Template for Referral Form for Health Insurance Medical Examination
According to Form No. 6 Appendix Issued Attached to Decree 146/2018/ND-CP, the sample of the referral form for medical examination and treatment under health insurance is as follows:
| SUPERVISING AGENCY (MOH/DOH..) NAME OF MEDICAL EXAMINATION AND TREATMENT FACILITY |
SOCIALIST REPUBLIC OF VIETNAM Independence - Freedom - Happiness--------------- | File Number: ...... Referral log number: ..... | No.: ...../20.../GCT | **** | **** |
|---|
HEALTH INSURANCE MEDICAL EXAMINATION AND TREATMENT REFERRAL FORM
To: ......................
The medical examination and treatment facility: ................................................. respectfully introduces:
- Full name of the patient: ........................................ Male/Female: .................. Age: ................
- Address: ..............................................................................................................................
- Ethnicity: .............................................. Nationality: ......................................
- Occupation: ................................... Workplace ........................................
Card Number:
Validity Period: .......................................................................................................................
Has been examined/treated:
+ At: ................(Level ......) From ........../ ........../ .......... to ........../ ........../ ..........
+ At: .................(Level ......) From ........../ ........../ .......... to ........../ ........../ ..........
SUMMARY OF MEDICAL RECORD
- Clinical signs: ................................................................................................................
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- Test results, paraclinical results: .................................................................
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- Diagnosis: .....................................................................................................................
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- Methods, techniques, and medicines used in treatment: ...........................
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- Condition of the patient at the time of referral: ...........................................................
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- Reason for referral: Circle the appropriate reason below:
Eligible for referral.
At the request of the patient or the patient's lawful representative.
- Next treatment direction: ............................................................................................
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- Referral time: ..... hours ....... minutes, on ................, 20......................
- Transportation means: .................................................................................................
- Full name, title, professional qualifications of the escort: ...........................................
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| PHYSICIAN, TREATMENT DOCTOR (Signature and full name) | Date .... month .... year 20... AUTHORIZED PERSON FOR REFERRAL (Signature, seal) |
Respectfully!
