Clinic Claim Form - Etiqa v1 - etiqahc.com.my Claim Etiqa.pdf · Maklumat yang diberi adalah benar...
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Clinic Claim Form for Etiqa // Borang Tuntutan Klinik untuk Etiqa Section A: Clinic Particulars // Maklumat Klinik (To be filled by the Clinic // Diisi oleh Klinik) Clinic’s Name // Nama Klinik Clinic’s Address // Alamat Klinik Tel. No. // No. Tel. Fax. No. // No. Faks. Section C: Treatment Details // Butiran Rawatan (To be filled by the Clinic // Diisi oleh Klinik) Consultation Charges Total RM Sen Medication Injection Nebulizers / Vaccination Surgical Procedures Lab / X-rays Other Medication Remarks Others (please specify): Quantity / Dosage Price (RM) Medical Certificate: day(s) from to Patient’s / Guardian’s / Dependent’s Signature // Tandatangan Pesakit / Penjaga / Tanggungan To confirm treatment rendered // Sebagai pengesahan rawatan yang diterima. We confirm that all information provided is true and complete // Maklumat yang diberi adalah benar dan lengkap. Doctor’s Signature and Official Stamp // Tandatangan Doktor dan Cop Rasmi Please submit this form within 30 days from the treatment date to // Sila serahkan borang ini dalam masa 30 hari daripada tarikh rawatan kepada: Etiqa Insurance & Takaful, Medical Claims Department, Level 17 Tower B Dataran Maybank, No. 1 Jalan Maarof, 59000 Kuala Lumpur. Section B: Patient’s Particulars // Maklumat Pesakit (To be filled by the Patient // Diisi oleh Pesakit) Staff’s Name // Nama Pekerja PF No. // No. PF I/C. No. // No. Kad Pengenalan Patient’s Name // Nama Pesakit Guarantee Letter No. (for Specialist visit) // No. Surat Jaminan (untuk lawatan Pakar) Date of Visit // Tarikh Lawatan Self // Sendiri Child // Anak Spouse // Suami / Isteri Visit Type // Jenis Lawatan D01 Abdominal Pain / Cramps General H71 Acute Otitis Media / Myringitis A92 Allergy / Allergic Reaction R96 Asthma L02 Back Symptom / Complaint A72 Chicken pox F70 Conjunctivitis Infectious D12 Constipation R05 Cough S87 Dermatitis / Atropic Eczema T90 Diabetes Non-Insulin Dependent D11 Diarrhoea D07 Dyspepsia / Indigestion U01 Dysuria / Painful Urination H01 Ear Pain / Earache H81 Excessive Ear Wax A03 Fever D73 Gastroenteritis Presumed Infection T92 Gout U06 Haematuria K96 Haemorrhoids N01 Headache K86 Hypertension Uncomplicated L20 Joint Symptom / Complaint T93 Lipid Disorder X02 Menstrual Pain N89 Migraine D83 Mouth / Tongue / Lip Disease L19 Osteoarthrosis Other D86 Peptic Ulcer Other W78 Pregnancy W05 Pregnancy Vomiting / Nauseas S07 Rash Generalised D16 Rectal Bleeding F02 Red Eye R02 Shortness of Breath / Dyspnose R07 Sneezing / Nasal Congestion A08 Swelling R21 Throat Symptom / Complaint R76 Tonsilitis Acute A80 Trauma / Injury R74 Upper Respiratory Infection Acute N17 Vertigo / Dizziness A77 Viral Disease Other D10 Vomiting Reason for Visit // Sebab Lawatan: Etiqa Takaful Berhad Etiqa Insurance Berhad
Transcript of Clinic Claim Form - Etiqa v1 - etiqahc.com.my Claim Etiqa.pdf · Maklumat yang diberi adalah benar...
Clinic Claim Form for Etiqa // Borang Tuntutan Klinik untuk Etiqa
Section A: Clinic Particulars // Maklumat Klinik (To be filled by the Clinic // Diisi oleh Klinik)
Clinic’s Name // Nama Klinik
Clinic’s Address // Alamat Klinik
Tel. No. // No. Tel. Fax. No. // No. Faks.
Section C: Treatment Details // Butiran Rawatan (To be filled by the Clinic // Diisi oleh Klinik)
Consultation
Charges
Total
RM Sen
Medication
Injection
Nebulizers / Vaccination
Surgical Procedures
Lab / X-rays
Other
Medication
Remarks
Others (please specify):
Quantity /Dosage Price (RM)
Medical Certificate: day(s) from to
Patient’s / Guardian’s / Dependent’s Signature //Tandatangan Pesakit / Penjaga / Tanggungan
To confirm treatment rendered //Sebagai pengesahan rawatan yang diterima.
We confirm that all information provided is true and complete //Maklumat yang diberi adalah benar dan lengkap.
Doctor’s Signature and Official Stamp //Tandatangan Doktor dan Cop Rasmi
Please submit this form within 30 days from the treatment date to //Sila serahkan borang ini dalam masa 30 hari daripada tarikh rawatan kepada:
Etiqa Insurance & Takaful, Medical Claims Department,Level 17 Tower B Dataran Maybank, No. 1 Jalan Maarof, 59000 Kuala Lumpur.
Section B: Patient’s Particulars // Maklumat Pesakit (To be filled by the Patient // Diisi oleh Pesakit)
Staff’s Name // Nama Pekerja
PF No. // No. PFI/C. No. // No. Kad Pengenalan
Patient’s Name // Nama Pesakit
Guarantee Letter No. (for Specialist visit) // No. Surat Jaminan (untuk lawatan Pakar)
Date of Visit // Tarikh Lawatan
Self // Sendiri Child // AnakSpouse // Suami / IsteriVisit Type // Jenis Lawatan
D01 Abdominal Pain / Cramps GeneralH71 Acute Otitis Media / MyringitisA92 Allergy / Allergic ReactionR96 AsthmaL02 Back Symptom / ComplaintA72 Chicken poxF70 Conjunctivitis InfectiousD12 ConstipationR05 CoughS87 Dermatitis / Atropic EczemaT90 Diabetes Non-Insulin DependentD11 DiarrhoeaD07 Dyspepsia / IndigestionU01 Dysuria / Painful UrinationH01 Ear Pain / EaracheH81 Excessive Ear Wax
A03 FeverD73 Gastroenteritis Presumed InfectionT92 GoutU06 HaematuriaK96 HaemorrhoidsN01 HeadacheK86 Hypertension UncomplicatedL20 Joint Symptom / ComplaintT93 Lipid DisorderX02 Menstrual PainN89 MigraineD83 Mouth / Tongue / Lip DiseaseL19 Osteoarthrosis OtherD86 Peptic Ulcer OtherW78 PregnancyW05 Pregnancy Vomiting / Nauseas
S07 Rash GeneralisedD16 Rectal BleedingF02 Red EyeR02 Shortness of Breath / DyspnoseR07 Sneezing / Nasal CongestionA08 SwellingR21 Throat Symptom / ComplaintR76 Tonsilitis AcuteA80 Trauma / InjuryR74 Upper Respiratory Infection AcuteN17 Vertigo / DizzinessA77 Viral Disease OtherD10 Vomiting
Reason for Visit // Sebab Lawatan:
Etiqa Takaful Berhad
Etiqa Insurance Berhad
