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Clinic Empanelment Registration Form - PEDULISIHAT

SELCARE MANAGEMENT SDN. PEDULI SIHAT | Hanya di SelangorHEALTHCARE PROVIDER Registration CHECKLISTSELECTION CRITERIA FOR SELCARE PANEL OF GENERAL PRACTITIONER (GP) CLINIC1. Practicing GP must be registered with Malaysia Medical Council (MMC) and has a valid Annual Practicing Certificate (APC).2. Facilities available : Internet, Fax Machine, and Clinic Fees charged must adhere to Malaysian Medical Association Schedule of Business Clinic Registration fee RM 100 per Clinic . Payable to SELCARE Management Sdn. Bhd. Account Number 8008292593 - CIMB Clinic meets selection criteria, a letter of offer will be prepared upon receiving letter of acceptance from Clinic , an agreement will be forwarded to Clinic to be signed by both parties.

skim peduli sihat | hanya di selangor selcare management sdn. bhd. healthcare provider registration checklist selection criteria for selcare panel of general practitioner (gp) clinic

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Transcription of Clinic Empanelment Registration Form - PEDULISIHAT

1 SELCARE MANAGEMENT SDN. PEDULI SIHAT | Hanya di SelangorHEALTHCARE PROVIDER Registration CHECKLISTSELECTION CRITERIA FOR SELCARE PANEL OF GENERAL PRACTITIONER (GP) CLINIC1. Practicing GP must be registered with Malaysia Medical Council (MMC) and has a valid Annual Practicing Certificate (APC).2. Facilities available : Internet, Fax Machine, and Clinic Fees charged must adhere to Malaysian Medical Association Schedule of Business Clinic Registration fee RM 100 per Clinic . Payable to SELCARE Management Sdn. Bhd. Account Number 8008292593 - CIMB Clinic meets selection criteria, a letter of offer will be prepared upon receiving letter of acceptance from Clinic , an agreement will be forwarded to Clinic to be signed by both parties.

2 A copy will be given to panel form (PS-AP-C) Clinic Details form (PS-CD-C)Annual Practicing Certificate (APC)Memorandum of Association (M&A) Clinic Summary of Quotation/ Charges (PS-CC-C)Healthcare Provider Panel Approval form (PS-AF-C)123456 Clinic Empanelment Registration FormSKIM PEDULI SIHAT | Hanya di SelangorPage 1 Tel / TownPS-AF-CClinic NameAddressClinic CodeBusiness HourUSER IDPerson in ChargeApplication ChecklistReason for RecruitmentCriteria of RecruitmentType of ProviderLetter Of AcceptanceRequested ByLocationGP ClinicSpecialist ClinicDentalMaternityAnnual Practicing Certificate (APC)Requested By MemberSmart TerminalType of ServicesAcceptable Charge List ( Summary of Charge ) - Please Refer AttachedDate ReceivedDuration DateDate SentDoctor in ChargeDate ReceivedDate SentYESA cceptMINOR SURGERYPRIMARY CARENOR ejectPRE-EMPLOYMENT CHECKUPP repared byApproved By (Medical)Approved By (Provider Management)Approved byNameNameNameNameSIGN HERESIGN HERESIGN HERESIGN HEREDDMMYYYY//DDMMYYYY//DDMMYYYY//DDMMYY YY//DateDateNotification To ED / MD OfficeNameIf Reject, Reason.

3 SIGN HEREDDMMYYYY//DateDateDateRequest StatusSKIM PEDULI SIHAT GP Panel Approval form (for office use only)SKIM PEDULI SIHAT | Hanya di SelangorPage 2 STAMP HEREDDMMYYYY//DateYESNOYESNO24 HoursClinic HoursRegistration CounterDoctor s RoomSharing / NetworkingStand AlonePS-AP-CToAttentionPlease tick either onePlease tick where appropriate0303 Tel Management Sdn. Management DepartmentYES! I would like to be a panel service provider of SELCARE Management Sdn. Bhd. I am pleased to forward to you a quotation of our charges. Please forward to me a copy of the Letter of Appointment of which I shall return to SELCARE Management Sdn. Bhd. signing. Following that, I look forward to a training session on SELCARE Management Sdn.

4 Bhd. Outpatient Management System you have internet connection for your PC?Do you have a fax machine at your Clinic ?Where do you station your computer terminal?Your computer system network?Business OperationADUNNO. I am not interested in being a panel service provider of SELCARE Management Sdn. in ChargeStaff in ChargeClinic StampClinic NameSKIM PEDULI SIHAT GP PanelLetter of Invitation (LOI)REPLY OF INVITATION / APPLICATION TO JOIN SELCARE A PANEL GP CLINIC5525660055256900 SKIM PEDULI SIHAT | Hanya di SelangorPage 3 SIGN HERES ignaturePS-CD-CToAttention0303 Tel Management Sdn. Management DepartmentDDMMYYYY//DateSTAMP HEREC linic StampClinic NameDUNNameGroup of (if any)Party To Be NamedIn Service Agreement( Clinic Name / Company Name pls provide us form 49 if registered as Sdn.)

5 Bhd. )Please attach the latest copy of Perakuan Amalan Tahunan (Annual Practicing Certificate) and photograph of your clinicAddressPostcodeCity / TownClinic HoursPayee NamePayee BankPayee BankAccount NRIC (if Individual)Payee Business Registration No. (BRN)(if Sole Proprietor / Partnership)Payee Company No. (if Company)EmailBank DetailsSKIM PEDULI SIHAT GP PanelClinic Details Form5525660055256900 SKIM PEDULI SIHAT | Hanya di SelangorPage 4 Minor Surgery (procedure)STAMP HEREC linic StampPrepared byNameDesignationPS-CC-CNoType of TreatmentRate / Charges (RM)Internal UseConsultation only1 Consultation and Medication (General)2X-ray5 Consultation + Medication + Injection3 Simple Investigation64 Pre-Employment Medical Check-Up (please list out all the tests)7 Blood glucose testUrine test (using test strip)ECGU ltrasound ExaminationPap SmearSKIM PEDULI SIHAT GP PanelSummary Of Clinic ChargesSKIM PEDULI SIHAT | Hanya di SelangorPage +603 5525 6600


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