律敦治及鄧肇堅醫院

` TSKH

Ruttojnee & Tang Shiu Kin Hospitals

Correspondence Address: Shroff Office, 266 Queen’s Road East Wanchai, Hong Kong, Telephone Number : 2291-1096

Application for Certificate of Payment

 Please return the completed form to Shroff Office for processing in ten working days.
PART A
I, (Name) ________________________ would like to apply for certification of the payment record
for my treatment at the Ruttonjee & Tang Shiu Kin Hospitals. Application fee is HK$230.00.

(A) The following documents are enclosed for application:

(i) Copy of HKID card / Passport (No. _______________ )

and Authorization Letter of patient
(ii) Original receipt of application fee (No. _______________ ) if applicable
(iii) Other hospitalization case (No. _______________ )
and date _______________ / Services (Please specify) _______________
_____________________________________________ if applicable

(B) Name of Patient: _______________________________

Correspondence address: _____________________________________________

_____________________________________________

Telephone: _______________________ Mobile phone: _______________________

Collect in person
I hereby authorize Mr / Ms ___________________________ (HKID card /
Passport No. ___________________ ) to collect the certificate on my behalf.
Mail to the above correspondence address

Signature: _________________________ Date: _________________________

PART B
The original certificate had been received by Patient / authorized person

Signature: ___________________________

Name: ___________________________ Date: ___________________________

(Please return by post to Shroff Office, 266 Queen’s Road East, Wanchai, Hong Kong)