AIA AFG Takaful Bhd.
(924363-W)
Health Services Department
Level 26, Menara AIA, 99 Jalan Ampang
50450 Kuala Lumpur
Tel No. : 03-2056 2666
Fax No. : 03-2056 2691
AIA-AFG.COM.MY
HOSPITALISATION CLAIM FORM
Borang Tuntutan Hospital
Part 1 (To be completed by Patient / Claimant)
Bahagian 1 (Untuk diisi oleh Pesakit / Penuntut)
1. Patient Name: 2. NRIC (Old & New):
Nama Pesakit K.P. (Lama & Baru)
3. a. Date of Birth: b. Age: c. Sex: Male Female
Tarikh lahir Umur Jantina Laki-laki Perempuan
4.Certificate No: 5. Admission / Planned Admission Date:
No Sijil Tarikh kemasukan hospital
6. Hospital Name: 7. Name of Attending Doctor:
Nama Hospital Nama Doktor yang merawat
Admission Reason (tick 3) and answer accordingly
Sila tanda (3) dan jawab soalan yang berkenaan
a. Occurred on: Date _______/________/_______Time ___________ am pm
Berlaku pada Tarikh Masa pagi petang
8. Accident b. Details of Accident:
Kemalangan Butir-butir kemalangan
a. Symptoms first appeared on: Date ______/_______/______
Tarikh simptom tersebut bermula Tarikh
9. Illness b. Doctor(s) consulted for this condition:
Penyakit Doktor-doktor yang dilawati bagi penyakit ini
c. Doctor’s contact (Address & Telephone):
Alamat & Telefon Doktor
10. Declaration and authorization
I declare that the answers given above are true and complete to the best of my knowledge and belief.
I, the undersigned, understand the delivery of this form is in no way an admission of AIA AFG Takaful Bhd.’s (“Takaful Operator”) liability and payment to the hospital by the Takaful Operator or its
representative shall not be construed as final admission of the Takaful Operator’s liability and for this and any further claims arising, the Takaful Operator reserve all rights for evaluation as
appropriate.
I am fully aware of the limits as to my medical takaful under the above-mentioned certificate. I hereby undertake to settle/reimburse any medical expenses exceeding my entitlement under the said
certificate contract, or that not covered by the same.
I, undersigned hereby irrevocably authorize any organization, institution, or individual that has any record or knowledge of my health and medical history or treatment or advice and that has been or
may hereafter be consulted, other personal information or details of related accident/injury, to disclose to the Takaful Operator or its representative such information. I agree that the Takaful Operator
or its representative may use or disclose any of the information collected or held to individuals/ organization related to and associated with Takaful Operator or selected third parties (within or outside
Malaysia, including retakaful operators, medical examiners, claims investigators and industry associations/federations etc.) in relation to this claim. This authorization shall bind my/the person
covered’s successors and assigns and remain valid notwithstanding my/person covered’s death or incapacity in so far as legally possible. A photocopy of this authorization shall be valid as the
original.
Pengisytiharan dan pemberikuasa
Saya mengisytiharkan bahawa jawapan yang diberikan di atas adalah benar dan lengkap setakat pengetahuan dan kepercayaan saya.
Saya memahami bahawa penyerahan borang ini, tidak sama sekali boleh dianggap sebagai pengakuan liabiliti AIA AFG Takaful Bhd. (“Pengendali Takaful”) dan bahawa bayaran kepada hospital
oleh Pengendali Takaful atau wakilnya tidak akan ditafsirkan sebagai pengakuan muktamad liabiliti Pengendali Takaful ke atas tuntutan ini atau apa-apa tuntutan yang timbul selanjutnya dan
Pengendali Takaful berhak menjalankan penilaian yang sewajarnya.
Saya memahami sepenuhnya had-had takaful perubatan saya di bawah sijil yang disebut di atas. Saya dengan ini berjanji akan menyelesaikan sebarang amaun yang melebihi had kelayakan saya,
yang tidak dilindungi oleh sijil berkenaan.
