Authorised claims administration

representative of AIA
AIA refers to AIA Bhd., AIA PUBLIC Takaful Bhd. and AIA General Berhad

AIA Health Services Sdn. Bhd. 199601016211 (388561–T)

Menara AIA, 99 Jalan Ampang
50450 Kuala Lumpur
P. O. Box 10140
50704 Kuala Lumpur
T : 03-2056 1111 / 03-2037 1333
T : 03-2056 2666 (Provider Line)
Care Line : 1300 88 1899 / 8860 / 8870 / 8933

AIA Health Services: Medi-Connect Portal Registration Form

AHS online portal for viewing of member's entitlement, document submission and retrieval of Guarantee Letter

A. PROVIDER DETAILS
Company Name & ROC No.

Business / Facility Name

(if different from above)

Address

B. ADDITIONAL USER DETAILS

User ID / Pin No User Name (PIC) Email Address

(to be filled out by AHS)
#1
#2
#3
#4

I hereby confirm and declare as follows:

1. That I'm duly authorised by the Company to access and operate the AIA Medi-Connect in accordance with
the terms and conditions stipulated by AHS
2. That I undertake to abide by and be bound by the AIA Medi-Connect Terms of Service accordingly

C. AUTHORISATION
I hereby authorise the above-named staff, to access the AIA Medi-Connect portal on behalf of the Clinic.
I also agree to safeguard the password at all times.

Signature & Date Company Stamp

Full Name & Designation :