Appendix A : Claim Procedures a. If seeking treatment within our Direct Billing Hospitals Network, please bring: Insurance Card Photo ID / Passport b. If seeking treatment out of our Direct Billing Hospitals Network, please bring: Claim form c. If the doctor is not willing to complete Part B of the Claim Form out of the Network, it can be replaced by the photocopy of the diagnosis. ……………………………………………………………………….……………………………………………… In Direct Billing Hospitals Network Out of Direct Billing Hospitals Network Please present your Photo ID with your Insurance Please bring our Claim Form with you to the Card and request a claim form hospital Please complete and sign Part A of the claim form The doctor should complete Part B of the claim form Please file the necessary documents including: Please sign the invoice or Part B of the claim form 1. Complete Claim Form to confirm expenses and leave the complete 2. Taxed Invoices documents with the hospital 3. Prescriptions (if any) 4. Discharge Summary/Medical Reports (Inpatient treatment) The hospital will bill us directly Complete Claims are suggested to be received by our Claim Center within 180 days 12 Appendix B: Direct Billing Hospitals List for Reference South East Asia Cambodia Vietnam Phnom Penh HCM City Central Hospital Centre Medical International Princess Clinic FV Hospital Sen Sok International University Hospital FV Sai Gon Clinic Sunrise Japan Hospital Phnom Penh Fortis Hoan My Medical Corporation CHHOUR Y SENG CLINIC Fortis Hoan My Sai Gon General Hospital Royal Phnom Penh Hospital Fortis Hoan My Tan Binh Clinic Dr.Agarwal's Eye Hospital jointly with Dr.Kong Piseth Eye Hospital FAMILY MEDICAL PRACTICE-DISTRICT 2 CLINIC Roomchang Dental & Aesthetic Hospital Fortis Hoan My Thao Dien Clinic Siem Reap Fortis Hoan My Breast Care Royal Angkor International Hospital Family Medical Practice HCMC (Guarantee Letter required) Battambang City International Hospital Sovann Polyclinic Victoria Healthcare clinics-Clinic 1 Thailand Yersin International Clinic Bangkok Victoria Healthcare clinics-Clinic 2 Bumrungrad International Hospital CARE1-EXECUTIVE HEALTH CARE CENTER & CLINIC BNH Hospital Can Tho City Mission Hospital Bangkok Fortis Hoan My Cuu Long General Hospital Bangkok Hospital Pattaya Da Lat City Vejthani Hospital Fortis Hoan My Da Lat General Hospital Samitivej Sukhumvit Hospital Da Nang City Samitivej Srinakarin Hospita Fortis Hoan My Da Nang General Hospital Bangkok Hospital Family Medical Practice Da Nang (Guarantee Letter required) Bangkok International Hospital Ca Mau City Bangkok Heart Hospital Fortis Hoan My Minh Hai General Hospital Bangkok Cancer Hospital/ Wattanasoth Hospital Hanoi Bangkok Hospital Hua Hin (BHN) Family Medical Practice Hanoi (Guarantee Letter required) Phyathai 2 International Hospital-International Nongkhai Binh Duong Province Nongkhai Wattana Gerneral Hospital Hanh Phuc International Hospital (Guarantee Letter required) Udonthani Indonesia North Eastern Wattana Hospital Jakarta Singapore MRCCC Siloam Hospitals Semanggi(MRCCC) National University Hospital International Patient Liaison Centre Siloam Hospitals Kebon Jeruk (SHKJ) Tan Tock Seng Hospital Patient Liaison Centre Siloam Hospitals Lippo Cikarang (SHLC) Fortis Surgical Hospital Siloam Hospitals Simatupang Healthway Medical Group (48 clinics) Klinik Utama Jantung Cinere International Medical Clinic (3 hospitals) Surabaya Johns Hopkins Singapore International Medical Centre Siloam Hospitals Surabaya (SHSB) 13 KK Women’s and Children’s Hospital, International Medical Services Tangerang Raffles Medical center (3 hospital and 52 clinics) Siloam Hospitals Lippo Village (SHLV) FeM Surgery Pte Ltd (3 hospitals) Rumah Sakit Umum Siloam (RSUS) Hope Gastroenterology and Liver Clinic Jambi ORTHOSPORTS Orthopaedic Surgery & Sports Medicine Siloam Hospitals Jambi (SHJB) Providence Orthopaedics Pte Ltd Balikpapan Quah Hak Mien Colorectal Centre Siloam Hospitals Balikpapan (SHBP) Singapore Pain Clinic Pte Ltd Makassar Siow Neurology Headache And Pain Centre Siloam Hospitals Makassar Yim Gastroennterology Liver and Endoscopy Center Manado David Lau ENT Centre Siloam Hospitals Manado (SHMN) PanAsia Surgery Pte Ltd (3 centers) Palembang Novena Pain Management Centre Siloam Sriwijaya Palembang Jarrod Lee Gastroenterology and Liver Clinic Bali Clinic for Digestive Suregry Klinik Penta Medica Jude Lee Gastrointestinal & Laparoscopic Surgery Klinik Penta Medica Candidasa Charles Tan Surgery Siloam Hospitals Bali (SHDP) Apex Cardiology Pte Ltd Korea Singapore General Hospital,International Medical Services Seoul Severance Hospital, Yonsei University Health System,International National Heart Centre Singapore, International Medical Services Health Care Center Seoul St. Mary’s Hospital, the Catholic University