National Health Insurance Refund Application Form - Chang-hua Taiwan

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Instructions for NHI Prepaid Medical Expense Reimbursement Application Form
1. Please note:
(1) The insured person should fill out the form completely; the
group insurance unit
should submit the application to the accepting unit.
(2) The
group insurance unit
is requested to make copies of the application form for its needs, or may request forms from a Bureau of National
Health Insurance (BNHI) branch.
(3) Persons at least 20 years of age who are mentally and physically competent must submit an application for themselves, and may not designate a
payer. A legal agent must apply on behalf of persons less than 20 years of age and attach personal identification documents. A legal heir may
apply if the original person has died; the heir must attach personal identification documents and a statement.
(4) If the
group insurance unit
prepays medical expenses, the insured person is requested to make a written statement designating the
group
insurance unit
as the payment recipient.
(5) If the case involves a major injury or illness, one photocopy of a document verifying the major injury or illness must be attached.
(6) Please fill out the payment address carefully so as to facilitate issuance of the refund.
(7) Starting from April 1, 2006 (hospital discharged date), when an insured applies for a refund for prepaid medical expenses for at least five days
of hospitalization in China, and a BNHI branch considers that the case requires verification, before the application can be accepted, a concerned
party must have the required medical verification documents (including original medical expense receipts, itemized expense lists, diagnostic
statements, and other verifying documents) first notarized at a notary office in China, and must apply bearing the original notarization certificate
to the Straits Exchange Foundation (phone: 02-2713-4726; http://www.sef.org.tw) for certification, and must complete certification documents.
2. Necessary conditions: An insured may apply for the refund of insured medical expenses in any of the following situations:
(1) If
the
insured has
not joined the NHI program
in accordance with the regulations of the National Health Insurance Act (herein referred to as
"this Act"), and has been punished with a fine and temporary suspension of insurance payments in accordance with Article 69-1 of this Act, the
insured prepays for medical care expenses at an insured medical service organization during the period of suspension of insurance benefits, and
has already paid all fines and insurance
premiums
in full.
(2) If the insured has been provisionally refused insurance payments in accordance with Article 30, Paragraph 3 of this Act, the insured prepays for
medical care expenses at
a contracted health provider
during the period of provisional refusal of insurance benefits, and has already paid all
insurance
premiums
and overdue payment in full.
(3) If the insured has failed to pay co-payments in accordance with Articles 33 and 35 of this Act, and has been provisionally refused insurance
premiums, the insured prepays for medical care expenses at
a contracted health provider
during the period of suspension of insurance premiums,
and has already paid all fines and insurance
premiums
in full.
(4) The insured has failed to submit any
certificate on exemption of co-payment
to
a contracted health provider
within seven
working
days
after
the
day
being treated
in accordance with Article 6 of this Act.
(5) One of the following situations applies and the case meets the requirements of Article 2 of the National Health Insurance Emergency Injury or
Illness Prepaid Medical Expense Refund Regulations (herein referred to as the "Refund Regulations"):
I. Within an area where NHI is in force, the insured is unable to go
receiving
care at a
contracted health provider
due to an emergency injury
or illness, and must seek care at a nearby
non-contracted health
provider.
II. Within an area where NHI is in force, the insured is unable to go for delivery care at
a contracted health provider
due to emergency
circumstances, and must go to a
non-contracted health
provider, or asks an approved physician or midwife to assist the delivery.
III. Within an area where NHI is not in force (including foreign countries and China), the insured suffers an unexpectedly injury, illness, or
emergency delivery, and must go to a local medical organization for care or delivery.
(6) In accordance with Article 35, Paragraph 2 of this Act and Article 64, Paragraph
3
of this Act's enforcement rules, the insured's
co-payments of
hospitalization
for the year exceed
10% of
the average per capita income during the most recent year.
3. Accepting units:
(1) In cases meeting the conditions of Subparagraphs 1~4 of Paragraph 2 above, please submit an application to the BNHI branch with jurisdiction
over the place of the hospital or clinic of treatment.
(2) In cases meeting the conditions of Subparagraph 5 of Paragraph 2 above, please submit an application to the BNHI branch with jurisdiction
over the place of the
group insurance
unit.
(3) In cases meeting the conditions of Subparagraph 6 of Paragraph 2 above, please submit an application to BNHI branch with jurisdiction over
the place of the first hospital or clinic of treatment.
