其他)； 

10. 驗證數據，不論是否為了對你或任何其他第三方行使我們的權利；及 

11. 與上述任何目的直接有關的其他目的。 

你可自願提供予保泰有關你的個人資料。倘若你未能提供所需個人資料，保泰或不能處理你的申請/資料遞交，或繼續提供予你你所須的產品或服務。
「你的個人資料」包括由你提供有關你本人、你的受養人、受益人、代表及其他人士的資料 (包括但不限於身份辨識資料、聯絡資料、生物辨識資料 (例
如面部圖像及自拍錄像) ) 。如你代表他人提供個人資料，你確認你乃是他們的父母或監護人或你已取得有關人士之同意提供有關人士之個人資料予保泰
作本聲明之用途。

個人資料承轉人的類別 

保泰可為以上目的披露你的個人資料予下列承讓人： 

1. 為協助保泰就上述用途 (不論在香港或其他地方) 而提供服務的第三方，包括索償調查員、醫療顧問、醫療服務提供者、緊急支援服務供應商、再保險
公司、專業顧問 (條件是有關承辦商須把所有個人資料保密並只會為提供有關服務而使用個人資料)； 

2. 你的銀行作繳款用途； 

3. 保泰的商業夥伴、服務提供者或被保泰任命的人； 

4. 保泰的關連公司 (根據公司條例訂明) ； 

5. 香港保險業聯會及其會員，以及其他保險公司及金融服務機構； 

6. 保泰及其關連公司因受 (香港或其他國家之) 法例、法規、法規指引、法庭命令或保泰與任何管轄區域的監管機構，政府，或於香港境內或境外存在的
財務服務供應商的自律監管或行業組織或協會所提供的，或之間的協議項目下的義務或要求或其他承諾 (其相關於洗黑錢、恐怖分子資金籌集、逃稅或其
他) 限制而需向其作出披露的任何人士或監管當局； 

7. 保泰及/或其資產的實際或建議受讓人等、或保泰就其權利的參與人等或附屬參與人等，可以讓其評核擬成為轉讓、參與或附屬參與的交易，及讓實際
受讓人等在運作被轉讓的業務或權利中使用你的資料； 

8. 代表你行事的任何授權人士、收款人、受益人、戶口代名人或往來及代理銀行；及 

9. 研究調查公司，信貸評級機構及保泰僱用的其他公司，藉以加強保泰向你所提供的服務。

使用個人資料作直接推廣 

保泰打算使用你的個人資料，以不同的渠道包括電話、郵件、電郵、電話短訊或任何電子信息等方法，聯絡你以作直接推廣。除非得到你的同意 (包括表
示不反對該用途)，否則保泰不可使用你的資料作為該用途。如你不願意保泰使用你的個人資料作直接推廣之用途，請於保泰每一次收集個人資料 (例
如，經保泰網站) 時所提供的方格，表示你的意願。如你沒有根據以上所述表達你的意願，你於下列確認這個人資料收集聲明，即代表你同意保泰可能使
用你的個人資料作直接推廣用途。如將來你希望更改你對保泰上述使用你的個人資料以作直接推廣用途的意願，請聯絡保泰的私隱保障主任 (參考下述聯
絡方法)。

保留資料 

保泰將僅在必要時保留你的個人資料，以實現收集資料的目的。我們亦可能保留存檔的個人資料以作統計之用。 

不再需要的個人資料將會被銷毀。

安全措施 

除上述情況外，你的個人資料 (無論如何存取) 將只會由獲得授權的保泰員工或承包商查閱。如果個人資料以電子方式存取，它將會被保存在獨立的伺服
器上，並受密碼保護 (或在相等的保護下)，亦只能由授權人士查閱。保泰指定處理個人資料的員工和承包商將會按指示，根據上述目的使用個人資料。

查閱及更正個人資料 

你有權查閱保泰持有有關你的個人資料；要求更正在保泰的紀錄內任何有關你的個人資料；及確定保泰有關個人資料的政策及慣例。有關要求可以書面
形式郵寄至香港灣仔皇后大道東 58-64 號帝后商業中心 1 樓，或 [email protected]，保泰的私隱保障主任。保泰可就處理該等要求收取合理費用。

PA001 / 202207 Page 8

修改個人資料收集聲明 

保泰保留權利可隨時且在無須通知的情況下修改本個人資料收集聲明。倘保泰決定修改其個人資料政策，保泰將於其網站或以電子訊息更新其個人資料
收集聲明。任何有關修改將在刊登後即時生效。

你/你們承認並確認你/你們已閱讀並理解個人資料收集聲明。你/你們確認已被建議閱讀並已仔細閱讀此個人資料收集聲明，及已仔細考慮其對保泰收集
或持有的你/你們的個人資料的效果和影響 (無論是否包含在本申請/資料遞交中)。基於上述內容，你/你們特此承認並同意保泰根據個人資料收集聲明使
用和轉讓你/你們的個人資料，包括使用和提供你/你們的個人資料，以作直接推廣。

Personal Information Collection Statement

Purpose of collection 

Bowtie Life Insurance Company Limited (“Bowtie”) may use the personal data collected from you for the following purposes, and your
personal data is necessary for the same: 

