FORM MM201 (Part 1) TRANSMISSION
CRD : Sp/Hosp. Fax No. : 082442600
GL Serial No. : 22082615001829 Other Fax No. : 082440055
Previous GL Serial No. : 22082615001829 By Hand/Courier/Mail :
Date / Time of Issuance : 26/08/2022 15:0:19.286 Visit Type : FIRST VISIT
Attention : CONS PHYSICIAN Service Type : CONSULTATION
To : NORMAH MEDICAL SPECIALIST CENTRE SDN Appointment
BHD Date : 30/08/2022
GUARANTEE LETTER (“GL”)
GL Validity Period:
i) To be utilized until 08/09/2022
ii) For one (1) Outpatient visit or one (1) Inpatient admission not exceeding five (5) days.
iii) For extension of admission, a new GL must be obtained upon expiry of five (5) days validity.
Name of Patient: NRIC No.:
RASHID B HAJI PADUPAI 630821135305
Name of Employee: Relationship:
RASHID B HAJI PADUPAI EMPLOYEE
Name of Employer: Program:
KUMPULAN WANG SIMPANAN PEKERJA_FLEXI TPA
PMCare Member ID: Benefit Plan:
KWB08_4OEA_IEB
K630821135305-I (GP&SP_30KAL)_(HP_R&B150_100KAL)
1. This is to acknowledge that PMCare Sdn Bhd undertakes to make payment for Outpatient visit / Admission expenses incurred for abovenamed
patient NOT EXCEEDING the following limits stated in Item No. 2.
2. The abovenamed patient is entitled to:
A total limit of not more than 800.00 ONLY
A daily Room & Board charges inclusive of Meals of not more than N/A
Surgical fees of not more than 0.00
Anesthetic fees of not more than N/A
Hospital Ancillary Services of not more than 0.00
A daily In–Hospital Physician Visit of not more than 0.00
Delivery Limit of not more than N/A
3. Diagnosis
ENCOUNTER FOR GENERAL ADULT MEDICAL EXAMINATION : NOT VALID FOR MEDICATIONS
Important note: Medications, vitamins and supplements are allowed up to a maximum of three (3) months supply if
prescribed for a valid medical indication declared by the attending doctor.
4. Kindly note that:
a. Expense entitlement is only for or directly related to medical / surgical condition referred to in above Item No. 3
b. Maternity Benefits coverage does not include expenses incurred for newborn beyond prenatal period.
c. 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.
d. Payment of claim is subject to timely submission of complete documents, i.e. within 30 days from date of service or discharge.
e. For extension of admission, the hospital must contact PMCare.
5. Kindly fax to our Careline Centre your final itemized bill, with diagnosis and surgical procedures done, so that we can advise you better on the
actual coverage, bills and payment.
6. Please attach the completed form MM201 (Part II) together with your invoice for payment.
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:
[email protected]OPS/GL-DA-38, Rev 1, Eff Date: 01/03/2018 Page 1 of 1 EPF_AP_1
FORM MM201 (Part II)
GL Serial No. : 22082615001829 Visit Type : FIRST VISIT
GL Issued To : NORMAH MEDICAL SPECIALIST CENTRE SDNService
BHD Type : CONSULTATION
Appointment Date : 30/08/2022
Name of Patient: NRIC:
RASHID B HAJI PADUPAI 630821135305
Name of Employee: Benefit Plan: KWB08_4OEA_IEB
RASHID B HAJI PADUPAI (GP&SP_30KAL)_(HP_R&B150_100KAL)
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
Treatment of cosmetic nature
pills, IUD, sterilization
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)
ENCOUNTER FOR GENERAL ADULT MEDICAL EXAMINATION : NOT VALID FOR MEDICATIONS
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:
[email protected]OPS/GL-DA-38, Rev 1, Eff Date: 01/03/2018 Page 2 of 2 38_GL Part 2_Rev 0.doc
