FORM MM201 (Part 1) Transmission: Arish Ali Lutfi Bin Zul 'Afiq Lutfi 141222140367
FORM MM201 (Part 1) Transmission: Arish Ali Lutfi Bin Zul 'Afiq Lutfi 141222140367
FORM MM201 (Part 1) Transmission: Arish Ali Lutfi Bin Zul 'Afiq Lutfi 141222140367
5. Please attach the completed form MM201 (Part I & II) together with your invoice for payment.
6. Please note that the following non-medical items are not covered:
Congenital Anomalies, Birth Control & Infertility investigation or treatment; Sexually Transmitted Disease; A.I.D.S; Cosmetic Surgery;
Psychiatry Disorder; and Dental Care. For complete listing, please refer to the Working Guidelines.
Yours faithfully, I, the abovenamed and/or on behalf of my dependent hereby consent to the
release of medical report and/or information to PMCare Sdn Bhd and my
Employer, and/or Payor for claims processing, adjudication, payment, and
reporting.
For and on behalf of
PMCare Sdn Bhd.
………………………………………………………
…………………………………………… Name :
Authorised Signatory NRIC No. :
Provisional Diagnosis
Final Diagnosis
Note: Once stable, please refer the patient back to the referring doctor or his/her regular GP with appropriate advise.