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We wish to appoint these clinics as our panel:
POLIKLINIK AMALMEDIK (ALL BRANCHES)POLIKLINIK AMALMEDIK TAMAN MELAWATIPOLIKLINIK AMALMEDIK KOTA DAMANSARAPOLIKLINIK AMALMEDIK KOTA WARISAN

Company Name*

Company Address*

Website

Tel*

Fax

Email*

No. of Employees*

Contact Person*

Designation*

FACILITIES CHARGEABLE
⦁ Normal Medical Treatment
YesNoCall HR

⦁ Minor Surgery
YesNoCall HR

⦁ Essential Laboratory / Urine Tests
YesNoCall HR

⦁ Chest X-ray
YesNoCall HR

⦁ Ultrasound / ECG
YesNoCall HR

⦁ Vaccination / Immunization
YesNoCall HR

⦁ Pre-employment Medical Exam
YesNoCall HR

⦁ Ultrasound-Guided Injection Pain Management
YesNoCall HR

⦁ Others: Yes

EMPLOYEE / PATIENT IDENTIFICATION METHOD (Please tick only one)
Company Authorization SlipsBooksCards Clinic Attendance ChitSlip Staff TagCompany ID CardOthers:

ELIGIBILITY OF MEDICAL COVERAGE
⦁ Company employees only
YesNo

⦁ Family members covered
YesNo

⦁ Family of All Employees
YesNo

⦁ Family of Management only
YesNo

⦁ Including children’s vaccination under MOH* guidelines
YesNo

⦁ Including pregnancy (antenatal/postnatal) care
YesNo

CHARGES LIMITATION/REQUEST
⦁ Please charge according to clinic rates (Please limit charges to maximum of RM.... per visit (Minimum RM35 and except in emergency cases)

I hereby agree to the terms and conditions mentioned in this letter. We shall pay all medical bills within 30 days from the date of receipt of invoice. Either party may terminate relationship by giving 14 days written notice to the other party.