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Clinical Abstract Application Form

This document contains an application form for a medical report from a hospital or clinic. It notes that the form must be completed by the patient or their legal guardian if the patient is under 18. It authorizes the doctor in charge to provide a detailed medical report including test results to the insurance company for the patient's insurance application. The patient or guardian must sign the form and it must be witnessed by another person providing their signature and contact details.

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cachoydap
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875 views1 page

Clinical Abstract Application Form

This document contains an application form for a medical report from a hospital or clinic. It notes that the form must be completed by the patient or their legal guardian if the patient is under 18. It authorizes the doctor in charge to provide a detailed medical report including test results to the insurance company for the patient's insurance application. The patient or guardian must sign the form and it must be witnessed by another person providing their signature and contact details.

Uploaded by

cachoydap
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

CLINICAL ABSTRACT APPLICATION FORM

Proposal No. Policy No.

IMPORTANT NOTICE:
1) This form is required for the application of medical report from hospital / clinic.
2) This form must be completed and signed by the patient or the patient's parent / legal guardian (if patient is below 18 years of age),
and be duly witnessed.
3) This form is to be submitted to the clinic or Medical Records Department of the hospital with the appropriate fee charged.

Date (dd/mm/yyyy) :

Name of Patient:
NRIC No. :
Address:

To: Doctor-in-charge / Medical Superintendent

Name of Doctor:
Name of Department:
Period of Treatment: From to

Dear Sir / Madam,


RE: APPLICATION FOR MEDICAL REPORT
I hereby authorise you to furnish GREAT EASTERN LIFE ASSURANCE (MALAYSIA) BERHAD with a detailed medical report on the
injuries, illness and/or treatment done with copy of tests or investigations report done, if any, on the above named patient which is
required for the patient's application for assurance with them.

Yours Faithfully,

Signature of Patient Signature of Patient's Parent / Legal Guardian (if patient is below
18 years old)

Name:
NRIC No. :
Relationship:

STATEMENT OF WITNESS
I hereby certify that the signature in this form was made in my presence.
NBZ-FCLAA-V00-032015 (EN)

Signature of Witness
Name:
NRIC No. :
Address:

Great Eastern Life Assurance (Malaysia) Berhad (93745-A)


Head Office Menara Great Eastern 303 Jalan Ampang 50450 Kuala Lumpur
Telephone +603 4259 8888 Facsimile +603 4259 8000 3022152667
E-mail: wecare-my@[Link] Website: [Link]

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