(Clinic Stamp)

Dear AIA,

RE: LETTER OF ACCEPTANCE

I/We hereby acknowledge and confirm that I/we have read your letter introducing the AIA Health Services
Programme and the terms set out in the AIA Health Services Working Arrangement.

In consideration of your agreeing to list the above clinic in the AIA Health Services panel at our request, I/We
hereby agree to the terms set out in the AIA Health Services Working Arrangement.

In the event I/we breach any terms set out in the Working Arrangement with AIA Health Services, I/we understand
that I/we will be deselected from the AIA Panel.

All payments are to be made in favour of _________________________________________________________

__________________________________________________________________________________________

Yours Sincerely,

_______________________________________________
(Signature & Date)

Proprietor/Doctor-in-Charge Name: ___________________________________________________________

NRIC No. : ___________________________________________________________