Our Ref: MR2/____________

CONSENT OF APPLICATION FOR MEDICAL REPORT

1) Application Particulars
Applicant’s Name Wong Jun Huan
NRIC/ Passport No. 961021-05-5071 Agent code 6658161
Relationship with
patient AGENT

Address
665 JALAN TEMIANG 70200 SEREMBAN
Email junhuan@myusminfo.com
Contact No. 016-243 6769 Call WhatsApp
2) Patient Particular
Patient’s Name CLARENCE LOW ZI GANG
NRIC/ Passport No. 101202-07-0115
Admission Date 13/03/2022
Consultant/
Doctor’s Name
DR KAHLIL KHAIRI
3) Medical Report Fee Schedule
Amount
No Type of Report Fee √ Endorsement
(RM)
1 Clarification Report For Insurance Company RM60
2 Insurance Form 1 Page RM60
3 Insurance Form 2 Pages RM80 80
Insurance Form/ Obstetrics and Gynaecology
4 RM100
Report >3 Pages
5 Insurance Form >5 Pages RM150
6 Medical Report / MAR RM150
7 Healing Progress Form RM50
8 SOCSO Report RM40
9 EPF (KWSP) Report RM50
10 Courier Service Charge RM8
11 Discharge Summary/ Investigation Report No Charge
12 Missing Of Medical Certificate (copy) No Charge
Police Report/ Government Report/
13 No Charge
Declaration Letter
14 All NGO’s Form and OKU, Baitumal Etc. No Charge

TOTAL
FOR OFFICE USE
Remarks: __________________________________________________________________________
Receipt No.: ______________________________________ Receipt Date: ____________________
Requested By: Collected By:

Signature: ___________________
Signature: ___________________
WONG JUN HUAN Name: ____________________________________
Name: _________________________________
961021-05-5071 NRIC : ____________________________________
Date : _________________________________
Date : ____________________________________
Note:
 The report will be processed after the received full payment.
 Please bring along authorise letter and a copy of patient’s NRIC/ Passport if apply on behalf.
CMH SPECIALIST HOSPITAL
Page 1 of 1 Consent of Application for Medical Report Form No. : CMH/MRD0004-21R03