4. Standards of the refund: The insurer shall process refunds in accordance with NHI Medical Expense Review and Payment Regulations and the
National Health Insurance Emergency Injury or Illness Prepaid Medical Expense Refund Regulations.
5. Ways of refunds: After approval of the expenses, the BNHI branch shall mail a check to the insured or remit the payment to the account of the
insured or insured's legal agent by
bank
transferation.
Addresses and Service Phone Numbers of Bureau of National Health Insurance Branches
Branch
Address
Area of jurisdiction
Phone
No.15-1, Gongyuan Rd., Jhongjheng District, Taipei
City
Taipei branch
Taipei, Ilan, Keelung, Kinmen, Matsu (02) 2523-2388
No.15-1, Gongyuan Rd., Zhongzheng District, Taipei
City
Northern Region branch
525 Jhongshan E. Rd. Section 2, Chungli, Taoyuan County
Taoyuan, Hsinchu, Miaoli
(03) 438-1111
st
Central Region branch
66 Shicheng N. 1
Rd., Taichung
Taichung, Changhua, Nantou
(04) 2258-3988
Southern Region branch
96 Gongyuan Rd., Tainan
Yunlin, Chiayi, Tainan
(06) 224-5678
nd
Kao-Ping Branch
157 Jioru 2
Rd., Sanmin District, Kaohsiung
Kaohsiung, Pingtung, Penghu
(07) 323-3123
Eastern Region branch
36 Syuanyuan Rd., Hualien City
Hualien, Taitung
(03) 833-2111
Instructions for NHI Prepaid Medical Expense Reimbursement Application Form
1. Please note:
(1) The insured person should fill out the form completely; the
group insurance unit
should submit the application to the accepting unit.
(2) The
group insurance unit
is requested to make copies of the application form for its needs, or may request forms from a Bureau of National
Health Insurance (BNHI) branch.
(3) Persons at least 20 years of age who are mentally and physically competent must submit an application for themselves, and may not designate a
payer. A legal agent must apply on behalf of persons less than 20 years of age and attach personal identification documents. A legal heir may
apply if the original person has died; the heir must attach personal identification documents and a statement.
(4) If the
group insurance unit
prepays medical expenses, the insured person is requested to make a written statement designating the
group
insurance unit
as the payment recipient.
(5) If the case involves a major injury or illness, one photocopy of a document verifying the major injury or illness must be attached.
(6) Please fill out the payment address carefully so as to facilitate issuance of the refund.
(7) Starting from April 1, 2006 (hospital discharged date), when an insured applies for a refund for prepaid medical expenses for at least five days
of hospitalization in China, and a BNHI branch considers that the case requires verification, before the application can be accepted, a concerned
party must have the required medical verification documents (including original medical expense receipts, itemized expense lists, diagnostic
statements, and other verifying documents) first notarized at a notary office in China, and must apply bearing the original notarization certificate
to the Straits Exchange Foundation (phone: 02-2713-4726; http://www.sef.org.tw) for certification, and must complete certification documents.
2. Necessary conditions: An insured may apply for the refund of insured medical expenses in any of the following situations:
(1) If
the
insured has
not joined the NHI program
in accordance with the regulations of the National Health Insurance Act (herein referred to as
"this Act"), and has been punished with a fine and temporary suspension of insurance payments in accordance with Article 69-1 of this Act, the
insured prepays for medical care expenses at an insured medical service organization during the period of suspension of insurance benefits, and
has already paid all fines and insurance
premiums
in full.
(2) If the insured has been provisionally refused insurance payments in accordance with Article 30, Paragraph 3 of this Act, the insured prepays for
medical care expenses at
a contracted health provider
during the period of provisional refusal of insurance benefits, and has already paid all
insurance
premiums
and overdue payment in full.
(3) If the insured has failed to pay co-payments in accordance with Articles 33 and 35 of this Act, and has been provisionally refused insurance
premiums, the insured prepays for medical care expenses at
a contracted health provider
during the period of suspension of insurance premiums,
and has already paid all fines and insurance
premiums
in full.
(4) The insured has failed to submit any
certificate on exemption of co-payment
to
a contracted health provider
within seven
working
days
after
the
day
being treated
in accordance with Article 6 of this Act.
(5) One of the following situations applies and the case meets the requirements of Article 2 of the National Health Insurance Emergency Injury or
Illness Prepaid Medical Expense Refund Regulations (herein referred to as the "Refund Regulations"):
I. Within an area where NHI is in force, the insured is unable to go
receiving
care at a
contracted health provider
due to an emergency injury
or illness, and must seek care at a nearby
non-contracted health
provider.
