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    Borang Helth Connect

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    klinik hafiz Putra perdana
    This document is a claims attendance log for LPPSA to track patient visits and claims submitted to Health Connect Sdn Bhd. It includes fields to record the patient name, membership number, IC number, visit date, amounts claimed and paid, as well as signatures from the patient and doctor. The log is to be submitted each month along with invoices to Health Connect by the 5th for verification and claims processing.

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    Borang Helth Connect

    Uploaded by

    klinik hafiz Putra perdana
    25 views1 page
    This document is a claims attendance log for LPPSA to track patient visits and claims submitted to Health Connect Sdn Bhd. It includes fields to record the patient name, membership number, IC number, visit date, amounts claimed and paid, as well as signatures from the patient and doctor. The log is to be submitted each month along with invoices to Health Connect by the 5th for verification and claims processing.

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    BORANG HELTH CONNECT

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    This document is a claims attendance log for LPPSA to track patient visits and claims submitted to Health Connect Sdn Bhd. It includes fields to record the patient name, membership number, IC number, visit date, amounts claimed and paid, as well as signatures from the patient and doctor. The log is to be submitted each month along with invoices to Health Connect by the 5th for verification and claims processing.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    25 views1 page

    Borang Helth Connect

    Uploaded by

    klinik hafiz Putra perdana
    This document is a claims attendance log for LPPSA to track patient visits and claims submitted to Health Connect Sdn Bhd. It includes fields to record the patient name, membership number, IC number, visit date, amounts claimed and paid, as well as signatures from the patient and doctor. The log is to be submitted each month along with invoices to Health Connect by the 5th for verification and claims processing.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    Download as docx, pdf, or txt
    of 1

    Claims Attendance Log - Separate Sheet by Company Clinic Information

    Company/ LPPSA Clinic Code Ph120


    Client Name Health Connect Sdn Bhd (599302-D) Clinic Name KLINIK HAFIZ
    F-G-6,Block-F,Pusat Komersial Parklane,No.21,Jalan SS7/26,
    Submission Period From To Kelana Jaya, 47301 Petaling Jaya, Selangor Tel:03-
    Contact Person Dr Linda
    Email-Id gphct@medix.com.my 7884 1919 Fax:03-7809 9333 Contact Number 03-83251902
    S. VISIT MEMBERSHIP NO PATIENT NAME IC No ACTUAL LESS TOTAL MC PATIENT CLAIM
    No DATE AMOUNT MEMBER AMOUNT SIGNATURE NUMBER
    PAY (EA)
    1

    GRAND TOTALS

    NOTICE TO PATIENT: By signing this Claims Attendance Log, you are hereby giving your NOTICE TO CLINIC: After register claim online, kindly submit your invoice together with
    consent for your medical record to be released to Health Connect Sdn Bhd and other relevant Claims Attendance Log to Health Connect for verification before, 5th of every month and
    parties in order to process your claim. please ensure that separate billing / invoice for different clients.
    DOCTOR’S SIGNATURE & STAMP

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