Saya yang bertandatangan di bawah, dengan ini membenarkan pada setiap masa, mana-mana organisasi, institusi atau individu yang mempunyai apa-apa rekod atau pengetahuan tentang
kesihatan dan latar belakang atau rawatan atau nasihat perubatan saya yang telah atau mungkin kemudian dari ini dirujuk untuk mendedahkan kepada Pengendali Takaful atau wakilnya segala
maklumat tersebut. Saya bersetuju membenarkan Pengendali Takaful atau wakilnya untuk mengguna atau mendedahkan apa-apa maklumat yang dikumpul atau dipegang kepada individu/
organisasi yang berhubung dan berkaitan dengan pengendali Takaful atau pihak ketiga yang dipilih (di dalam atau di luar Malaysia, termasuk syarikat induk pengendali retakaful, pemeriksa
perubatan, penyiasat tuntutan dan pertubuhan/persekutuan industri dll.) berkaitan dengan tuntutan ini. Pengesahan ini hendaklah mengikat waris dan penerima serah hak saya/orang dilindungi dan
kekal sah meskipun setelah kematian atau kehilangan upaya saya/orang dilindungi setakat yang dibenarkan di sisi undang-undang. Salinan pengesahan ini adalah sah sebagaimana yang asli .
________________________ _____/_____/_____ _________________________________
Signature of Patient / Claimant* Date Contact Number or Handphone
Tandatangan Pesakit / Penuntut* Tarikh Nombor untuk dihubungi atau Telefon bimbit
E-mail: _______________________________________
* If Claimant is not the Patient, please also state:
* Sekiranya Penuntut bukan Pesakit, sila nyatakan:
______________________ _________________________ ___________________________________
Claimant Name NRIC Relationship to Patient
Nama Penuntut No. KP Hubungan dengan Pesakit
Part 2 ADMISSION SECTION (To Be Completed by Doctor at Insured’s Own Expenses)
1.a. Patient name: b. NRIC: c. Age: d. Sex: Male Female
2. Certificate No: 3. Admission No. / MRN:
4. Admission Date: 5. Expected days of stay / Discharge Date:
6. a. Symptoms / Conditions requiring admission:
b. Date first appeared: ______/_______/______ c. Date first consulted: ______/_____/_____
7. Any previous consultation / treatment / hospitalization for this symptom / illness or related conditions, or other disorders whether in this hospital or
any other facilities? Yes No. If Yes, please provide details below:
Date Disease / Disorder Details of Treatment / Hospitalization Doctor / Hospital
8. a. Admitting Diagnosis: c. Diagnosis confirmed on _____/______/_____
Advised patient on _____/______/_____
or d. Cause and pathology underlying the present diagnosis:
b. Provisional Diagnosis:
e. Any possibility of relapse? Yes No
9. Estimated total 10. Is the illness / condition related to: (please tick () if YES). Please provide details:
costs: a) Pregnancy / Childbirth / Infertility
b) Congenital / Hereditary diseases
RM c) Influence of Drugs / Alcohol
d) Nervous / Mental / Emotional / Sleeping Disorder
e) Cosmetic reason / Dental care / refractive errors correction
f) AIDS / STD / VD
g) Self-inflicted injuries / Violation of laws / Strike / Riots
h) None of the above
11. Medical treatment, Investigations and Surgical procedure to be performed, if any (please supply copy of all investigation results):
12. Any other medical/surgical conditions present? No Yes, details below: 13. Was the patient pregnant at the time of
hospitalization? (For Female Only)
a. _______________________________________________ since ______/_____/_____ No Yes, _______ months
b. _______________________________________________ since ______/_____/_____
14. a. If hospitalization was due to injury, please describe circumstances and cause of injury:
b. Please indicate date/time of accident: (dd/mm/yy) _______/________/______ (hrs) _____________ am pm
15. I hereby certify that I have personally examined and treated the person covered for his/her injuries/illness described above and that the facts as
stated above represent my medical opinion of his/her condition.
_____________ ______________________________ ____________________________
Date Name & Signature of Attending Doctor Doctor / Hospital Stamp
DISCHARGE SECTION (To Be Completed Upon Discharge by Doctor)
16. Guarantee Letter Ref No.: 17. Date of Discharge:
18. a. Final Diagnosis: b. Cause and pathology of the diagnosis:
ICD code:
19. Treatment given / Investigation done:
20. Surgical procedures performed:
MMA OPCS code / PHFSR code:
21. Recovery complication that arose (if any):
_______________ _______________________________ ____________________________
Date Name & Signature of Attending Doctor Doctor / Hospital Stamp
