MediExpress (Malaysia) Sdn Bhd (474674-P)
F-G-7, BLOCK F, PUSAT KOMERSIAL PARKLANE
N0.21, JALAN SS7/26, 47301 KELANA JAYA, SELANGOR
Tel : 03-7884 1919 Fax : 03-7809 9333
LETTER OF GUARANTEE
(Please Submit Invoice within 15days after treatment date)
Name of Patient Sanusi Bin Ramli GL No. EA15224810-LINDA
Membership No. SEHA0152590*04-00 Date of Issuance 20/09/2023
Employee Name SANUSI BIN RAMLI Date of Appt. 27/09/2023
SARAWAK ENERGY BERHAD
Company Coverage OUTPATIENT TREATMENT
ONLY
Hospital BINTULU MEDICAL CENTRE[B296] Fax No.
Diagnosis MEDICAL HEALTH SURVEILLANCE - NOISE IC Number 810630136207
Treating Dr. DR TAN TEIK GUAN
Remarks 1. This GL is valid for Medical Health Surveillance only.
2. This GL valid for One (1) visit only within 7days from treatment date.
This is to confirm that we guarantee the medical expenses in connection with the outpatient
treatment of the above-mentioned patient up to a limit of – AS CHARGED
No.
Noise Surveillance - Hearing test Requirement
1. Audiometry test
** Please take note that we will cover the medical examination fee for the medical examination
and/or test called for only. Any other extra test(s) will not be covered.
1. Kindly direct all bills with itemized pharmacy report stating a complete DIAGNOSIS with separate by
individually of employee / staff to the above address.
Please email the copies of the individual candidates report in pdf format (softcopy) to DR AFFENDI
2. Please email the copy of the report in pdf format to email at [email protected],
[email protected], and [email protected] within 7 days
working days.
The above medical cardholder is scheduled for consultation / treatment at your hospital on the
above mentioned date. We hereby guarantee payment of the charges for this consultation /
treatment.
Any late sending of invoices to us (15days after treatment date) will not be entertained & paid.
Health Connect reserves the right not to make FULL payment to hospital if the above requirements are not
fulfilled
Thank you.
Yours faithfully,
MEDIEXPRESS (MALAYSIA SDN BHD
Foo Sik Ngo
Assistant Vice President
MediExpress (Malaysia) Sdn Bhd (474674-P)
F-G-7, BLOCK F, PUSAT KOMERSIAL PARKLANE
N0.21, JALAN SS7/26, 47301 KELANA JAYA, SELANGOR
Tel : 03-7884 1919 Fax : 03-7809 9333
OUTPATIENT SPECIALIST CLAIM FORM
Hospital / Clinic Name :
Employee’s Name :
Employee’s NRIC / Passport No :
Patient Name :
Patient NRIC / Passport No :
Date and Time of Consultation :
I, …………….......................................................... NRIC / Passport No………………………………………. do solemnly and sincerely
declare that the information provide is full, complete and true. I hereby authorize my medical record to be released to
my insurer, Health Connect Sdn Bhd in order to processing my insurance claim.
I hereby undertake to pay any excess to the above named hospital/clinic in the event that my outpatient specialist
treatment cost is not covered by the medical policy.
…..………………………………………………….. ....………………….
(Signature of Employee / Dependent) ( Date )
This column needs to be completed by attending Doctor / Specialist
Final Diagnosis :
Sick Leave :
Illness / Injury related to : (if any)
Congenital / Development Psychotic / Psychological Refractive Error
Pregnancy Cosmetic / Beauty Purposes Genetic/Hereditary
Infertility / Contraceptive Dental Others …………………………..
Declaration by attending Doctor / Specialist
I hereby declare that the information given by me is full, complete to the best of my knowledge and true.
………………………………………….. …………………….. ………………………...
(Signature Attending Doctor) ( Date ) (Doctor’s Stamp )
