MiCare Sdn Bhd (727400-M)

(formerly known as Metronic iCares Sdn Bhd)

Block A, No. 22, Jalan Astaka U8/84,
Seksyen U8, Bukit Jelutong,
40150 Shah Alam,
REIMBURSEMENT MEDICAL FORM Selangor Darul Ehsan
Borang Tuntutan Kemasukan Hospital General Line: 03-7843 9459 / 03-7839 7200
Private and Confidential / Sulit dan Persendirian 24 Hours Hotline: 03-7839 7813
Fax No: 03-5590 5207 / 03-5590 5208

Part 1 (To be completed by Patient / Claimant)

Bahagian 1 (Untuk diisi oleh Pesakit / Penuntut)
1. Patient Name: 2. NRIC (Old & New):
Nama Pesakit K.P. (Lama & Baru)
3. a. Date of Birth: b. Age: c. Sex: Male Female
Tarikh lahir Umur Jantina Laki-laki Perempuan
4. Address 5. Policy No. / Member ID/ Certificate No/ Plan/ Company Name :
Alamat No. Polisi / No. Ahli / No. Sijil / Pelan / Nama Syarikat

6. Tel No : 7. Pay to (Name) : ___________________________

No.Tel Bayar kepada (Nama)
(Home) : __________________ (Office) : ____________________
Kediaman Pejabat Bank & Branch : ___________________________
Bank & Cawangan
(Mobile) : __________________(Email) : ____________________
Bimbit Emel Account No : ___________________________
No Akaun
Admission Reason (tick) and answer accordingly
Sila tanda ( ) dan jawab soalan yang berkenaan
a. Occurred on: Date _______/________/_______Time ___________ am pm
Berlaku pada Tarikh Masa pagi petang

8. Accident b. Details of Accident:

Kemalangan Butir-butir kemalangan
a. Symptoms first appeared on: Date ______/_______/______
Tarikh simptom tersebut bermula Tarikh

9. Illness b. Doctor(s) consulted for this condition:

Penyakit Doktor-doktor yang dilawati bagi penyakit ini

c. Doctor’s or Clinic Contact(Address & Telephone):

Alamat & Telefon Doktor

10. Is the claim for Pre / Post-hospitalization treatment? Yes / No (If yes, kindly indicate the date of admission ) ____/____/_____
Adakah tuntutan ini untuk rawatan Pra/Susulan hospital? Ya / Tidak (Jika ya, sila nyatakan tarikh kemasukan wad)

11. Declaration and authorization

I declare that the answers given above are true and complete to the best of my knowledge and belief.

I understand the delivery of this form is in no way an admission of claim by MiCare/Payor Company/the Insurer and payment to the hospital by MiCare/Payor Company/the Insurer or its representative
shall not be construed as final admission of claim by MiCare/Payor Company/the Insurer for this and any further claims arising, MiCare/Payor Company/the Insurer reserves all rights for evaluation as
appropriate.

I am fully aware of the limits as to my/covered person’s medical/Takaful entitlement under the above-mentioned policy. I hereby undertake to settle/reimburse any medical expenses exceeding my
entitlement under the said policy contract, or that is not covered by the same.

I hereby irrevocably authorize any organisation, institution, or individual that has any record or knowledge of my health and medical history or treatment or advice that has been or may hereafter be
consulted, other personal information or details of related accident/injury, to disclose to MiCare/Payor Company/the Insurer or its representative such information. I agree that MiCare/Payor
Company/the Insurer or its representative may use or disclose any of the information collected or held to third parties (within or outside Malaysia, including MiCare's/the Insurer’s/ Payor Company's
parent company, subsidiaries or any other associated companies within the MiCare/ Payor Company Group /the Insurer, reinsurers/retakaful, medical examiners, claims investigators and industry
associations/federations etc.) in relation to this claim. This authorization shall bind my/the covered person’s successors and assigns and remain valid notwithstanding my/ covered person’s incapacity in so
far as legally possible. A photocopy of this authorization shall be valid as the original.
I agree that in the event I make, or have in the past made, any false or untrue statement and/or suppressed and/or concealed any material facts in respect of my/the covered person’s condition,
MiCare/Payor Company/the Insurer shall absolutely forfeit my/the covered person’s right to compensation and further reserves the right to recover any amounts paid earlier as a result thereof.

Pengisytiharan dan pemberikuasa

Saya mengisytiharkan bahawa jawapan yang diberikan di atas adalah benar dan lengkap setakat pengetahuan dan kepercayaan saya.

Saya memahami bahawa penyerahan borang ini, tidak sama sekali boleh dianggap sebagai persetujuan tuntutan saya/orang yang dilindungi ke atas MiCare/Syarikat Pembayar/pihak Insurer dan saya
bersetuju bahawa bayaran kepada hospital oleh MiCare/Syarikat Pembayar/pihak Insurer atau wakilnya tidak akan ditafsirkan sebagai persetujuan muktamad tuntutan ke atas MiCare/Syarikat
Pembayar/pihak Insurer dan MiCare/Syarikat Pembayar/pihak Insurer berhak menjalankan penilaian sewajarnya berhubung tuntutan ini atau apa-apa tuntutan yang timbul selanjutnya.

Saya memahami sepenuhnya had-had kelayakanTakaful/Perubatan saya di bawah Polisi yang tersebut di atas. Saya dengan ini berjanji akan menyelesaikan sebarang amaun yang melebihi had kelayakan saya,
yang tidak dilindungi oleh Polisi berkenaan.