II. Within an area where NHI is in force, the insured is unable to go for delivery care at
a contracted health provider
due to emergency
circumstances, and must go to a
non-contracted health
provider, or asks an approved physician or midwife to assist the delivery.
III. Within an area where NHI is not in force (including foreign countries and China), the insured suffers an unexpectedly injury, illness, or
emergency delivery, and must go to a local medical organization for care or delivery.
(6) In accordance with Article 35, Paragraph 2 of this Act and Article 64, Paragraph
3
of this Act's enforcement rules, the insured's
co-payments of
hospitalization
for the year exceed
10% of
the average per capita income during the most recent year.
3. Accepting units:
(1) In cases meeting the conditions of Subparagraphs 1~4 of Paragraph 2 above, please submit an application to the BNHI branch with jurisdiction
over the place of the hospital or clinic of treatment.
(2) In cases meeting the conditions of Subparagraph 5 of Paragraph 2 above, please submit an application to the BNHI branch with jurisdiction
over the place of the
group insurance
unit.
(3) In cases meeting the conditions of Subparagraph 6 of Paragraph 2 above, please submit an application to BNHI branch with jurisdiction over
the place of the first hospital or clinic of treatment.
4. Standards of the refund: The insurer shall process refunds in accordance with NHI Medical Expense Review and Payment Regulations and the
National Health Insurance Emergency Injury or Illness Prepaid Medical Expense Refund Regulations.
5. Ways of refunds: After approval of the expenses, the BNHI branch shall mail a check to the insured or remit the payment to the account of the
insured or insured's legal agent by
bank
transferation.
Addresses and Service Phone Numbers of Bureau of National Health Insurance Branches
Branch
Address
Area of jurisdiction
Phone
No.15-1, Gongyuan Rd., Jhongjheng District, Taipei
City
Taipei branch
Taipei, Ilan, Keelung, Kinmen, Matsu (02) 2523-2388
No.15-1, Gongyuan Rd., Zhongzheng District, Taipei
City
Northern Region branch
525 Jhongshan E. Rd. Section 2, Chungli, Taoyuan County
Taoyuan, Hsinchu, Miaoli
(03) 438-1111
st
Central Region branch
66 Shicheng N. 1
Rd., Taichung
Taichung, Changhua, Nantou
(04) 2258-3988
Southern Region branch
96 Gongyuan Rd., Tainan
Yunlin, Chiayi, Tainan
(06) 224-5678
nd
Kao-Ping Branch
157 Jioru 2
Rd., Sanmin District, Kaohsiung
Kaohsiung, Pingtung, Penghu
(07) 323-3123
Eastern Region branch
36 Syuanyuan Rd., Hualien City
Hualien, Taitung
(03) 833-2111
□Prepaid Medical Expense Due To Emergency Injury or Illness
□Prepaid Medical Expense Due to Special Circumstances
National Health Insurance Refund Application Form
Co-payments of Hospitalization Expenses Exceeding the Annual Statutory Limit
*
If the case involves an occupational injury or illness, please fill out the following information and send directly to: Bureau of Labor Insurance, 14 Roosevelt Rd.
Section 1, Taipei City
□Outpatient □Hospitalization □Domestic □Out-of-country
Date accepted:
Acceptance No.:
(Please fill out separate outpatient and hospitalization applications)
□The
insured □Designated payee:
Designated payee
No. of the
group
Name of the
group
insurance unit
insurance unit
Name
Address of designated
□□□
payee
ID card number
Date of birth
y/
m/
d/
Phone
Office( )
Home( )
mobile phone:
Date of outpatient
y/
m/
d/
Name
(emergency) care
Hospital or clinic
Date of
y/
m/
d/
Address
hospitalization
1. Occupational injury
2. Occupational disease
Date of discharge
y/
m/
d/
3. General injury
4. General illness
Payment type
5. Pre-natal check-up
6. Natural delivery
Days of
Days
7. Cesarean section
8. Major injury or illness
hospitalization
In accordance with Article 72 of the National Health Insurance Act,
□NT$ □Yen □Euros □RMB □Hong Kong$ □US$
"A person who collects an insurance benefit through improper
□Thai Baht □Indonesian rupiah □other (country of care)
behavior or false proof, reporting, or accounts shall be fined twice the
(please write in long form)
amount of the payment received, and the case shall be forwarded for
prosecution when criminal liability is involved."
