KKM/LP/1/2008 HA (Pind.

2/2021)

BORANG PERMOHONAN LAPORAN PERUBATAN HOSPITAL AMPANG

A) Maklumat Pemohon * ( sila tandakan √ ) bagi Laporan siap : Pos Datang Ambil Sendiri
Applicant’s Details Please ( √ ) your option for report ready Post Collect at Counter

Nama Pemohon - Applicant’s Name :

No. KP (Baru) / Passport / Lain-lain : Hubungan Dengan Pesakit :
Ic No / Passport / Others Relationship with patient

Alamat Pemohon :
Applicant’s Address

No. Telefon - Telephone No : (H/P) Mobile No : Tandatangan / Signature :

B) Maklumat Pesakit / Simati – Patient’s Details / Deceased

Nama Pesakit / simati
:
Patient’s Name / Deceased name
No. KP (Baru) No. Passport / lain-lain
: :
Identification No Passport / Others
Jantina Lelaki Perempuan Umur Wad/ Klinik
: : :
(Gender) Male Female Age Ward / Clinic
Tarikh mula rawatan di klinik pakar / Tarikh masuk hospital
:
Date of treatment / date of admission
Tarikh keluar hospital / Tarikh meninggal dunia
:
Date of discharge / date of death
C) Laporan yang dipohon ( sila tandakan √ ) * - Type of the Application. Please ( √ ) the option
i) Laporan perubatan biasa oleh pegawai perubatan (RM 40) - Medical Report by Medical officer ( non citizen RM120 )
ii) Laporan perubatan biasa oleh pakar (RM 80) - Medical Report by Specialist ( non citizen RM 240 )
iii) Laporan terperinci oleh pakar (RM 200 – RM 1000 mengikut kerumitan)
- Details Report by Specialist according to complexity ( non citizen RM 400 - RM2000 )

Laporan perubatan diperlukan untuk PERKESO / INSURANS / BURUH ’90 / KWSP / lain-lain : ...................................................................................

D) Butiran Bayaran - Payment’s Details

Bersama-sama ini disertakan Cek / Kiriman Wang / Wang Pos bernombor ...................................................... / Wang Tunai berjumlah
RM .................... bertarikh ......................... bagi bayaran laporan tersebut.
Together this is included check / money Order / Postal Order numbered ................................... / Cash amounted to RM .......................
dated ......................... for the payment of the report

E) Keizinan daripada pesakit – Consent by patient

Saya membenarkan pihak hospital mengeluarkan laporan perubatan kepada pemohon bernama ................................................
......................................................................................No K.p / Passport ................................................... dan melepaskan pihak
Hospital dari sebarang tindakan perundangan yang berkaitan dengannya.
I hereby authorize the hospital to issue a medical report to the named applicant …………… ……..…………………..…………..
Ic.No / Passport: ........................................... And discharge the Hospital from any legal action in relation thereto.

F) Untuk Kegunaan Pejabat Rekod Perubatan

Tanda tangan / cop jari pesakit : .........................................................................
Sign / Thumb print Tandatangan
Nama Pesakit / Waris : .........................................................................
Patient’s Name / Beneficiary
No. KP Nama Saksi/Cop Rasmi :..........................................................
Ic No/Passport/Others : ........................................................................... Jawatan :..........................................................
Tarikh - Date : ............................................................................ Tarikh :..........................................................

Nota : Wakil yang hadir untuk mengambil laporan bagi pihak pemohon perlu mempunyai Surat Turun Kuasa
Note : Representatives who are present to take a report on behalf of the applicant must have Authorized from Applicant

G) Untuk Kegunaan Pejabat

Tandatangan : No. Resit :

No. Daftar Permohonan
Sign ......................................................................................... Receipt No ..................................

Nama ..................................................................... Tarikh Resit

: : ............................... .................................
Name . Receipt Dated
 SENARAI SEMAK PERMOHONAN LAPORAN PERUBATAN

A. PESAKIT (sendiri) – PATIENT

1. Salinan kad pengenalan/passport pesakit – Copy Identification/passport Patient
2. Salinan kad temujanji / discaj note / bil Hospital – Copy Appointment Card /Discharge Note /
Hospital Bill
3. Borang berkaitan (Insurans/KWSP/PERKESO/Buruh ‘90 dll) – Related Form
(Insurance/KWSP/PERKESO/’Buruh ’90 etc)
4. Bayaran - Payment

B. IBU BAPA (pesakit berumur 18 tahun kebawah) – PARENT (Patient below 18 years)
1. Salinan kad pengenalan/passport pesakit – Copy Identification/passport Patient
2. Salinan Sijil Lahir Pesakit – Copy of Patient Birth Certificate
3. Salinan kad pengenalan ibu/bapa/penjaga yang sah - Copy of valid parent Identity Card
4. Salinan kad temujanji / discaj note / bil Hospital
Copy Appointment Card /Discharge Note / Hospital Bill
5. Borang berkaitan (Insurans/KWSP/PERKESO/Buruh ‘90 dll)
Related Form (Insurance/KWSP/PERKESO/’Buruh ’90 etc)
6. Bayaran - Payment

C. WAKIL PESAKIT / WARIS TERDEKAT ( Suami Isteri, Anak, Adik beradik kandung)
– PATIENT REPRESENTATIVE / NEXT OF KIN (Husband Wife, Children, Biological
Siblings)
1. Surat keizinan ASAL dari pesakit (menyatakan nama agen atau wakil)
Original Consent letter from patient (mention agent name or representative)
2. Salinan kad pengenalan/passport pesakit – Copy Identification/passport Patient
3. Salinan kad pengenalan/pasport pemohon - Copy Identification/passport Applicant
4. Salinan kad temujanji / discharge note / bil hospital pesakit
Copy Appointment Card / Discharge Note / Hospital Bill
5. Borang berkaitan (Insurans/KWSP/PERKESO/Buruh ‘90 dll)
Related Form (Insurance/KWSP/PERKESO/’Buruh ’90 etc)
6. Salinan kad pengenalan ibu/bapa/penjaga yang sah (Jika berkaitan)
Copy of valid parent / guard Identity Car (If Applicable)
7. Salinan sijil nikah (jika berkaitan) – Copy of married Certificate (If Applicable)
8. Salinan sijil lahir (jika berkaitan) - Copy of Birth Certificate (If Applicable)
9. Perintah Makamah (jika berkaitan) – Court Order (if Applicable)
10. Salinan permit kubur / Sijil Kematian – Copy of graves permit / death certificate (If Applicable)
11. Bayaran – Payment

i) Borang KWSP, Insurans, PERKESO TIDAK disediakan. Sila dapatkan borang

berkenaan di jabatan/agensi berkenaan.
NOTA : KWSP, Insurance , PERKESO form NOT provided. Kindly please get the form at
the relevant department / agency

ii) Wakil yang hadir untuk mengambil laporan bagi pihak pemohon perlu mempunyai
Surat Turun Kuasa
Representatives who are present to take a report on behalf of the applicant must have
Authorized from Applicant

HOSPITAL AMPANG
JALAN MEWAH UTARA
PANDAN MEWAH 68000 AMPANG, SELANGOR
TEL: 03-4289 6000 SAMBUNGAN 6039