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    rptHosOPGL 2

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    Subba Rao Semenchalam
    This letter guarantees payment for outpatient specialist treatment for Nongnut Subba Rao at Sunway Medical Centre from June 22 to July 6, 2021. The treatment is for cervical spondylosis with disc bulge, diabetes mellitus, dyslipidemia, and HPT. MiCare will pay up to RM500 and the patient must pay a RM15 co-payment. The guarantee covers consultation fees, treatment, procedures, x-rays, scans, labs, and drugs related to the treatment. It does not cover vitamins or unrelated drugs and tests. Original invoices and forms must be submitted to MiCare for reimbursement.

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    rptHosOPGL 2

    Uploaded by

    Subba Rao Semenchalam
    50 views1 page
    This letter guarantees payment for outpatient specialist treatment for Nongnut Subba Rao at Sunway Medical Centre from June 22 to July 6, 2021. The treatment is for cervical spondylosis with disc bulge, diabetes mellitus, dyslipidemia, and HPT. MiCare will pay up to RM500 and the patient must pay a RM15 co-payment. The guarantee covers consultation fees, treatment, procedures, x-rays, scans, labs, and drugs related to the treatment. It does not cover vitamins or unrelated drugs and tests. Original invoices and forms must be submitted to MiCare for reimbursement.

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    This letter guarantees payment for outpatient specialist treatment for Nongnut Subba Rao at Sunway Medical Centre from June 22 to July 6, 2021. The treatment is for cervical spondylosis with disc bulge, diabetes mellitus, dyslipidemia, and HPT. MiCare will pay up to RM500 and the patient must pay a RM15 co-payment. The guarantee covers consultation fees, treatment, procedures, x-rays, scans, labs, and drugs related to the treatment. It does not cover vitamins or unrelated drugs and tests. Original invoices and forms must be submitted to MiCare for reimbursement.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    50 views1 page

    rptHosOPGL 2

    Uploaded by

    Subba Rao Semenchalam
    This letter guarantees payment for outpatient specialist treatment for Nongnut Subba Rao at Sunway Medical Centre from June 22 to July 6, 2021. The treatment is for cervical spondylosis with disc bulge, diabetes mellitus, dyslipidemia, and HPT. MiCare will pay up to RM500 and the patient must pay a RM15 co-payment. The guarantee covers consultation fees, treatment, procedures, x-rays, scans, labs, and drugs related to the treatment. It does not cover vitamins or unrelated drugs and tests. Original invoices and forms must be submitted to MiCare for reimbursement.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
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    OUTPATIENT SPECIALIST TREATMENT GUARANTEE LETTER

    Our Ref : CQPVOP06210142 Claim No : CQPVCOP06210142


    Issue Date : 21 Jun 2021 Issued by : syarmizi
    Time : 10:08:24 PM
    Patient Information
    Patient Name : NONGNUT SUBBA RAO Patient IC : AA16566659
    Relationship : Spouse
    Hospitalization Information
    Consultation Date : 22 Jun 2021 Diagnosis : Cervical spondylosis with disc bulge, diabetes
    mellitus, dyslipidemia,HPT
    Hospital : SUNWAY MEDICAL CENTRE
    Guarantee Amount (RM) : 500.00
    Attending Doctor : Dr. Wong Ming
    Validity Period : 22 Jun 2021 - 06 Jul 2021 Coverage Type : Outpatient Specialist
    (Please submit a completed Outpatient Specialist Claim Form when submitting original invoices)
    If exceeded guarantee amount, please call MiCare for Top Up. Top Up is subject to the available balance.
    Please collect RM 15.00 co-payment from the patient.
    This GL is valid for 1 visit within 14 days.
    Insurance Policy Information
    Company Name : SUNWAY BERHAD (ETIQA) Employee Name : SUBBA RAO A/L V SEMENCHALAM
    Bill To : Sunway Berhad C/O MiCare Sdn Bhd
    Benefit Group : PLAN5 System ID : CQPV008436

    MiCare Sdn Bhd hereby guarantees to bear the medical and surgical expenses for the above treatment incurred by the
    aforesaid patient at your hospital. The guarantee of outpatient treatment is valid only for the above stated treatment provided
    by your hospital during the aforesaid specified date(s).

    This guarantee letter is ONLY applicable for Outpatient Specialist care and NOT for hospitalization and will only
    cover for ONE Outpatient Treatment inclusive of the following items:
    1) The Attending Physician's Consultation fees, Treatment and Procedure which medically related to the above treatment
    only.

    2) X-ray, Ultrasound, Scanning, Laboratory Test, which medically related to the above treatment only.
    This guarantee letter DOES NOT COVER the following items and shall be borne by the patient:
    1) Vitamins and any drugs not related to the treatment of the aforesaid diagnosis.

    2) Any test not related to the treatment of the aforesaid diagnosis.

    Please Note:
    1) The Patient understands that this letter does not supersede or vary the terms and conditions.
    2) If there is any other medical update, hospital to contact MiCare Sdn Bhd immediately at 1-800-88-2678 for further review.
    We will not accept excess charges without further reference to MiCare Sdn Bhd.
    Please post the original itemized bill, Guarantee Letter, and Outpatient Specialist Claim Form duly completed to:
    MiCare Sdn Bhd
    No. 22, Block A, Jalan Astaka U8/84,
    Seksyen U8, Bukit Jelutong,
    40150 Shah Alam, Selangor Darul Ehsan,
    (Attention: Claims Department)

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