QUOTATION FORM FOR OUTPATIENT TREATMENT (FOR RECORDING PURPOSE)
CLINIC NAME :
ADDRESS :
TELEPHONE NO :
FAX NO :
OPERATING HOURS :
E-MAIL ADDRESS :
INTERNET FACILITY :
X-RAY FACILITY :
A. Consultation Fee & Treatment Charges
1 Normal Operation Hours RM 10 - RM 25
2 24 Hours Service RM 25 - RM 30
ACUTE CASES & treatment CHARGES, eg: Fever, URTI, Headache,
Age, Gastritis, Skin Infection, Eye/Ear infection, Period pain, Injury.. Etc
1 URTI / Sore Throat
ACUTE Cases: there is NO ANNUAL LIMIT for LHDN staffs on VISITS & ACCUMULATED CHARGES
2 Cough / Cold STRICTLY: DO NOT COLLECT CASH from patient, if UNSURE, please call HELPDESK 04-202 0909 (24hrs)
3 Bronchitis Clinics are EXPECTED to maintain Treatment Charges within MARKET PRICE. THIS APPLY to ALL ACUTE CASES claims
4 Gastritis - charges for COMPLICATED or INJURY cases, please justify these charges, by DIAGNOSIS & ITEMIZE all treatment accordingly
- COMPLICATED cases, means, treatment may include injection, xray, blood test, certain medical procedures etc
5 Gastroenteritis / Diarrhea
- CLINICS are required to follow ASP PRICE (listed in the system), if the medicine is not listed, please contact HELPDESK 04-202 0909 (24hrs)
6 Fever - LHDN EXCLUSIONS, SPECIALIST/PAKAR or HOSPITAL based treatment/investigations & including PRESCRIPTIONS.
7 Vomiting - Clinic must ITEMIZE all claims: medicine name/dose/quantity, including blood test, xray, medical procedures, injection name etc
- Please itemize blood test contents (DO NOT use lab code), Xrays (body parts & no films), injections names, dressing/procedure details
8 Headache / Migraine /Vertigo - All Claims must have DIAGNOSIS (listed under ACUTE category, if not listed, choose ACUTE / OTHER, please add specific ACUTE diagnosis )
- PAYMENT may be WITHOLD if the diagnosis, either, not included, incomplete or suspicious (exclusions, unsually expensive than current market price)
9 Dermatitis / Skin Disorder
Panel will be TERMINATED
10 Eye Infection
1) if repeatedly breaching the above terms & conditions
2) Submission of FALSE CLAIMS (claims submitted in the system, not the same received by patients)
11 Ear Infection
take note: every patient will receive post visit notification (with charges & treatment details, submitted by clinic to ASP earlier)
12 Backache / Body ache
3) Any Appeals, should be made within 3 months after claim submission.
13 Burns & Scalds
14 Injury & Cuts
15 Gynaecological Disorder
CHRONIC CASES & treatment charges, eg: Hypertension, Diabetes, Hyperlipidaemia, etc ..
Hypertension
16 CHRONIC Cases: there is NO ANNUAL LIMIT for LHDN staffs on VISITS & ACCUMULATED CHARGES
Diabetes STRICTLY: DO NOT COLLECT CASH from patient, if UNSURE, please call helpdesk 04-202 0909 (24hrs)
- MAXIMUM supply of chronic mediactions is ONE month for EACH month,
Hyperlipidaemia
- SUPPLY beyond than ONE month , need official written approval from LHDN CYBERJAYA HR (only), other LHDN branches/cawangan are INVALID
- LHDN EXCLUSIONS: SPECIALiST/PAKAR, HOSPITAL based treatment/investigations & including PRESCRIPTIONS
17 Coronary Heart Disease etc
- CLINICS are required to follow ASP PRICE (listed in the system), if the medicine is not listed, please contact HELPDESK 04-202 0909 (24hrs)
Asthma, Chronic
18
Rhinitis/Sinusitis etc - Clinic must ITEMIZE all claims: medicine name/dose/quantity, including blood test, xray, medical procedures, injection name etc
- Please itemize blood test contents (DO NOT use lab code), Xrays (body parts & no films), injections names, dressing/procedure details
19 Chronic dermatitis, Eczema etc
- All Claims must have DIAGNOSIS (listed under CHRONIC category, if not listed, choose CHRONIC / OTHER, please add specific CHRONIC diagnosis )
- PAYMENT may be WITHOLD if the diagnosis, either, not included, incomplete or suspicious (exclusions, unusually expensive than current market price)
20 Chronic Thyroid Disorder
Panel will be TERMINATED
Osteoarthritis, Chronic Joint 1) if repeatedly breaching the above terms & conditions
21
Pain 2) Submission of FALSE CLAIMS (claims submitted in the system, not the same received by patients)
take note: every patient will receive post visit notification (with charges & treatment details, submitted by clinic to ASP earlier)
22 Piles, chronic backpain,
3) Any Appeals, should be made within 3 months after claim submission.
