BORANG TUNTUTAN UNTUK RAWATAN PERUBATAN PESAKIT LUAR

Outpatient
Reimbursement Form
NAMA SYARIKAT :
Company Name :
Sila isi borang ini dengan HURUF BESAR
Please fill out this form in CAPITAL LETTERS

MAKLUMAT PEKERJA / EMPLOYEE INFORMATION

No.Kad Perubatan /No.IC:
Membership No / I/C No:
Nama Pekerja:
Name of EMPLOYEE:
Talian /Contact :

(HP no)
(Email)

Nama & No Akaun Bank :

Bank Account No & Bank Name :
# TREATMENT DESCRIPTION CODE
A

Asthma

Dc

Dental: * Extraction

Gastritis

Prenancy Related *

Backache, Bodyache, Joint Pains

Df

Dental: * Filling

Gy

Gynaecology * (NON-maternity related)

Others *

Cough, Cold, Sore Throat

Dt

Dental: * Scaling

Headache, Giddiness

Skin Conditions *

Cu

Cuts, Wounds, Scalding

Ear, eye infection

Hy

Hypertension

Vomiting

Diabetes

Em

Di

Diarrhoea

Emergency *

Immunisation *

* specify treatment or claim

Fever

will be returned / rejected

PERINGATAN PENTING

INCOMPLETE CLAIMS WILL BE RETURNED / REJECTED

Please attached the following:
1. Original Receipt/s (invoices, billings and credit card slips are NOT receipts)
2. Breakdown for Medication, Vaccination, Lab Test, Scans & X-ray (mandatory for billings above RM 150 for Specialist & RM 60 for GP)
Sila susun nombor resit tuntutan
Please Number & Arrange Your Receipts Accordingly
1 PENUNTUT / MAKLUMAT TUNTUTAN (CLAIMANT / PATIENT INFORMATION)

Jumlah / Receipt Amount (RM)

Nama Pesakit / Patient's Name:

Tarikh Rawatan/Date of Visit:

Total Bill :
GP

Petalian dengan Pekerja:

Relationship to Employee
# Diagnosis / Sakit
# Diagnosis / Illness

Sendiri /
Self

Suami-Isteri /
Spouse

Kanak-Kanak /
Child

Bil.Cuti Sakit(pekerja sahaja) /

MC Days (only for employees)

2 PENUNTUT / MAKLUMAT TUNTUTAN (CLAIMANT / PATIENT INFORMATION)

Jumlah / Receipt Amount (RM)

Nama Pesakit / Patient's Name:

Petalian dengan Pekerja:
Relationship to Employee
# Diagnosis / Sakit
# Diagnosis / Illness

Tarikh Rawatan/Date of Visit:

Sendiri /
Self

Suami-Isteri /
Spouse

Kanak-Kanak /
Child

Jumlah / Receipt Amount (RM)

Tarikh Rawatan/Date of Visit:

Sendiri /
Self

Suami-Isteri /
Spouse

Kanak-Kanak /
Child

Total Bill :

Bil.Cuti Sakit(pekerja sahaja) /

MC Days (only for employees)

GP
Rawatan Pakar / Specialist

4 PENUNTUT / MAKLUMAT TUNTUTAN (CLAIMANT / PATIENT INFORMATION)

Jumlah / Receipt Amount (RM)

Nama Pesakit / Patient's Name:

Tarikh Rawatan/Date of Visit:

Sendiri /
Self

Suami-Isteri /
Spouse

Kanak-Kanak /
Child

Total Bill :

Bil.Cuti Sakit(pekerja sahaja) /

MC Days (only for employees)

GP
Rawatan Pakar / Specialist

Saya dengan ini memberi kebenaran kepada Health Connect Sdn Bhd atau mana-mana pihak yang terlibat mendapatkan
rekod perubatan saya dari mana-mana doktor, hospital atau klinik dalam memproses tuntutan ini.
Saya dengan ini mengesahkan bahawa semua maklumat yang diberikan di dalam Borang Tuntutan ini
adalah benar dan lengkap
I hereby certify that the statements and information in this application form are true and correct to
the best of my knowledge and belief, I authorize Health Connect Sdb Bhd to investigate all statements
or other information contained in this application form and any attachments submitted with it,
unless I have stated in writing to the contrary.

Tandatangan Pekerja /
Employee's Signature

GP
Rawatan Pakar / Specialist

Nama Pesakit / Patient's Name:

Petalian dengan Pekerja:

Relationship to Employee
# Diagnosis / Sakit
# Diagnosis / Illness

Total Bill :

Bil.Cuti Sakit(pekerja sahaja) /

MC Days (only for employees)

3 PENUNTUT / MAKLUMAT TUNTUTAN (CLAIMANT / PATIENT INFORMATION)

Petalian dengan Pekerja:

Relationship to Employee
# Diagnosis / Sakit
# Diagnosis / Illness

Rawatan Pakar / Specialist

Tarikh Tuntutan /
Date of claim submissiion

Jumlah Tuntutan
/Claim Total

RM