CONSENT TO RELEASE INFORMATION

SURAT KEBENARAN MENGELUARKAN MAKLUMAT

Dear Sirs/Tuan/Puan

POLICY NO :
Polisi No

NAME OF ASSURED & NRIC No (new and old) :

Nama Pemegang Polisi & No KP (baru dan lama)

NAME OF LIFE ASSURED & NRIC No (new and old) :

Nama Hayat Yang Diinsurankan & No KP (baru dan lama)
________________________________________________________________________________________________

I/We, the above-named Assured/Life Assured J..JJJJJJJJJJJJJJJJJJJJJJJ. confirm as

follows./Saya/Kami, Pemegang Polisi/Hayat Yang Diinsuranskan seperti yang dinamakan di atas mengesahkan seperti
berikut :
1. I/We, consent to JJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJ...(“Medical
Service Provider”) to disclose and provide to PRUDENTIAL ASSURANCE MALAYSIA BERHAD (“PAMB”), LEVEL
17, MENARA PRUDENTIAL, 10 JALAN SULTAN ISMAIL, 50250 KUALA LUMPUR and/or its representatives any
and all health (physical and/or mental) and medical information about me/us and my/our health (physical and/or
mental) and medical history./Saya/Kami memberi kebenaran kepada JJJJJJJJ..JJJJJJJJJJJ..
(“Pemberi Perkhidmatan Perubatan”) untuk mendedahkan dan memberi kepada PRUDENTIAL ASSURANCE
MALAYSIA BERHAD, LEVEL 17, MENARA PRUDENTIAL, 10 JALAN SULTAN ISMAIL, 50250 KUALA LUMPUR
dan/atau wakil-wakilnya apa-apa dan segala maklumat kesihatan (fizikal dan/atau mental) dan perubatan mengenai
diri saya/kami dan rekod kesihatan (fizikal dan/atau mental) dan perubatan saya/kami yang lampau.
2. I/We, release PAMB and the Medical Service Provider from all legal responsibilities and liabilities that may arise from
this consent and disclosure./ Saya/Kami melepaskan PAMB dan Pemberi Perkhidmatan Perubatan daripada segala
tanggungjawab dan liability di sisi undang-undang yang mungkin berbangkit daripada keizinan dan pendedahan ini.

Thank you / Terima kasih

___________________________________________ _____________________________________
Signature of Assured/Life Assured/Parent Signature of Witness
Tandatangan Pemegang Polisi /Hayat Yang Diinsurankan/Ibubapa Tandatangan Saksi

m Name ___________________________________ Name _______________________________

Nama Nama

NRIC No ___________________________________ NRIC No _____________________________

No K/P No K/P

N Address ___________________________________ Address ______________________________

Alamat Alamat

Tel No ____________________________________ Tel No ______________________________

No tel No tel

Nov 2014 v2