Regulations Governing the National Health Insurance Referral
Table 1
The National Health Insurance
Hospital (Clinic) Examination
Male
Basic information of
beneficiary
Name
Gender
Hospital (Clinic) )
Date of birth
Female
YY
MM
DD
National
identification
card No.
Allergy
Preliminary
diagnosis
Referring hospital/clinic
Code
Address
Name
Name of
physician
Signa
ture/s
eal of
physi
cian
Date of
issuance
Contact
phone
No.
YY
MM
Expiry
date
DD
Code of examination
item
Fax
No.
YY
MM
DD
Name of examination
Name of the
designated medical
care institution where
the beneficiary shall
receive the
examination service
Contact
person
Address
Contact phone no.
Results of examination: (Below shall only be filled out by the contracted medical care institution which accepts the referral)
Date of examination (test):
YY
Signature/seal of medical personnel conducting the examination: ___________
MM
DD
Date of report:
YY MM DD
※ The examination of the item specified in this form is limited to one time only.
1
The first part: shall be kept by the contracted medical care institution which accepts the referral.
The second part: shall be replied to the referring hospital/clinic by the contracted medical care institution which accepts the referral.
The third part: shall be kept by the referring hospital/clinic.
Referral Form (Referred to
Table 2
The National Health Insurance
Form (Referred to
Hospital (Clinic) Referral
Hospital (Clinic) )
Code of the contracted medical care institution:
Contact
person
Date of birth
YY
Phone
number
MM
National identification
card No.
DD
Contact address
A. Abstract of medical condition (Chief complaint and short history) D. Allergy:
The referring hospital/clinic
Date of
Scheduled date
YY
MM
YY
MM
DD
issuance
of visit:
Department
Clinic No.
Recomme
Address and
nded
direct line of Address:
(Must be filled out) Hospital
departmen
the
(Must be filled out) Department
t
and
hospital/clinic Phone No.:
hospital/cl
accepts the
Physician
inic
referral
2
DD
No.
The third part: shall be kept by the referring hospital/clinic.
Contact
phone
No.
Departm
ent
Name
Abstract of
B. Diagnosis
ICD-9-CM
Name of illness:
medical
1. (Primary diagnosis)
records
2.
3.
C. Abstract of examination and treatment
1. Results of thelatest examination
2. Name of the latest medication or
operation
Date:
Date:
Report:
Purpose of 1.  Emergency care
4.  Further examination: examination items
5.  Follow-up by referral-back, referral or suitable
referral 2.  Inpatient care
hospital/clinic
3.  Outpatient care
6.  Others
Fax No.:
Address
Email
address:
Physician
Signature/seal
of physician
The second part: shall be replied to the transferring hospital/clinic by the hospital/clinic
The first part: shall be kept by the hospital/clinic which accepts the referral
which accepts the referral (transfer).
(transfer).
Name
Gender
Basic
informatio
n of the
beneficiary
Male
Female
2. Name of medication or operation
Abstract of 1. Primary diagnosis
3. Results of examination by computer-aided diagnosis
treatment
ICD-9-CM:
Name of illness:
Name of
Phone No. or
hospital/cl
inic
Signature/
seal of
physician
Name
Physician
Fax No.:
Email address:
Department
The hospital/clinic that accepts the referral
1. The patient has already received emergency care and referred to
Hospital
2.  The patient has already received emergency care and admitted to
Ward of
this hospital for treatment
3. The patient has already been admitted to
Ward of this hospital for
Handing
treatment
4.  The patient has already received medical outpatient care from
Department of this hospital
5. The patient has already received adequate treatment and referred back to the
referring hospital/clinic with the following recommendations:
Date
of
reply
YY
MM
※ This referral form shall only be used once.
※ All of the columns above shall be filled out, fill in none if it is not applicable.
3
DD