Healthcare Subsidy Scheme ______ Application Form for Printing

Form No.:VS02_________________
澳 門 特 別 行 政 區 政 府
Governo da Região Administrativa de Macau
Serviços de Saúde
Healthcare Subsidy Scheme ______
Application Form for Printing Vouchers
<For beneficiaries with smart identity card which has lost data chip or data read failure>
I, __________________(name in Chinese) ________________________________ (name in foreign
language), holder of valid Macao Special Administrative Region Permanent Resident Identity Card No.
___________________, Sex: □Male/□Female, with contact telephone number ___________________and
contact address__________________________________________________________________________.
I hereby declare a printing failure of my healthcare vouchers from a self-service voucher kiosk for the
reason that my identity card as mentioned above has □ lost the data chip / □ data read failure (please “9”
where appropriate). I hereby raise a print request for my ten healthcare vouchers of MOP50.00 each in face
□ Statement of Authorization
Due to________________________________________________ (reason for being unable to apply
in person), I hereby authorize ________________________(name of the authorized person), my
_______________ (relationship of the applicant), holder of
__________________________(type of
identification document), No. ________________, with telephone number___________________ and
contact address_________________________________________________________________, to process
the application and collect the healthcare vouchers on my behalf.
(Making a false statement can cause criminal liabilities)
Applicant* (Voucher Beneficiary)
Authorized person
(Same signature as shown on the ID) Affix a print of right finger in the box if unable to sign
*If the applicant is under the age of 18, this form should be signed by his/her legal representative
Name of legal representative: __________________________
ID no. of legal representative: _________________________
Date: _____ /_____/_____ (dd/mm/yy)
1) Photocopy of the applicant (the voucher beneficiary)’s identity card
2) Photocopy of the legal representative’s identity document (if the applicant is under the age of 18)
3) Photocopy of the authorized person’s identity document (if processed by a third party)
4) Documentary proof issued by the Identification Services Bureau (DSI) verifying the authenticity of the identity