1. Name: fill in the name of the insured.

2. Social security number: fill in the social security number of the insured.

3. Location of medical treatment: fill in the name, address, telephone number and other relevant information of the hospital.

4. Date of seeing a doctor: fill in the specific date of seeing a doctor, including year, month and day.

5. Diagnosis result: fill in the diagnosis result of the insured by the doctor, including the name of the disease, the degree of illness and other related information.

6. Medical expenses: fill in the medical expenses of this visit, including medical service fees, medicine fees, examination fees and other related expenses.

7. Commitment content: The insured who signs the commitment letter should promise that he really suffers from unnatural diseases, and does not provide false certification materials and information during the medical treatment, and at the same time abide by the rules and regulations of the hospital and medical discipline.