FORM MM201 (Part 1) Transmission: Arish Ali Lutfi Bin Zul 'Afiq Lutfi 141222140367

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FORM MM201 (Part 1) TRANSMISSION

CRD : Sp/Hosp. Fax No. : 0342707300


GL Serial No. : 23081310092726 Other Fax No. : 0342702500
Previous GL Serial No. : 23081310092726 By Hand/Courier/Mail :
Date / Time of Issuance : 13/08/2023 10:9:28.470 Visit Type : FOLLOW UP
Attention :
DR MOHD NASIR HASSAN
Service Type :
CONSULTATION
To :
KPJ AMPANG PUTERI SPECIALIST HOSPITAL
Appointment Date :
14/08/2023

GUARANTEE LETTER (“GL”)


GL Validity Period:
i) To be utilized until 26/08/2023
ii) For one (1) Outpatient visit only.

Name of Patient: NRIC No.:


ARISH ALI LUTFI BIN ZUL 'AFIQ LUTFI 141222140367
Name of Employee: Relationship:
ZUL 'AFIQ LUTFI BIN MOHD KARIB CHILDREN
Name of Employer: Program Type:
TM TECHNOLOGY SERVICES SB TPA
PMCare Member ID: Benefit Plan:
T5B_Y05
00047141-C1 GP,SP,HP(SBR)_M
1. This is to acknowledge that PMCare Sdn Bhd undertakes to make payment for Outpatient visit expenses incurred for abovenamed patient NOT
EXCEEDING the following limits stated in Item No. 2.

2. The abovenamed patient is entitled to (RM) AS CHARGED

3. Diagnosis (Provisional or Primary)


INFLUENZA DUE TO OTHER IDENTIFIED INFLUENZA VIRUS WITH OTHER RESPIRATORY MANIFESTATIONS

4. Kindly note that:


a. Expense entitlement is only for or directly related to medical / surgical condition referred to the Diagnosis as per above Item No. 3.
b. PMCare will not pay or be responsible for any expenses in excess of the above entitlement or incurred for non-entitlement as indicated
above. The excess amount must be recovered by the hospital from the patient upon their discharge.
c. Payment of claim is subject to timely submission of complete documents, i.e. within 7 days from date of service or discharge.
d. Maternity Benefits coverage does not include expenses incurred for newborn beyond prenatal period.

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. :

PMCARE SDN BHD (458443-P)


No.1, Jalan USJ 21/10, UEP Subang Jaya, 47630 Selangor, Malaysia. General Line: 03-8026 6888
Careline: 03-8026 7799 Careline Centre Fax: 03-8023 9999 Email: gl@pmcare.com.my
OPS/GL-DA-1a, Rev 10, Eff Date: 01/03/2018 Page 1 of 2 PMC_OP_1
FORM MM201 (Part II)

GL Serial No. : 23081310092726 Visit Type : FOLLOW UP


GL Issued To : KPJ AMPANG PUTERI SPECIALIST HOSPITAL
Service Type : CONSULTATION
Appointment Date : 14/08/2023

Name of Patient: NRIC:


ARISH ALI LUTFI BIN ZUL 'AFIQ LUTFI 141222140367
Name of Employee: Benefit Plan: T5B_Y05
ZUL 'AFIQ LUTFI BIN MOHD KARIB GP,SP,HP(SBR)_M

THE FOLLOWING ITEMS ARE NOT COVERED UNDER THE PROGRAM


Treatment by acupuncturist, homeopath and traditional Expenses incurred during hospitalization which are of a
medicine practitioner personal nature, e.g food, telephone, extra bed.
Contraceptive treatment such as taking family planning
pills, IUD, sterilization Treatment of cosmetic nature
Infertility treatment Abortion and venereal disease treatment
Aids for correction of eyesight and hearing Treatment arising from intentional or self-inflicted injuries

REASON FOR REFERRAL (Based on Referral/Previous Notes)


INFLUENZA DUE TO OTHER IDENTIFIED INFLUENZA VIRUS WITH OTHER RESPIRATORY MANIFESTATIONS

SPECIALIST CONSULTANT OR ADMISSION NOTES

Provisional Diagnosis

Final Diagnosis

ICD10 coding, if available


Since when condition deemed to have started

Major Procedure(s) - if any

Please indicate √ Pregnancy-related Chronic Psychological


if this illness Infertility-related Cosmetic MVA-related
or treatment is/are Congenital Work-related

Follow-up necessary? No Yes


Please indicate √ if patient needs to be/was crossed referred? No Yes

If Yes, to which specialist? (Please state reasons)

N/A = Applicable FU = Follow Up FV = First Visit

Signature of Attending Specialist Medical Facility Stamp

Note: Once stable, please refer the patient back to the referring doctor or his/her regular GP with appropriate advise.

PMCARE SDN BHD (458443-P)


No.1, Jalan USJ 21/10, UEP Subang Jaya, 47630 Selangor, Malaysia. General Line: 03-8026 6888
Careline: 03-8026 7799 Careline Centre Fax: 03-8023 9999 Email: gl@pmcare.com.my
OPS/GL-DA-1a, Rev 10, Eff Date: 01/03/2018 Page 2 of 2 1a_GL Part 2_Rev 9.doc

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