Allianz @) Allianz General Insurance Company (Malaysia) Berhad (5108. Heder; Sth ee eA i Ser, Janse red tang Srl soo Lup ‘We ran an oa fete mabey Cater Seee: Ge et skh a eh dese ee fatness np POUCYWO. Na PoUs TOI Ta AO re NDS ase enc my ‘REIMBURSEMENT CLAIM FORM / BORANG TUNTUTAN BAYARAN INSTRUCTIONS / AN 1. This orn must be hl completed tad ay delay i the steent of cae Been pr i dengan engl nik meng sabre elect dal proses bay. 2 era rail / cepts covering hespaliaten and surg exenses fr whch cam smade mst beatae Sl prin et st esa dengan Dang 5. the patents hd an below 8 yeas of age, the asred shoud inthe statement af coset / any per hop ta pejagaji psa eur dl bonoh ‘etakin { INSURED INFORNATION/ MARLUMAT PIHAK DINSURANSKAN + Tobe led by the daimant Pre del ph yang menu ‘Name of sured / ono pik insonskon New cn Hou sou [ |. mm 4 (141 No / No KP Lama (Wapiti Hal ia Perego Pulsed an) | “elephoe No No lfon | PATIENTS INFORMATION / MAKLUMAT PESAKIT Tobe fle byte datmnt/ Pasa sce a ong menan Tae Piet aa Psa Dat of ith ok Loi elation wth seed set [] spouse [~] cna nea tear ae Sinel et ‘nangon degen pak dinaershon Sensi [| Paxongan [| Anat SERVICE INFORMATION / MAKLUMAT RAWATAN * Tbe led by the tending Doct Pe i lh Dor yng meronat Ll Preteens And (misono od [Epson (ncn nto ensen e [asters pe Ae eet een ene 2am | Cimeercaseminanmanscesenrsaartienta [_] teslbebe eset th: ate & Time ot Acdet Tah & se Kerang ‘TREATMENT DETAILS / KETERANGAN RAWATAN be ile bythe attending Dar / et dis cle Daio ong meant igus Jens peat (Onset ate / rth mule pry Procedure Posy Mediation / Usb Remar ee ese Dod’ Signature Date Tine Decir/ spt Stam Tandetangan Dator Tent xe Cap Doi Hosp (CLAIMANT'S OR PATIENT CONSENT / KEBENARAN DARI YANG MEMBUAT TUNTUTAN "hereby autorizeany physica hsp who has atanded to met faish or cose al known fac cncering any dl to ALLIANZ GENERAL INSURANCE COMPANY (MALAYSIA) BERHAD.A photocopy of tis autarzaon shale cuiered a effective and lds erga Soa merce cbvrar ep mannan doy hospi yang member mtn kp syst elimina at bet pant ede ALN CEN NSA COMP ALA EEO Sn een i hep ‘Sguatere of Patient] Guardian ite andtargan Psa Pej TelaHOSPITAL FORM For Pre-Admission / Admission Ez) asia assistance Plas complete form gly in BLOCK LETTERS using BLACK INK PEN. (X) were applica PATENT aes tein Monto Cad fsomiNo: HOURS HOTLNES — I 1800-18-1919 or 03-7628 3719 oy soir Mein Ca oc Fax: Se 03-7629 8850 / 03-7958 7677 LI “aloe pyvee emia a ae eve pr. A aioe an San Bnet ny pron tsh ona pseren ot mea ee ‘een toms own ate Taare nay aoe be ys acne my mes cs ante cra pst mde a en pte, de ‘esos ton See Shed ny wae reuse clammy by ke uate bral cats ptsng my wewarce cam ah coe e teSecnse calmed rand eeaela mara ean sso my ‘esperar bob Dspaes coanuh years Some “Daa ssisnce Nemec Sn Bude sae ect ah eon 6 edu saves pvr alesplan rede rd steed meen why see ran tenors ete tl covey sy nares nla) ‘easenwhauere fins Hare ber ses) funy ba wrens eu germ ny eotaxin ane yon my dee et dese se Toc ay ova They ute 8 nya nds Mel Ply oot ec sa esse ik ir 3 net epniaon ues rs) een eh te ated ea snc eek Seed ny bear eae nD ag Fone u's un oy bay Sage dey reed neers hey semeson ass acho dal eer si ny cane ieee acy Ours sn ox: tie Cra: i ep Cn Pon (9), please provide HISTORY opravios estes ae cation (@ Pasa provi Name & Atos ol praviou Pid (7) DIAGNOSIS (Please Cice: PROVISIONAL FINAL) sooe|_[ ]/(1]/ (@)ETIOLGGY ithe save danas (9) Wen pat const yo ri omg? ‘LO (10) Was Patent PREVIOUSLY TREATED fortis agnosis?’ Clves C1 No ‘Sao aio ate en pi aa nn ony ma svar ruven Amen] sata 2 Natewor tae tet site: ou: Cl [ /C hn Pena Cott 4 T aowissionoxte[ | ]/] 1 1/| Tee {| (0) Peserrg SYMPTOMS. atunet Aisin: {@)WTAL sien. [Fis cosuafons deo a ace. plete sat (jury Susie Te: ise (1 ectansmer uy. ees [T)/CL1/ I esp i (0) PHYSICAL ONS: a va rcceenoae T]/7L4/| met [Ld : (15 Hopton egies? ver Ine (1) This prose agro redo: Fregany ‘Cah Cl YesC] No ~ Aen ug ate CI Yes (Oe iste FAST TINE patents srs syrpars? Clon Lino | CengeraNeorat Cl YosC]N> eri Asie Dud) Yes HW ADS D Ves No Atonpte Side Sotsices C) Yes) Ho (17) Hos Paton SUFFERED fom /e Pat SUFFERING any ness saad blow? Hypatensin no Ces sree Cardiovasc tisease CINo Cl Yee ace GastoestnaOiseaso CIN CI Ves. sine Maignarey ot Arya C)No Cves size Diabetes Tne Fives since ()8| Ae OTHER MEDICAL CONGITIONS preset eon eed ard Unrated ‘Sure Siagnccs}? shoe (19) Name & Adore of tein Pystian tan (20) Peas sate TREATMENT PLAN: Tinindonas ny coe inlmoenon stom ftv ey ‘spe Inne spied Wt lmnon (cia eat hepoe, [Serpe AantegPyccanSapcn YES, please adie Date of Tesment and Name & Adesso Physi: OV/OVOT1 |) gn yer oon. has the CONDITION ERISTED? ye] veaie[_]_] none yea) ‘aa cians Heer (SB TEA) Lee A ne, Blo es Ov, T2A nn Ure Spas ohana Pea Spec {Adit Ovo Med (epPandons feel ame ply Dar» ae Ernest oti Pon conan - J aesHOSPITAL FORM For Discharge ED asiaassisrance Pease complete form leg n BLOCK LETTERS using BLACK INK PEN, (X] whee spicata Panes tna name DE OURS HOTINES = I 1800-18-1919 of 02-7628 3719 cpa sad oie nei orFax 03-7629 8850 03-7958 7677 = ame syn: ate = reel 7 scrance one | ]/[ 1 J/ Te (])FINAL DIAGNOSIS (Any ADDITIONAL Mea craton: Cote Cote ote (@) MEDICAL TREATMENT Provided (Peat state) » ip ii) (9) OtherTREATIENT(S) Provides (Please sate) a ) {6) MEDICATION dspensed (@)SURGICAL PROCEDURE PERFORMED IN CHRONOLOGICAL ORDER ‘SuagenyProcedure Date (applicable) saegeyProceeue bate eapicney: [| ]/ LL ]/ (1) Any possity ofa RELAPSE? (@)No of Mc cays given ‘SurgenyProcedure Dat i appleabe Ove Ifthe Final Diagnosis DIFFERS from the Admitting Dlagnasis, kindly flim below: (@)ETIOLOGY oft above dagnesis (10) How ong, in your opinion, has the CONDITION EXISTED? (12) Was Patient PREVIOUSLY TREATED fortis diagnosis? Cl Yes C1 No IVES, please advise Date of Treatment / /| and Name & Adress of Physician: (19) Ary COMPLICATIONS developed dung hussain? YES Kindy eaborae bbw ayo{_[ J wees [_]rounl_| rate (19) present agro elated i ‘Pregnancy! Cildbirth Dyes no argent eon Creve ‘HIV/AIDS DresO no Aethel/Ong bie Drene Menal/Amiey Oates Ces Ine Atiompted Suicide! Sef-nficied C1 Yes) No a (i) inte case DEATH, plas sve ierdnand ey deioetttenimaion [Bothnia roaibioame ‘rma poe pene aie | Dale fea “ee Death itherteiranmbee | /CL rn (6) CAUSE of Deat | ‘Sigatae of eimting PhyeoanvSingeen Sssteeeeiaaais = | (7D to: ‘Mele Phare Contact No: | ‘Ral Aasatance Network (it) Sch Bhd (7 O56H-A) Lvel © AA One, BisckW Jaya One, T2A Jalan Universit @280 Peiatg Joya, Scangor, Maloyla, Posi