Clinic Claim Form / Borang Tuntutan Klinik - etiqahc.com.my Claim Form- final.pdf · Clinic Claim...
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Clinic Claim Form / Borang Tuntutan Klinik Section A: Patient’s Particulars / Maklumat Pesakit (To be completed by the Patient / Diisi oleh Pesakit) Patient’s Name / Nama Pesakit ___________________________________________________________ Patient’s I/C. No. / No. Kad Pengenalan Pesakit ______________________________________________ PF No. / No. PF _______________________ Visit Type / Jenis Lawatan Self / Sendiri Spouse / Suami / Isteri Child / Anak Section B: Treatment at Panel Clinic / Rawatan di Klinik Panel (To be completed by the Patient / Diisi oleh Pesakit) Declaration by Spouse / Child (above eighteen (18) years of age) of Staff / Pengakuan daripada Suami / Isteri / Anak Pekerja (melebihi umur lapan belas (18) tahun). I hereby declare that / Saya dengan ini mengakui bahawa: I am self-employed / unemployed / Saya bekerja sendiri / tidak bekerja. My current employer does not provide such medical benefit / Majikan saya tidak menyediakan kemudahan perubatan seperti ini. I have fully utilised my entitlement of medical benefits for this year / Saya telah menggunakan sepenuhnya kelayakan kemudahan perubatan untuk tahun ini. The medical benefits provided by my employer is inferior to the family medical benefits provided to my spouse by Maybank / Kemudahan perubatan yang diberi oleh majikan saya tidak sebagus kemudahan perubatan keluarga yang diberi kepada suami/isteri saya oleh Maybank. I am still pursuing continuous education (eligibility as stipulated in my parent’s Terms & Conditions of Service / Collective Agreement) / Saya masih melanjutkan pengajian (kelayakan adalah seperti di dalam Terma & Syarat Perkhidmatan / Perjanjian Berkelompok ibubapa saya). Please provide documentary evidence (e.g. student card) / Bukti dokumen diperlukan (contoh kad pelajar) Date of Visit / Tarikh Lawatan ____________________ Patient/Guardian’s Signature / Tandatangan Pesakit/Penjaga Time of Visit / Masa Lawatan ____________________ __________________________________________________ Name / Nama __________________________________________________ Section C: Treatment Details / Butiran Rawatan (To be completed by the Clinic / Diisi oleh Klinik) Remark Medication Quantity / Dosage Price (RM) Other (please specify) MC Days : ________________day(s) Date From ______________________ to ______________________ ------------------ (Please detach & return the completed slip below to Etiqa for Payment)--------------------- Section D: For Etiqa Submission / Untuk Penyerahan Kepada Etiqa Clinic’s Name / Nama Klinik ___________________________________________________________ Clinic’s Code / Kod Klinik __________________ Contact person __________________________ Tel. No. / No. Tel. __________________ Email / Emel ________________________________________ Patient’s Particulars / Maklumat Pesakit (To be filled by the Patient / Diisi oleh Pesakit) Patient’s Name / Nama Pesakit ____________________________________________________________ Patient’s I/C. No. / No. Kad Pengenalan Pesakit _______________________________________________ PF No. / No. PF _________________________ Visit Type / Jenis Lawatan Self / Sendiri Spouse / Suami / Isteri Child / Anak Date of Visit / Tarikh Lawatan ___________________ Time of Visit / Masa Lawatan ____________________ Charges RM Sen Consultation Medication Injection Nebulizers / Vaccination Surgical Procedures Lab / X-rays Other Total Doctor’s Signature AND Clinic Stamp Name / Nama : Patient/Guardian’s Signature / Tandatangan Pesakit/Penjaga _______________________________________________ Name / Nama _______________________________________________ Total Amount (RM) Etiqa Claim No.
Transcript of Clinic Claim Form / Borang Tuntutan Klinik - etiqahc.com.my Claim Form- final.pdf · Clinic Claim...
Clinic Claim Form / Borang Tuntutan Klinik Section A: Patient’s Particulars / Maklumat Pesakit (To be completed by the Patient / Diisi oleh Pesakit)
Patient’s Name / Nama Pesakit ___________________________________________________________
Patient’s I/C. No. / No. Kad Pengenalan Pesakit ______________________________________________ PF No. / No. PF _______________________
Visit Type / Jenis Lawatan Self / Sendiri Spouse / Suami / Isteri Child / Anak
Section B: Treatment at Panel Clinic / Rawatan di Klinik Panel (To be completed by the Patient / Diisi oleh Pesakit) Declaration by Spouse / Child (above eighteen (18) years of age) of Staff / Pengakuan daripada Suami / Isteri / Anak Pekerja (melebihi umur lapan belas (18) tahun). I hereby declare that / Saya dengan ini mengakui bahawa:
I am self-employed / unemployed / Saya bekerja sendiri / tidak bekerja.
My current employer does not provide such medical benefit / Majikan saya tidak menyediakan kemudahan perubatan seperti ini.
I have fully utilised my entitlement of medical benefits for this year / Saya telah menggunakan sepenuhnya kelayakan kemudahan perubatan untuk tahun ini.
The medical benefits provided by my employer is inferior to the family medical benefits provided to my spouse by Maybank / Kemudahan perubatan yang diberi oleh majikan saya tidak sebagus kemudahan perubatan keluarga yang diberi kepada suami/isteri saya oleh Maybank.
I am still pursuing continuous education (eligibility as stipulated in my parent’s Terms & Conditions of Service / Collective Agreement) / Saya masih melanjutkan pengajian (kelayakan adalah seperti di dalam Terma & Syarat Perkhidmatan / Perjanjian Berkelompok ibubapa saya).
Please provide documentary evidence (e.g. student card) / Bukti dokumen diperlukan (contoh kad pelajar)
Date of Visit / Tarikh Lawatan ____________________ Patient/Guardian’s Signature / Tandatangan Pesakit/Penjaga
Time of Visit / Masa Lawatan ____________________ __________________________________________________
Name / Nama __________________________________________________
Section C: Treatment Details / Butiran Rawatan (To be completed by the Clinic / Diisi oleh Klinik)
Remark
Medication Quantity / Dosage Price (RM)
Other (please specify)
MC Days : ________________day(s)
Date From ______________________ to ______________________
------------------ (Please detach & return the completed slip below to Etiqa for Payment)--------------------- Section D: For Etiqa Submission / Untuk Penyerahan Kepada Etiqa
Clinic’s Name / Nama Klinik ___________________________________________________________ Clinic’s Code / Kod Klinik __________________
Contact person __________________________ Tel. No. / No. Tel. __________________ Email / Emel ________________________________________
Patient’s Particulars / Maklumat Pesakit (To be filled by the Patient / Diisi oleh Pesakit)
Patient’s Name / Nama Pesakit ____________________________________________________________
Patient’s I/C. No. / No. Kad Pengenalan Pesakit _______________________________________________ PF No. / No. PF _________________________
Visit Type / Jenis Lawatan Self / Sendiri Spouse / Suami / Isteri Child / Anak
Date of Visit / Tarikh Lawatan ___________________
Time of Visit / Masa Lawatan ____________________
Charges RM Sen
Consultation
Medication
Injection
Nebulizers / Vaccination
Surgical Procedures
Lab / X-rays
Other
Total
Doctor’s Signature AND Clinic Stamp
Name / Nama :
Patient/Guardian’s Signature / Tandatangan Pesakit/Penjaga
_______________________________________________
Name / Nama _______________________________________________
Total Amount (RM) Etiqa Claim No.
