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Love Can Help Scheme
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Form
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Internal
李嘉誠基金會「愛能助」組織碎化技術（Histotripsy）資助計劃
Li Ka Shing Foundation “Love can Help” Histotripsy Subsidy Scheme
Supported by the Li Ka Shing Foundation’s Love Can Help Scheme, this program aims to provide financial assistance for Hepatocellular Carcinoma (HCC) patients who are HK permanent residents suitable for Histotripsy treatment, but lack the means or insurance coverage to seek private assistance. For more details about the programme, treatment and application process, please visit:
https://go.ghk.hk/lksf-HCC_en
本計劃由李嘉誠基金會「愛能助」計劃資助，為符合條件的香港原發性肝癌（HCC）患者引入組織碎化技術這項無創治療選擇。計劃旨在為適合接受該治療但因經濟能力有限，或缺乏相關保險保障的香港永久性居民提供經濟援助。有關計劃詳情、治療簡介及申請流程，請瀏覽：
https://go.ghk.hk/lksf-HCC
Please complete the preliminary screening form below.
Note: This form is intended for applications to our hospital only. To avoid duplicate processing, please do not submit applications to multiple hospitals at the same time.
請填妥以下初步篩選表格。
注意：此表格僅供本院使用。為免重複處理，請勿同時向多間醫院提交申請。
Contact Information / 聯絡資料
English Given Name 英文名字:
English Surname 英文姓氏:
Chinese Given Name 中文名字:
Chinese Surname 中文姓氏:
HKID 香港身分證:
Date of Birth / 出生日期:
(*Applicants must be aged 22 years or above. 申請人須年滿22歲。)
Sex / 性別
Female 女
Male 男
Contact Number / 聯絡電話:
Email Address / 電郵地址:
Auto-reply to email will be received upon successful submission
成功提交申請後將收到自動回覆郵件
1. When were you diagnosed with HCC ? 您在何時確診原發性肝癌 (HCC)?
Date of Diagnosis / 確診日期：
2. Do you have Hepatitis B? 您是否患有乙型肝炎?
Yes
No
If yes, please provide the date of diagnosis / 如有，請提供確診日期:
3. Which government clinic/ hospital did you receive your HCC diagnosis? 您在哪間公立診所/醫院接受原發性肝癌診斷？
Name of Hospital / 診所或公立醫院名稱:
4. Are you currently undergoing treatment? / 您是否正在接受治療？
Yes
No
If yes, please provide the following information / 如有，請提供以下資料:
Name of Hospital / 公立醫院名稱:
Date of Last Treatment / 上次接受治療的日期:
I have received the following treatments / 我曾接受以下治療:
Chemotherapy / 化學治療
Immunotherapy / 免疫治療
Targeted Therapy / 標靶治療
Transarterial Chemoembolization (TACE) / 經動脈化療栓塞術
Stereotactic Body Radiation Therapy (SBRT) / 軀體立體定位放射治療
Surgery / 手術
Others (please specify) / 其他（請註明）：
By submitting this form, I agree to the processing and release of my medical records for preliminary assessment, and I understand that the hospital will contact me directly.
聲明：提交此表格即表示本人同意將個人資料和醫療紀錄作初步評估之用，並明白醫院將直接與我聯絡。
I also declare that I do not have insurance coverage and am in need of financial assistance.
本人亦聲明目前未有保險覆蓋，並有確切經濟援助。
As a condition of eligibility for treatment, I accept paying for the cost of initial consultation and ultrasound screening. The estimated total fee ranges from HKD 4,300 to 5,400, which includes specialist consultation and liver ultrasound examination.
I also understand I shall be responsible for the reduced medical fee of HKD50,000 payable directly to the hospital if I elect to undergo histotripsy treatment.
作為符合治療資格的條件，本人同意自費接受超聲波篩查及醫生諮詢。相關費用約為港幣 4,300 至 5,400 元，包括專科醫生診症及肝臟超聲波檢查。
本人亦明白，如選擇接受組織碎化術治療，本人須直接向醫院支付港幣 50,000 元之減免醫療費用。
I consent to Gleneagles Hospital Hong Kong accessing my relevant medical records through the Electronic Health Record Sharing System (eHRSS) for the purpose of preliminary assessment under this programme.
本人同意港怡醫院經由電子健康紀錄互通系統（eHRSS）查閱本人之相關醫療紀錄，以作為本計劃初步評估之用。
Signature 簽名:
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Date 日期:
Internal Remarks:
Date:
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