CLAIM FORM (for MN AL FALAH SDN.

BHD)
Month : _______________ Year : ________________________________
Personnel Name : __________________________________________
I/C : __________________________________________ Tel : ________________________________
Address : __________________________________________
Department / Position : __________________________________________ Email :
_____________________________________

Checklist
Fees $ (RM/hr) or Total no.of Time Sheet Clinical
Date Day Patient Name TYPE OF VISIT/ CARE Total Fees
(RM/session) hours Notes/
Report

Mileage

Grand Total (RM)

Note (as per Terms of Service) :
1) Claim(s) must be submitted weekly, 2weekly or monthly
2) Claim(s) will be processed when all forms are received and found to be complete
3) Processing of claim(s) within 3-5 working days

CLAIM BY (Signature) RECEIVED BY APPROVED BY (Signature)

Name :
Date : office use only office use only