of Korea,International Charles Chan Heart Clinic Health Care Center The Sole Clinic Seoul Wooridul Spine Hospital The Sulk Private (Thoracic & Cardiovascular Surgery Specialist) Seoul ChungDam Wooridul Spine Hospital Singapore National Eye Center International Health Service Samsung Medical Center SoonChunHyang University Hospital Seoul-International Healthcare SNEC Eye Associates Center Parkway East Hospital Korea University Anam Hospital-International Health Care Center Parkway Mount Elizabeth Hospital BUMIN HOSPITAL SEOUL Parkway Mount Elizabeth Novena Hospital Daegu Parkway Gleneagles Hospital Daegu Wooridul Hospital Parkway Shenton Pte Ltd (21 centers) Busan Tan Tock Seng Hospital International Patient Liaison Centre Busan Wooridul Spine Hospital National University Hospital International Patient Liaison Centre Busan Dongrae Wooridul Spine Hospital The Sole Clinic(Bukit Timah) Singapore National Eye Center Good Gang An Hospital Apicare Medical Pte Ltd Good Moonhwa Hospital Complete Healthcare International BUMIN HOSPITAL BUSAN Julian Lee Ear Nose Throat Specailist Incheon HC Chang Orthopaedic Surgery Inha University Hospital International Healthcare Center Synergy Orthopaedic Surgery Gachon University Gil Hospital,International Healthcare Center 14 International St. Mary Hospital-International Healthcare and The Harley Street Clinic(2) Cooperation Department International Medical Clinic-East Coast Clinic Anyang Malaysia Anyang SAM Hospital (SAM Medical Center) Ara Damansara Medical Centre Japan Loh Guan Lye Specialists Centre Kameda Medical Center ParkCity Medical Centre Keio University Hospital Subang Jaya Medical Centre St.Luke’s International Hospital Tropicana Medical Centre (TMC) The University of Tokyo Hospital KPJ Group （6） Juntendo University Hospital Institut Jantung Negara (National Heart Institute) Nippon Medical School Hospital Sime Darby Medical Centre Subang Jaya Tokyo Medical And Dental University Hospital Japan Community Healthcare Organization Tokyo Shinjuku Medical Brunei Center Gleneagles JPMC Tokyo Women's Medical University Hospital Philippines Tokyo Medical University Hospital Makati Medical Center The Jikei University Hospital India Aiiku Hospital Healthcare Global Hospital Bangalore Toranomon Hospital Kauvery Hospital Tokyo Metropolitan Matsuzawa Hospital Balabhai Hospital Teikyo University Hospital Continental Hospital-International Patient Center Japanese Red Cross Medical Center Mongolia Laos UB Songdo Hospital Alliance International Medical Centre United Family Intermed Hospital Greater China Hong Kong Taiwan Hong Kong Raffles Medical (5 clinics) Taiwan Adventist Hospital, International Healthcare Center Human Health Medical Centre (115 clinics) St. Martin De Porres Hospital Taipei Chang Gung Memorial Hospital International Service Center (4 Ken Lee Medical Centre (2 clinics) Clinics) ParkwayHealth Medical Centre Kaoshiung Medical University Chung-Ho Memorial Hospital Quality Healthcare Medical Services Limited (QHMS) (569 clinics) Wan Fang Hospital, International Medical Center National Taiwan University Hospital, International Medical Service Tsuen Wan Adventist Hospital Center UMP Medical Center (3 clinics) Changhua Christian Hospital, International Medical Service Center International Medical Service Center, Taichung Veterans' General Bayley & Jackson Dental Surgeons Ltd. (5 clinics) Hospital Hong Kong Adventist Medical Center Taiwan Landseed Hospital, International service center OT&P hospital (5 clinics) China Medical University Hospital, International Medical Service Center 15 Silver Cross-Institute Of Medical Specialists Min-Sheng General Hospital Hong Kong Sanatorium & Hospital Ajour University Hospital-International medical center Specialist Consortium Day Surgery Centre (31 Clinics) Macau Matilda International Hospital Quality Healthcare Medical Services Limited--Macau GP group Trinity Health Enterprise Shanghai Tongren Hospital, Shanghai Jiaotong University School of Hong Kong Union Hospital Medicine,International Outpatient Poly Dental (Tsim Sha Tsui) American-Sino OB/GYN/Pediatrics Services weHealth Medical Diagnostic & Endoscopy Centre ParkwayHealth - Hong Qiao Medical Center Chiron Healthcare Group Limited Shanghai Aier Eye Hospital International Patient Service District Chiron Company Limited Shanghai Delta West Clinic Beijing Shanghai United Family Hospital Beijing Ditan Hospital Capital Medical University VIP Department Shanghai United Family Hospital QK Clinic China-Japan Friendship Hospital - International Department St. Michael Hospital Angel Hospital for Women & Children (2 hospitals) Sun-Tec Medical Center AMCARE Women’s & Children’s Hospital (2 hospitals) Alpha Dental Clinic Bayley and Jackson Beijing Medical Center Jing Xian Dental Clinic Beijing Aier-Intech