Great Eastern

HOSPITALISATION & SURGICAL CLAIM - ATTENDING PHYSICIAN'S STATEMENT
BORANG TUNTUTAN RAWATAN HOSPITAL - KENYATAAN DOKTOR YANG MERAWAT
Policy No. New NRIC No.

No. Polisi No. KP Baru
- -
Policy No. Old NRIC/BC/Passport No.
No. Polisi No. KP Lama/Sijil Kelahiran/
Policy No. Paspot
No. Polisi Name of Patient
Nama Pesakit
1. If treatment was a result from an accident, please provide details of accident. Jika rawatan akibat kemalangan, sila kemukakan butiran berikut.
Date of Accident Tarikh kejadian kemalangan Time Masa AM/PM Pagi/Petang
Nature of Accident Jenis Kemalangan
2. Hospitalisation Detail Butiran Masuk ke Hospital

Admission No. Nombor Pendaftaran
Date of Admission/Day Surgery Time Masa AM/PM Pagi/Petang
Tarikh Kemasukan Hospital/Pembedahan Harian
Date of Discharge Time Masa AM/PM Pagi/Petang
Tarikh Discaj
3. What were the symptoms the patient complained when he/she first saw
you?
Apakah simtom yang diberitahu oleh pesakit ketika pertama kali dia
berjumpa dengan anda?
4. The date on which you first saw the patient for this condition. Date Tarikh
Sila nyatakan tarikh pertama kali anda memberi rawatan kepada pesakit
bagi keadaan ini.
5. (a) According to the patient, how long had the patient been having
these symptoms prior to the initial consultation with you?
Berdasarkan maklumat yang diberi oleh pesakit, berapa lamakah
dia telah mengalami simtom ini sebelum kali pertama menemui anda?
(b) Based on your professional opinion, how long had the patient been
having these symptoms prior to the initial consultation with you?
Pada pandangan anda, berapa lamakah dia telah mengalami simtom
ini sebelum kali pertama menemui anda?
6. Had the patient previously received any medical consult for the above Yes Ya No Tidak
symptom(s)? If yes, please indicate the doctor's name, address, date Name Nama
of consultation and provide a copy of referral letter (if any).
Pernahkah pesakit menerima perundingan perubatan untuk simtom
diatas? Jika ya, sila nyatakan nama, alamat doktor tersebut, tarikh
rawatan serta berikan salinan surat rujukan (jika ada). Address Alamat
Date Tarikh
7. Have any investigation, test or procedure been performed? If yes,
Yes Ya No Tidak
please furnish us the detail or provide a certified true copy of result.
Adakah sebarang siasatan, ujian atau prosedur dilakukan? Jika ya, sila
nyatakan maklumat lanjut atau lampirkan satu salinan siasatan yang
disahkan daripada dokumen asal.
8. What was the diagnosis? Apakah diagnosis anda?
9. What is the underlying cause(s)/pathology/mechanism of injury for the

above diagnosis? Please indicate the doctor's name, address and date of
consultation (if any).
Apakah punca penyebab/patologi/mekanisme kecederaan bagi penyakit
diatas? Sila nyatakan nama, alamat doktor tersebut dan tarikh rawatan
(jika ada).
10. Did you inform the patient of the diagnosis? If yes, when? Yes Ya No Tidak
Adakah anda memberitahu pesakit tentang diagnosis tersebut? Jika
ya, bila? Date Tarikh
HSD-HSAPS-V02-042015
Great Eastern Life Assurance (Malaysia) Berhad (93745-A)
HealthCare Services Department, Level 16, Menara Great Eastern 303 Jalan Ampang 50450 Kuala Lumpur
Page 1 of 2 0493302023
Contact Centre Hotline: 1-300-1-300-18 Fax: (603) 4813 3598
E-mail: [email protected] Website: www.greateasternlife.com
11. Nature of medical treatment given/planned and/or surgery to be
performed.
Apakah jenis rawatan perubatan yang diberi/dirancang dan/atau
pembedahan yang akan dijalankan.
12. For surgery/procedure: Untuk pembedahan/prosedur:

(a) Indication and Nature of surgery/procedure performed
Petunjuk dan Jenis pembedahan/prosedur
(b) Name of surgeon(s)

Nama pakar bedah
(c) MMA OPCS code/PHFSR code
Kod MMA OPCS/Kod PHFSR
(d) Date(s) of surgery/procedure performed
Tarikh pembedahan/prosedur dilakukan
13. Has the patient previously been treated (outpatient) or Yes Ya No Tidak
hospitalised for this or any other disease? If yes, please furnish
the details. Date Tarikh
Pernahkah pesakit diberi rawatan secara pesakit luar atau
dimasukkan ke hospital untuk rawatan penyakit ini atau Illness Penyakit
penyakit-penyakit lain? Sila berikan maklumat lanjut.
Details of Treatment Butir Rawatan
Hospital/Clinic Hospital/Klinik
Address Alamat
14. Was the illness/condition caused directly or indirectly by the following condition. If yes, please tick.
Adakah penyakit ini secara langsung atau tidak langsung berkaitan dengan keadaan berikut. Jika ya, sila tanda.
Pregnancy/Childbirth/Caeserean section/Miscarriage/Prenatal/Postnatal/Sterilization/Infertility.
(If pregnancy related, gestation period _______ weeks).
Kehamilan/Kelahiran/Kelahiran secara Pembedahan/Keguguran/Sebelum Kelahiran Anak/Selepas Kelahiran Anak/Pensterilan/
Kemandulan. (Jika berkaitan dengan Kehamilan, tempoh kehamilan_____minggu).
Drug abuse/Intoxication
Penyalahgunaan Dadah/Kemabukan
Nervous/Mental/Emotional/Sleeping Disorder /Alternative Therapy
Penyakit Mental/Penyakit Gangguan Tidur/Alternatif Terapi
Cosmetic surgery/Dental care/Refractive errors connection
Pembedahan Kosmetik/Rawatan Pergigian/Pembetulan Penglihatan melalui Pembiasan
AIDS/HIV/STD/VD
AIDS/HIV/STD/VD
Self-inflicted injuries/Suicide/Attempted Suicide
Tindakan Melukakan Diri Sendiri/Bunuh Diri/Percubaan Bunuh Diri
Strike/Riot/Insurrection
Mogok/Rusuhan/Pemberontakan
None of the above
Semua diatas tidak berkenaan
Declaration
"I hereby certify that the information above are full, complete and true as per record from the hospital/clinic."
"Saya dengan ini mengesahkan bahawa maklumat di atas adalah lengkap dan benar mengikut rekod hospital/klinik."
Signature and Stamp of Attending Physician/Surgeon

Tandatangan dan Cop Pengawai Perubatan/Pakar Bedah
Name of Physician/Surgeon Hospital/Clinic
Nama Doktor/Pakar bedah Hospital/Klinik
Qualification Kelayakan Address Alamat
Contact No. No. Tel
Fax No. No. Faks
Date Tarikh
Page 2 of 2 6100302024

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HOSPITALISATION & SURGICAL CLAIM - ATTENDING PHYSICIAN'S STATEMENT

BORANG TUNTUTAN RAWATAN HOSPITAL - KENYATAAN DOKTOR YANG MERAWAT

Policy No. New NRIC No.

Nature of Accident Jenis Kemalangan

2. Hospitalisation Detail Butiran Masuk ke Hospital

9. What is the underlying cause(s)/pathology/mechanism of injury for the

12. For surgery/procedure: Untuk pembedahan/prosedur:

(b) Name of surgeon(s)

Details of Treatment Butir Rawatan

Signature and Stamp of Attending Physician/Surgeon

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