Lea 15224810
Lea 15224810
Lea 15224810
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 Affendi.Imran@sarawakenergy.com,
Alifah.Hassan@sarawakenergy.com, and YiiChange.Bong@sarawakenergy.com 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
Employee’s Name :
Patient Name :
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 )
Final Diagnosis :
Sick Leave :
Illness / Injury related to : (if any)
I hereby declare that the information given by me is full, complete to the best of my knowledge and true.