CASE NUMBER: 9FC6B50

TO: Gleneagles Hospit al (Check Add

info)
EMAIL/FA X:
FROM: ASSIST CARD
DA TE: Tuesday, January 10, 2023
REFERE NCE: DIE GO GONZA LO PAULO
MEMBERSHIP NUMBER: 510-9500607
DA TE OF BIRTH: Apr 26, 1984
REPORTE D ISSUE: Waist pain or low back pain
AUTHORIZE D COS T: 2342,20HKD

OBS ERV ATIONS: PAYMENT AUTHORI ZATION-EMERGENCY ROOM ASSISTANCE

Dear Colleagues,

Following our telephone conversation, regarding the patient above we confirm that our company will
take charge of the costs for t reatment on dat e Tuesday, January 10, 2023, up to a limit of
2342,20HKD.

This Guarantee of Payment does not cover medicines for outpatient services .

After patient seeing a doctor, you s hould provide (within 1 day ) to ASSIS T CARD the following
documents:

1. Invoice wit h total cost of treatment

2. Copy of Guarantee of Payment (GOP)
3. Medical report with the full name of the patient, date of treatment, complaints upon admission,
exact diagnosis, and all the services rendered, and the medicine prescribed. If the patient needs
follow up, please inform ASSIS T CARD in the medical report.

Please forward the above mentioned documents to both billing.asia@assistcard.com and

assistances@assistcard.com // Tel: +54 11 5555 1500 or +852 5808 5657

Thank you for your cooperation.

Yours sincerely,

Stefany Celis

"The present document does not imply acceptance or commitment of payment in case of the medical staff of ASSIST- CARD
considers that there is any inconsistency in billing including, but not limited to, over-invoicing, clinical exams not directly
related to diagnosis, or pre-existing condition."
 ASSIST CARD

"The present document does not imply acceptance or commitment of payment in case of the medical staff of ASSIST- CARD
considers that there is any inconsistency in billing including, but not limited to, over-invoicing, clinical exams not directly
related to diagnosis, or pre-existing condition."
 Medical Information Release Form
For Assist Card International

I DIEGO GONZALO PAULO, agree to have my medical information released to ASS IS T CA RD

International for the purpose of claim evaluation process.

I hereby aut horise and request that my medical information to be released to an ASSIS T CA RD
staff member when requested.

ASSIST CARD agrees that my medical information shall only be released to the above-mentioned
people / organizations on my behalf.

Patient’s Full Name and ID number: DIEGO GONZA LO PAULO (510-9500607)

Signed: ………………………………

Date: Tuesday, January 10, 2023

Case reference for Assi st – Card: 9FC6B50

Please send the signed Form and Medical notes to the following email address:
billing.asia@assi stcard.com ; assi stance s@a ssi stcard.com

"The present document does not imply acceptance or commitment of payment in case of the medical staff of ASSIST- CARD
considers that there is any inconsistency in billing including, but not limited to, over-invoicing, clinical exams not directly
related to diagnosis, or pre-existing condition."