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Transaction Form

This transaction form from Red Alert Online Sdn Bhd is for clinics to request top ups, itemizations, visit adjustments or transaction adjustments for patient accounts. It collects information like the clinic code and name, patient name and card number, visit date and time, charges and diagnoses. Doctors must sign off and the form is then submitted to Red Alert for approval and processing, with an adjustment code and any new or old transaction numbers provided.

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UMGC Sri Rampai
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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613 views1 page

Transaction Form

This transaction form from Red Alert Online Sdn Bhd is for clinics to request top ups, itemizations, visit adjustments or transaction adjustments for patient accounts. It collects information like the clinic code and name, patient name and card number, visit date and time, charges and diagnoses. Doctors must sign off and the form is then submitted to Red Alert for approval and processing, with an adjustment code and any new or old transaction numbers provided.

Uploaded by

UMGC Sri Rampai
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

RED ALERT ONLINE SDN BHD CALL CENTER : 03-2167 8126 FAX : 03-21678186

TRANSACTION FORM
Please Tick One
Top Up Itemization Add Visit Transaction Adjustment

CLINIC USE Date

Clinic Code
Clinic Name

Company Name

Patient Name

Patient Card No.

VISIT INFORMATION
Diagnosis Code 1 2 MC Days

Visit Date Visit Time am/pm

CHARGES RM Itemization
Consultation Name of Drug/Injection Quantity RM
Medication
Injection
Special Medication
Others (Please Specify)

Total amount charged

Item(s) need to be adjusted: MC Amount Others Please Specify

Remarks:

Doctor's Name :

Signature Clinic Rubber Stamp

RED ALERT USE Adjustment Done Not Done

Transaction Approval Code [1][2]

Old Transaction Number [3]

New Transaction Number [3]

Remarks :

Name / Signature Date

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