clinic_registration_form

Healthcare Provider Empanelment Registration Form
SELECTION CRITERIA FOR SELCARE PANEL OF HEALTHCARE PROVIDER

1. Healthcare Provider must be registered with Malaysia Medical Council (MMC) and has a valid Annual Practicing Certificate (APC).
2. Facilities available e.g. : Internet, PC and Telephone.
3. Location.
4. Healthcare Provider Fees charged must adhere to Malaysian Medical Association (MMA)’s terms & conditions.
5. Business Hours.
6. Healthcare Provider Services.
7. For GP clinic applications,

a) Your GP clinic will be automatically empanelled under Selcare Third Party Administrator program .
b) Your application will be empanelled under the State Programs handled by Selcare Management subject to each of State
Government’s discretion. Please tick (X) your GP clinic’s location:-
7.1 Perak (Perak Sejahtera program) 7.3 Terengganu (Kad Sejahtera Terengganu program)
7.2 Selangor (Iltizam Selangor Sihat program) 7.4 Others (Please specify) : ____________________
c) Your GP clinic will be required to send all laboratory tests to Selcare Diagnostics for processing and analysis after success ful
empanelment.
If Healthcare Provider meets selection criteria, a letter of offer will be prepared upon receiving letter of acceptance from Healthcare
Provider, an agreement will be forwarded to Healthcare Provider to be signed by both parties . A copy will be given to panel Healthcare
Provider.
HEALTHCARE PROVIDER REGISTRATION CHECKLIST
No. Documents Checklist
1 Panel of Healthcare Provider: Letter of Invitation
2 Panel of Healthcare Provider: Details Form
3 Annual Practicing Certificate (APC)
4 Malaysian Medical Certificates (MMC)
Private Healthcare Facilities and Services Act 1998 (GP Clinic : Form B/Form F, Dental Clinic :
5
Form C, Hospital : Form G)
6 Healthcare Provider Summary of Charges
Company Registration Suruhanjaya Syarikat Malaysia for “Sdn. Bhd.” company only (Form 24 and
7
Form 49)
8 Bank Account Statement of Payee
Note: Please submit the completed application to our dedicated email at provider@selcare.com. Any enquiries
regarding this application to call our Customer Care at 1-800-22-6600.
FOR OFFICE USE ONLY

Approved / Rejected by: Signature
Reason Rejected Date D / /
SELCARE MANAGEME NT S DN. BHD. Page 1 SMS BFORM S/22, Rev. 11, Eff. Date: 7/08/2023
Panel of Healthcare Provider
- Letter of Invitation (LOI)
To SELCARE Management Sdn Bhd
Tel. No. 1-800-22-6600
Fax No. 03-5525 6900
Attention Provider Management Department
REPLY OF INVITATION / APPLICATION TO JOIN SELCARE A PANEL GP CLINIC
Hospital General Practitioner Dental Others _____________
Please tick either one.

YES. I would like to be a panel service provider of SELCARE Management Sdn . Bhd. I am pleased to forward to
you a quotation of our charges. Please forward to me a copy of the Letter of Appointment of which I shall
return to SELCARE Management Sdn. Bhd. signing.
NO. I am not interested in being a panel service provider of SELCARE Management Sdn . Bhd.
Healthcare Provider
Name
Doctor-in-charge Staff-in-charge
Name Name
MyKad / I.C No. MyKad / I.C No.
Membership / Membership /
Valid Practising No. Valid Practising No.
Contact No. Contact No.
Please tick where appropriate
Do you have internet connection for your PC? Yes No
Where do you station your computer terminal? Registration Counter Doctor’s Room
Your computer system network? Stand Alone Sharing / Networking
- Details Form
To SELCARE Management Sdn. Bhd.

Tel. No. 1-800-22-6600
Fax No. 03-5525 6900
Attention Provider Management Department
Dewan Undangan Negeri/

State Constituency
Healthcare Provider
Name*
Party to be Named in
Service Agreement
*(Healthcare Provider Name / Company Name – please provide us “Form 49” if registered
as “Sdn. Bhd.”)
Group of (if any)
Address
Postcode City / Town

Healthcare Provider
Latitude Longitude
Coordinates
Healthcare Provider 24 Hours a day Others. Please specify below:
Hours
i) Monday to Friday. Time
ii) Saturday. Time
iii) Sunday. Time
Tel. No. Mobile No.
Email
Bank Details Payee Name
Payee Bank
Payee Bank Account No.
Payee NRIC (if individual)
Payee Business Registration No. (BRN)

(if sole Proprietor / Partnership)
Payee Company No. (if Company)
Important note: Please attach the latest copy of “Perakuan Amalan Tahunan” (Annual Practicing Certificate).
Signature Healthcare
Provider Stamp
Name
Date D / /
- Summary of Charges
Rate / Charges
No. Type of treatment Internal Use
(RM)
1 Consultation only
2 Consultation and Medication (General)
3 Consultation + Medication + Injection
4 Minor Surgery (procedure)
5 X-ray
6 Simple investigation
Blood glucose test
Urine test (using test strip)
ECG
Ultrasound examinantion
Pap Smear
7 Pre-employment Medical Check-up (please list out all the tests)
Prepared by
Healthcare Provider Stamp
Name
Designation

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Healthcare Provider Empanelment Registration Form

SELECTION CRITERIA FOR SELCARE PANEL OF HEALTHCARE PROVIDER

2. Facilities available e.g. : Internet, PC and Telephone.

6. Healthcare Provider Services.

7. For GP clinic applications,

HEALTHCARE PROVIDER REGISTRATION CHECKLIST

No. Documents Checklist

1 Panel of Healthcare Provider: Letter of Invitation

2 Panel of Healthcare Provider: Details Form

3 Annual Practicing Certificate (APC)

4 Malaysian Medical Certificates (MMC)

6 Healthcare Provider Summary of Charges

8 Bank Account Statement of Payee

FOR OFFICE USE ONLY

Reason Rejected Date D / /

To SELCARE Management Sdn Bhd

Tel. No. 1-800-22-6600

Fax No. 03-5525 6900

Attention Provider Management Department

REPLY OF INVITATION / APPLICATION TO JOIN SELCARE A PANEL GP CLINIC

Hospital General Practitioner Dental Others _____________

Please tick either one.

MyKad / I.C No. MyKad / I.C No.

Contact No. Contact No.

Please tick where appropriate

Do you have internet connection for your PC? Yes No

Your computer system network? Stand Alone Sharing / Networking

To SELCARE Management Sdn. Bhd.

Dewan Undangan Negeri/

Group of (if any)

Postcode City / Town

ii) Saturday. Time

iii) Sunday. Time

Tel. No. Mobile No.

Bank Details Payee Name

Payee Bank Account No.

Payee NRIC (if individual)

Payee Business Registration No. (BRN)

Payee Company No. (if Company)

2 Consultation and Medication (General)

3 Consultation + Medication + Injection

4 Minor Surgery (procedure)

Blood glucose test

Urine test (using test strip)

7 Pre-employment Medical Check-up (please list out all the tests)

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