23 Anaemia etc
24 chronic neurological conditions
ANTENATAL - ANC) - LHDN EXCLUSIONS: specialist/pakar, hospital
treatment/investigations & including prescriptions
a) Ultra Sound RM 50 - 60 (2D scans only), EXCLUSIONS: specialist/pakar, hospital based antenatal checkups & treatment, including 3D-4D scans
25 RM 30 - 80 (Please itemize blood test contents, DO NOT use lab code), EXCLUSIONS: specialist/pakar & hospital based tests - investigations
b) ANC Blood Test Package
c) individual ANC tests /
RBS/FBS RM 20, UFEME RM 20, MGTT RM 70, IM ATT RM20
injection
d) Ante-natal supplements RM 10 - 50 (if clinically indicated), limited to Obimin, Folic, Iron, please include diagnosis. Eg: Antenatal check up & Enemia,
Medical Procedures
1 X-Rays: RM 50 for chest xray (CXR), RM 80 AP & LAT (2 films), RM 120 ( 3 films), RM 160 (4 films), please include BODY PARTS, NO of FILMS, EXCLUSIONS: Mammogram
2 Ultra Sound - abdomen RM 60 - 80 EXCLUSIONS : specialist/pakar & hospital based investigations eg: Ultrasound breast / Neck / Thyroid etc
3 Dressing RM 40. if above RM40, please itemize the details: material used, name, etc eg: gauge, bactigrass, safratule, etc
4 Nebulizer (per neb) RM 20-35, please itemize NEB content names & quantity, eg: ventolin, pulmicort, berodual, oxygen, etc
5 Minor Surgery
Incision & Drainage RM 30-90, foreign body removal RM 30-60, suture-glue stitch RM30-100 (please itemize no of sutures), referral letter RM 10
ECG RM 50, ear wax removal RM30-50 per ear, ivd/drips RM80, nail avulsion RM 50-100 (simplc, complicated),
6 injections: RM 20 each (voltaren, buscopan, maxalon, piriton), RM 35 (shincort, bufencon), EXCLUSIONS: vitamin, mecobalamin,
Others (procedures, injections)
please ITEMIZE all procedures & injections, if UNSURE please call HELPDESK 04-202 0909 (24hrs)
D. LAB & BLOOD TEST - Please ITEMIZE blood test contents eg: FBS, hb1ac, FLP, LFT, RP, TSH FT4,
hb1ac, ufeme, (DO NOT use lab code eg: QDG, G2000, M50)
EXCLUSIONS: ABO/RH blood group, Tumor Markers (psa, ca125, ca19-9, afp etc), Pap smears, STD screening (except antenatal), Hepatitis A or B screening
RM 50 - 150 EXCLUSIONS: ABO/RH blood group, Tumor Markers (psa, ca125, ca19-9, afp etc), Pap smears, STD screening (except antenatal), Hepatitis screening
a) Chronic Illness
LAB & BLOOD TEST - Please ITEMIZE blood test contents eg: FBS, hb1ac, FLP, LFT, RP, TSH FT4, hb1ac, ufeme, (DO NOT use lab code eg: QDG, G2000, M50)
1
b) FBC RM 35-55
1
RM 50 - 90, Please itemize blood test contents, eg: NS1, Ig M, Ig A, FBC, RTK Influenza RM 70, RTK covid RM 60
c) Dengue, Influenza, EXCLUSIONS: mycoplasma, rotavirus, leptospirosis, covid swab PCR, influenza swab PCR
E. Children under 2yo - Vaccinations (for LHDN)
LHDN will ONLY COVER: LATEST KKM SCHEDULE (under 2yo, including JE for sarawak), eg: pentaxim, hexaxim, infanrix, mmr, hep B (children), tetanus
if delayed (>2yo), please call HELPDESK for clarification & approval. 04-202 0909 (24hrs). Exclusions: rota virus, influenza, HPV, hepatitis A, meningococcal etc
1 a) Infanrix, hexaxim - 6 in 1 RM 180 STARTING 1dec2020, LHDN will cover PNEUMOCOCCAL VACCINES eg: SYNFLORIX RM 230, PREVENAR RM 290
b) Pentaxim - 5 in 1 RM150
c) MMR RM 60 - 75
ALL ADULT Vaccination are under EXCLUSIONS (including for Haji, Umrah, Personal Travel) , EXCEPT: for TETANUS (injury & antenatal cases only)
2
HEPATITIS B vaccination (LHDN only cover for PEGAWAI and for each DOSE (primary or booster), LHDN will only cover HALF of the cost (1/2 of RM60), Pegawai need to pay for the balance RM30
I AGREE with all the above TERMS and CONDITIONS (including the EXPECTED CHARGES & Medical EXCLUSIONS)
Clinic Stamp & Address
Dr Incharge or PIC Name & SIGNATURE:
Date :
