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Addressee

Sender

Clinica Peruano Suiza Reiseversicherung AG HanseMerkur


Postfach 210960 50533 Urb. Magisterio Kln Tel.: +49 221 8277- 9759 Fax: +49 221 8277-7228 ambulance@roland-assistance.de Your contact person:

Regulierungsstelle

Telefax: E-mail:

1 page(s) Our file

Michael Bredohl
Date / Hour

3/14/2012 19:57 number HMA/12/PE/10042458 Schlund, Dominik 15.11.1982 777736397 HanseMerkur Reiseversicherung AG

Name of the client: Date of birth: Policy number Insurance company: Dear Sirs,

We were informed that our policy holder has been admitted to your hospital. This client has valid health insurance with HanseMerkur Reiseversicherung AG that covers the costs arising during inpatient hospital treatment. the extra fees for single / double room and treatment by head physician. However, before we can send a guarantee of payment, we urgently need the following documents: - an official document stating the exact date of departure (e.g. a copy of the booking, confirmation or a copy of the flight ticket). - Patientenfragebogen Thanks in advance for your co-operation! p.o. Michael Bredohl ROLAND Assistance on behalf of HanseMerkur Reiseversicherung AG

Datenschutzhinweis / Data protection advice


Durch die Annahme unseres Auftrages versichern Sie die Einhaltung der fr Sie geltenden rechtlichen Datenschutzverpflichtungen gegenber unserem Kunden, insbesondere hinsichtlich der Zweckbindung, der Verwendung und der sicheren Aufbewahrung und Lschung der Daten. In jedem Fall drfen Sie die Daten nur zur Erfllung des Auftrages verwenden. By accepting our request you assure compliance of the current legal data protection obligations regarding our client. This is imperative regarding the purpose limitation as well as the use and safe custody and deletion of the data. In any case you must only use the data in order to fulfill this request. Hauptgeschftsfhrer: Frank Feist Geschftsfhrer: Robert Buchberger, Dr. Ulrich Scholten Sitz der Gesellschaft: Kln Handelsregister Kln HRB 18 648 Ust-IdNr.: DE 811 389 386 Kontoverbindungen: Westdeutsche Landesbank Girozentrale Dsseldorf BLZ 300 500 00 Konto 4 634 861 IBAN: DE90 3005 0000 0004 6348 61 Postbank Kln BLZ 370 100 50Konto 395 477-500 ROLAND n ASSISTANCE 24 Stunden-ServiceLine: +49 221 82778277 ROLAND Assistance GmbH Postanschrift: 50664 Kln Hausanschrift: Deutz-Kalker Str. 46 - 50679 Kln Telefon: +49 221 8277-8277 - Telefax +49 221 8277-7583 www.roland-assistance.de - service@rolandassistance.de