□1. Insured failed to
join the NHI program
in accordance with regulations, and the temporary refusal of
Application deadline
beneficiary
period was still in force. Insured prepaid medical expenses and has paid off all fines and
Within six months
on the
date of
insurance premiums.
fulfillment of owed fees
□2. Insured owed insurance premiums, and the provisional
benefit
refusal period was still in force. Insured
prepaid medical expense and has paid off all insurance
premiums
and late penalties.
□3. Insured owed some co-payments, and the provisional
benefit
refusal period was still in force. Insured
prepaid medical expense and has paid off all owed
co-payments
□4. Insured is unable to submit
certificate on exemption of co-payment
and apply to the hospital or clinic for a
Within six months on
the
date of
refund within seven days (not including weekends and holidays) after the date being treated due to some
ambulatory care or discharge of
reasons not attributable to the insured (please
specify
the reason in the column provided)
hospitalization.
□5. Insured is unable to submit proof of waiver of payment responsibility within seven days (not including
weekends and holidays) of the date of care due to some reason not attributable to the insured (please
specify
the reason in the column provided)
The i
□6
nsured received care at a non-contracted health provider or clinic or overseas (including China) due to
an emergency injury or illness. Please provide a detailed account of the circumstances and reasons in the
column provided, and please state the reason for going overseas when care was received in a foreign country.
□7. Other (please clearly state reason in the column provided).
□8.
The
insured
has stayed in an acute bed of a hospital for less than 30 days or a chronic bed for less than 180
Before the end of June of the
days during the year, and the insured's
co-payments of hospitalization
for the year exceeded 10% of the
following year
average per capita income during the most recent year.
Explain the reason for prepayment of medical expenses: (If item 4, 5, 6, or 7 has been checked, no refund will be given unless a reason is provided.)
Domestic
Foreign Area of (including China)
Partially refund of
co-payments
for full-year hospitalization
□1. Original
□1. Original
□1. Original
receipts of expenses
and itemized list of
receipts of expenses
and itemized list of
receipts of expenses
□2. Letter of authorization
expenses
expenses
(power of
□2.
□2.
Medical diagnosis
or
medical
history information
Medical diagnosis
or
medical
history information
attorney) (must be filled out when
□ 3. Hospitalization documentation with attached
□3. One photocopy of documents verifying exit and
applicant is not the insured)
□3. Photocopied receipts with reason
medical diagnosis
statement or
discharged
case
entry (passport photo and ROC exit and entry
history abstract
stamps)
why originals cannot be provided
The
□ 4. Labor insurance occupational injury or illness
□4.
insured who
has
not yet re-entered the ROC
outpatient care form or hospitalization application
must write a letter of authorization.
□5. Photocopied receipts with reason why originals
form
□5.
Certificate of exemption on co-payments
cannot be provided
□6. Letter of authorization
(power of
attorney) (must be
Please attach translations of the foregoing documents
filled out when applicant is not the insured)
if not in Chinese or English.
□7. Photocopied receipts with reason why originals
*Documents from China must be notarized. (please see
cannot be provided.
explanations on reverse side)
□1
Bank
transfer: bank name _________________ Account number ____________________, please attach a photocopy of passport’ cover.
(Bank
transfers are limited to
make
at the following 17 banking institutions: Post Office, Central Trust of China, The Chinese Bank, Chinatrust Commercial
Bank, Farmers Bank of China, Land Bank, Taiwan Business Bank, Taiwan Cooperative Bank, Entie Commercial Bank, Jihsun Bank, Changhwa
Bank, Hua Nan Bank, First Commercial Bank, Bank of Taiwan, Taipei Fubon Bank, Chiao Tung Bank, Bank of Kaohsiung)
□2 Check
*Please use
bank
transfer as much as possible in order to facilitate the speedy refund of your medical expenses.
It has been verified that the insured has indeed
joined the NHI program
in this
*If the insured owes any insurance fees or late fees, the insured agrees that
unit.
the amount owed shall be paid first from the refunded amount.
The
insured □has□has not applied for a relief fund loan.
Organization stamp or official seal:
*
Seal/signature of the insured or legal agent:
group
Seal/signature of the statutory responsible person/unit executive of the
Address:
insurance
unit:
Phone:
Date:
(y, m, d)

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