Panel Application Form Panel Application FormCompany NameCompany Registration No.AddressTelFaxEmail AddressNo. of EmployeesNature of Business/IndustryContact PersonDesignationPricing LimitSpecial Requirements (if any)Facilities ChargeableNormal Medical TreatmentYesNoCall HRMinor SurgeryYesNoCall HRVaccination/ImmunizationYesNoCall HRPre-employment Medical ExamYesNoCall HROthersEmployee / Patient Identification MethodEmployee / Patient Identification MethodName list provided (please inform clinic promptly of any updates)Company Authorization Slips / Books / CardsClinic Attendance Chit / SlipStaff Tag / Company ID CARDOthers (please specify)Eligibility of Medical CoverageCompany Employees onlyYesNoFamily members coveredYesNoFamily of All EmployeesYesNoFamily of Management onlyYesNoIncluding children's vaccination under MOH* guidelinesYesNoIncluding pregnancy (antenatal/postnatal) careYesNoCharges Limitation / RequestPlease charge according to clinic ratesYesNoPlease limit charges to maximum of (RM) per visit (minimum RM40 EXCEPT in emergency cases)MYRAll the information provided are correct and valid as per my / our understanding. *I agree by clicking the submit button, all the information provided are correct and valid as per my / our understanding. We shall pay all medical bills within 30 days / 60 days from the date of receipt of your invoice. Either party may terminate relationship by giving 14 days written notice to the other party.Submit
