LOCUM DOCTORS CLAIMS FORM

MONTH: DECEMBER Ad Hoc Activation

YEAR: 2022 Weekdays 8-5 100.00
NAME: TEOH CHER SHONG Weekdays 5-12 125.00
BANK & ACCOUNT NUMBER: HONG LEONG BANK --> 04851333946 Weekends 125.00
DATE OF SUBMISSION: Additional Patient
on same visit 50.00

Use this column if you have been For provider that is

activated during "Standby" activate immediately

Housecall Related Avixo Related Ringgit Malaysia (MYR)

Per Case
Standby Rate Activation
No Date Time Avixo PNO Invoice Number (RM20 / hr) Ad Hoc Activation Procedures Mileage (RM0.30 / km) Toll Parking Total
(RM70 / visit)

1 12/10/2022 6PM-7PM 012171 KUL2212-02760 70 5 19KM (RM5.70) 2.1 82.8

2 12/10/2022 9PM-10PM 012169 KUL2212-02761 70 20 65KM+55KM (RM36) 6.77 132.77
3 12/10/2022 7PM-9PM 40 40
4 12/10/2022 10PM-12AM 40 40
5 12/18/2022 6PM-7PM 12214 KUL2212-02830 70 35KM(2 WAYS) (RM10.50) 80.5
6 12/18/2022 10PM-11PM 12222 KUL2212-02832 70 33KM(2 WAYS) (RM 9.90) RM17 96.9
7 12/18/2022 7PM-10PM 60 60
8 12/18/2022 11PM-12AM 20 20

Grand Total 552.97

Submitted by: Verified by: Approved by:

TEOH CHER SHONG

DR AARON CHEAH RYAN SOH
MEDICAL OFFICER DIRECTOR, CLINICAL SERVICES GENERAL MANAGER
DR TEOH CHER SHONG
Locum DR. Claim Guideline (Update as 06/12/22)

#1 All claim must be submit to Dr. Aaron email, aaron.cheah@speedoc.com by 5th of every month.
Example : All Nov 22 Claim (Between 04/11 - 04/12) should be submit by 5th Dec 22.

#2 Kindly use the locum rate below for your reference on activation & procedure rate
https://drive.google.com/file/d/102PPMJkb0PFVc2boQgb99sObnEX8VxHE/view?usp=sharing

#3 Details of every column as follow :

No Sequence Number
Date Date of Visit
Time Time of Visit

Avixo PNO Avixo patient registration number. If you are not sure on the registration
number, kindly put patient full name.
Avixo invoice number generated under patient profile. Kindly leave it blank
Invoice Number if you are not sure on the number
Standby Rate Use this column to claim on your standby hours with Speedoc
(RM20 / hr)
Per Case
Activation Use this column to claim on your activation rate during your standby period.
(RM70 / visit)
Use this column to claim on your ad-hoc activation rate when you have
Ad Hoc Activation been deployed immediately by Speedoc

Use this column to claim your procedure work. Kindly check on the table for
Procedures your claim reference
Mileage
(RM0.30/km) For all Mileage/Toll/Parking claim, Kindly provide together the evidence
from :
Toll
#1 - Google Map/Waze (Distance Travel between Clinic/Your Activation
Parking Place to Patient/Customer house)
#2 - TnG/E-Wallet, etc for tolls & parking claim
Total Your total claim for a particular visit

#4 Basically there are 2 type of activation which are :

A. Activation During "Standby"

For this claim, kindly use only Column G & Column H for Activation Claim. Your claim should be put as follow :
Standby Claim (RM20/h) + Activation Claim (RM70/visit) + Procedure Claim (Refer Table Rate) + Mileage Claim (RM0.30/km) - Including Tolls & Parking

B. Ad-Hoc Activation
For this claim, kindly use only Column I for Activation Claim. Your claim should be put as follow :
Ad-Hoc Activation Claim (Refer Table Rate) + Procedure Claim (Refer Table Rate) + Mileage Claim (RM0.30/km) - Including Tolls & Parking