Connecting Healthcare

ATTN.: GP PANEL MANAGEMENT TEAM DATE: …………………………….

OFFICIAL ACCEPTANCE AS MICARE PANEL 21-03-2018

(By fax: 03-5590 5208 or 03-7846 1664 / 3595)

I, the undersigned hereby confirm have read through, understand and accept of the following: -

1 - PROTOCOL as described under the FCS and FFS schemes

2- TERMS AND CONDITIONS duly set by MiCare.

3- List of services that are EXCLUSIONS.

4 - To submit all claims through MICARE PORTAL on REAL TIME basis.

5 - To REFER to MICARE for any concerns that may arise from time to time.

6- To ABIDE by all PROCEDURES AND PROTOCOLS as laid down by MMC in the practice of
medicine.

…………………………………………………..…………. (NAME AND IC NO) as (DOCTOR IN – CHARGE / CLINIC

OWNER) agree to abide by the above.
Attached herewith are the: -

a) Clinic information form duly filled up.

b) Clinic services.
c) Update of price list of services provided by clinic
COMPULSORY, please complete the next page. Thank you.

SIGNATURE OFFICIAL CLINIC STAMP

NAME OF DOCTOR IN - CHARGE

NAME OF CLINIC OWNER

TEL

FAX

EMAIL ADDRESS

MICARE SDN BHD (727400-M)

Block A, No. 22 Jalan Astaka U8/84, Section U8, Perindustian Bukit Jelutong,
40150 Shah Alam, Selangor D.E Malaysia
Tel: +603 7843 9459 Fax: +603 7847 4304
Email: customerservice@micaresvc.com Website: www.micaresvc.com