1. Processing and evaluating applications/data submissions; 

2. Checking and authenticating identity; 

3. Administering and providing services in relation to the Bowtie products you hold; 

4. Processing and investigating claims in relation to the Bowtie products you hold; 

5. Conducting customer surveys; 

6. Researching, designing and/or enhancing Bowtie's products and services; 

7. Selecting you to participate in reward, loyalty or privileges program and providing you with related services; 

8. Contacting you for the above purposes; 

9. Complying with all applicable laws, regulations, regulatory guidance and/or court orders; or obligation or requirement under an
agreement, or other commitment, between Bowtie or its associated companies and the regulator or government in any jurisdiction (in
relation to money laundering, terrorist financing and tax evasion or otherwise) to which Bowtie and its associated companies are
subject to (of Hong Kong or any other countries); 

10. Verifying data, whether or not for the purpose of taking adverse action against you; and

11. Fulfilling other purposes which are directly related to any of the above purposes.

It is voluntary for you to provide the personal data to Bowtie. If you do not provide the requested personal data, Bowtie may not be
able to process your application/data submission or continue to provide you with the products or perform the services you require. Your
personal data includes the data relating to you, your dependents, your beneficiaries, your delegates and other persons provided by you
(including but not limited to identification information, contact information, biometric data (including facial image and selfie video)). If
you provide personal data on behalf of another person, you confirm that you are either his/her parent or guardian or you have obtained
that person's consent to provide his/her personal data for use by Bowtie for the purposes set out in this PICS.

Classes of transferees 

Bowtie may disclose your personal data to the following transferees for the purposes mentioned above: 

1. Third parties who provide services in Hong Kong or elsewhere which assist Bowtie to carry out the above purposes, including, but not
limited to, claims investigators, medical advisors, medical service providers, emergency assistance service providers, investment
management companies, reinsurers and professional advisors (provided that such contractors are required to keep all such personal
data confidential and may only use the personal data to provide those services); 

2. Your bank for payment purposes; 

3. Bowtie's business partners, service providers and appointed persons of Bowtie; 

4. Bowtie's associated companies (as defined in the Companies Ordinance); 

5. Hong Kong Federation of Insurers and its members, and other insurance companies and financial services companies; 

6. Any person or authority or self-regulatory or industry bodies or associations of financial services providers within or outside Hong Kong
to whom Bowtie is required to disclose under applicable law, regulation, regulatory guidance or court order or obligation or requirement
under an agreement, or other commitment, between Bowtie & its associated companies and the regulator or government in any
jurisdiction (in relation to money laundering, terrorist financing and tax evasion or otherwise) that Bowtie and its associated companies
are subject to or required to comply with (of Hong Kong or any other countries); 

7. Actual or proposed assignees of Bowtie's business and/or assets, or participants or sub-participants of Bowtie's rights in respect of
you, to allow them to evaluate the intended assignment, participation or sub-participation, and enable the actual assignees to use
your data in the operation of the business or rights assigned; 

8. Any authorised persons acting on your behalf, payment recipients, beneficiaries, account nominees, correspondent and agent banks;
and 

9. Research companies, rating agencies and other companies engaged by Bowtie to enhance the products and services Bowtie
provides to you.

Use of personal data for direct marketing 


Bowtie intends to use your personal data for the direct marketing purposes through various communication means such as phone call,
mail, email, SMS or any type of electronic message. 

Bowtie may not so use your data unless Bowtie has received your consent (which includes an indication of no objection of the intended
use). If you object to Bowtie's use of your personal data for direct marketing purposes, please tick the box enclosed with each of our
information request (e.g., via Bowtie’s website) to indicate your preference. If you do not indicate your preference, then by
acknowledging this PICS below you agree that Bowtie may use your personal data for direct marketing purposes. 

If you wish to change your preference in the future in respect of Bowtie’s use of your personal data for direct marketing purposes, please
contact Bowtie's Privacy Officer (see below for contact details).

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Retention of data 

Bowtie will keep your personal data only for as long as necessary to fulfil the purpose(s) for which the data was collected. We may also
retain archived personal data for statistical purposes. 

Personal data which is no longer required will be destroyed.

Security 

Except as mentioned above, your personal data, however stored, will be accessed only by Bowtie's employees or contractors who are
authorised to do so. Where personal data is stored electronically, it will be kept on a separate server, password-protected (or under
some equivalent form of protection) and accessible only by authorised personnel. Bowtie employees and contractors authorised to
handle personal data will be instructed to do so for the above mentioned purposes for which personal data are to be used.

Access to and correction of personal data 


You have the right to request access to and correction of any of your personal data relating to you in any of Bowtie's records, or
ascertain Bowtie’s policies and practices in relation to personal data, by sending a written request to Bowtie's Privacy Officer at 1/F,
Queen’s Centre, 58-64 Queen’s Road East, Wan Chai, Hong Kong, or to [email protected]. Bowtie may charge a reasonable fee for
processing such requests.

Amendment of this PICS 


Bowtie reserves the right to amend this PICS at any time and without prior notice. If Bowtie changes its personal data policy, Bowtie
may update the PICS on Bowtie’s website or through electronic messages. All amendments will be effective immediately upon posting.

YOU ACKNOWLEDGE AND CONFIRM that you have read and understood the Personal Information Collection Statement (“PICS”). You
confirm that you have been advised to read and have carefully read the PICS, and you have carefully considered its effect and impact
in respect of your personal data collected or held by Bowtie Life Insurance Company Limited (“Bowtie”) (whether contained in this
application/data submission or otherwise). Based on the foregoing, you hereby acknowledge and agree to the use and transfer of your
personal data by Bowtie in accordance with the PICS, including the use and provision of your personal data for the purpose of direct
marketing.

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