GUARANTEE LETTER REQUEST FORM

Important Notice referral letter or appointment card to us. : Please complete this form and fax/email together with yo ur Reason for seeking treatment...

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GUARANTEE LETTER REQUEST FORM To :PMCare Sdn Bhd Fax No. :03-8023 9999

PMCare Careline :1 300 88 6868 Email Address :[email protected]

Please fill up the details as follows: From

:___________________________________________________

Name of Employer

:___________________________________________________

Your Mobile number :_______________________

I m portant Notice : P lease com plete this form and fax / em ail together w ith your referral letter or appointm ent card to us. Reason for seeking treatment; please tick (√) whichever approriate:For Consultation

First Visit (please attach referral letter)

For Admission

Follow-up Visit (please attach appointment card)

Outpatient Post Hospitalization

Information on Employee & Patient: PMCare Membership ID

>

Name of Employee

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Employee NRIC number

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Name of Patient

>

Information on Clinic & Hospital/Specialist: Name of Clinic issuing referral letter

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Name of Hospital/Specialist referred to

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Name of Doctor you wish to meet

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Diagnosis

>

Date of visit/admission

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Information on recipient of Guarantee Letter: Contact number

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Email address

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GL to be faxed? a) Yes. If yes, please specify fax number

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b) No

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OPS/GL-DA-5, Rev 2, Eff Date: 25/03/14

Fax number

5_GL Request Form_Rev 2