Saya yang bertandatangan di bawah, dengan ini membenarkan pada setiap masa, mana-mana organisasi, institusi atau individu yang mempunyai apa-apa rekod atau pengetahuan tentang kesihatan dan latar
belakang atau rawatan atau nasihat perubatan saya/orang yang dilindungi, yang telah atau mungkin kemudian dari ini dirujuk untuk mendedahkan kepada MiCare/Syarikat Pembayar/pihak Insurer atau
wakilnya segala maklumat tersebut. Saya bersetuju membenarkan MiCare/Syarikat Pembayar/pihak Insurer atau wakilnya untuk mengguna dan mendedahkan apa-apa maklumat yang dikumpul atau
dipegang kepada pihak ketiga (di dalam atau di luar Malaysia, termasuk syarikat induk, anak syarikat atau syarikat berkait dalam Syarikat, pihak Insurer, syarikat reinsurans/retakaful, pemeriksa perubatan,
penyiasat tuntutan dan pertubuhan/persekutuan industri dll.) berkaitan dengan tuntutan ini. Pengesahan ini hendaklah mengikat waris-waris dan penama saya/ nyawa yang dilindungi dan kekal sah meskipun
setelah kematian saya/orang yang dilindungi setakat yang dibenarkan di sisi undang-undang. Salinan pengesahan ini adalah sah. Saya bersetuju sekiranya saya membuat pengakuan palsu atau tidak
mendedahkan maklumat yang berkaitan, MiCare/Syarikat Pembayar/pihak Insurer berhak membatalkan tuntutan saya dan menarik balik sebarang tuntutan awal yang telah dibayar.

Signature of Patient /Tandatangan Pesakit Signature of Covered person/ claimant / Tandatangan Orang Signature of Witness / Tandatangan Saksi
yang dilindungi /Penuntut

____________________________________ ____________________________________ ____________________________________

Full Name/Nama Penuh : Full Name/Nama Penuh: Full Name/Nama Penuh:
IC No./No. KP : IC No./No. KP: IC No./No. KP:
Date/Tarikh : Date/Tarikh: Date/Tarikh:
Relationship to Patient:/ Hubungan dengan Pesakit Contact No / No untuk dihubungi:
Part 2 TREATMENT DETAILS ( TO BE COMPLETED BY ATTENDING DOCTOR )
1.a. Patient name: b. NRIC: c. Age: d. Sex: Male Female

2. Policy No. / Member ID/ Certificate No/Plan/ Company No: 3. Admission No. / MRN and Hospital Name/ Hospital Contact and Fax
No :
4. Admission Date and Time: 5. Discharge Date and Time:

6. a. Symptoms / Conditions requiring admission: b. How long is patient aware of the condition:

c. Patient’s BP/ Temp/ Pulse:

d. Date symptoms first appeared: ______/_______/______ e. Date first consulted: ______/_____/_____

7. a. Any previous consultation / treatment / hospitalization for this symptom / illness or related conditions, or other disorders whether in this hospital or
any other facilities? Yes No.
b. Was this patient referred? If Yes, please provide details below:

c. If this condition existed before symptoms became apparent to the patient, please indicate in your professional opinion how long has the condition
existed :

Date Disease / Disorder Details of Treatment / Hospitalization Doctor / Hospital/ Clinic

d. Can the condition be managed under the Outpatient basis: □ Yes □ No

If no please provide reasons of admission :

e. Any possibility of relapse? Yes No

8. Is the illness / condition related to: (please tick () if YES). Please provide details:
a) Pregnancy / Childbirth / Infertility/ Caesarean section/ miscarriage
Or any complications arising therefrom.
b) Congenital / Hereditary diseases
c) Influence of Drugs / Alcohol
d) Nervous / Mental / Emotional / Sleeping Disorder
e) Cosmetic reason / Dental care / refractive errors correction
f) AIDS / STD / VD/ HIV
g) Self-inflicted injuries / Violation of laws / Strike / Riots
h) None of the above

9. Medical treatment and Investigations performed, if any (please supply copy of all investigation results):

10. Any other medical/surgical conditions present? No Yes, details below: 11. Was the patient pregnant at the time of
hospitalization? (For Female Only)
a. _______________________________________________ since ______/_____/_____ No Yes, _______ months
b. _______________________________________________ since ______/_____/_____

12. a. If hospitalization was due to injury, please describe circumstances and cause of injury:

b. Please indicate date/time of accident: (dd/mm/yy) _______/________/______ (hrs) _____________ am pm

13. Undertaking Letter Ref No:( If available )

14. a. Final Diagnosis: b. Cause and pathology of the diagnosis:

ICD code:
15. Treatment given / Investigation done: (Please supply copy of all investigation results)

16. a. Surgical procedures performed: b. Date of surgery / procedure:

MMA code / PHFSR code:

17.a. Recovery complication that arose (if any):

b. In the case of DEATH, please advise Date/ Time and Cause of death :

18. I hereby certify that I have personally examined and treated the Patient for his/her injuries/illness described above and that the facts as stated above
represent my medical opinion of his/her condition.

________________ ______________________________________ __________________________________

Date Name & Signature of Attending Doctor Doctor / Hospital Stamp

Updated: 1/7/2017 (HRD)