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Branch
Klinik Menara Shah Alam
Services
Audiometry
Corporate Medical Solutions
Diabetic Foot Care
General Healthcare
Home Visit Service
Medical Imaging
Occupational Health and Safety
Pain Management
Primary Care
Wound Debridement
Panel
Career
Contact
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Appointment
Panel
Register as a Klinik Menara panel.
Fill In The Form Below
Branch
*
Select Clinic Branch
Klinik Menara Shah Alam
COMPANY INFORMATION
Company Name
Street Address
Apartment, suite, etc
City
State
Postal Code
Business Registration Number (BRN)
*
SST Number
*
Tax Identification Number (TIN)
*
Phone
*
Email Address
*
AUTHORIZED PERSON
Name
*
NRIC
Designation
PANEL SERVICE DETAILS
1. FACILITIES CHARGEABLE
Normal Medical Treatment
Yes
No
Require Permission
Minor Surgery
Yes
No
Require Permission
Essential laboratory/urine tests
Yes
No
Require Permission
Chest X-ray
Yes
No
Require Permission
Audiometry
Yes
No
Require Permission
Ultrasound/ECG
Yes
No
Require Permission
Vaccination/Immunization
Yes
No
Require Permission
Antenatal / postnatal care
Yes
No
Require Permission
Pre-employment Medical Exam
Yes
No
Require Permission
Occupational Health & Medical Surveillance
Yes
No
Require Permission
Other facilities, please specify
2. IDENTIFICATION METHOD
Patient Identification By
Namelist
Medical chit
Company Authorization Slips / Card
Staff Tag / Company ID Card
3. ELIGIBILITY OF MEDICAL COVERAGE
Eligibility of Medical Coverage
Employees' only
Employees' spouse
Employees' children
Staff Tag / Company ID Card
4. CHARGES LIMITATION/REQUEST
Charges Limitation
Charge according to clinic rates
Limit charges (please specify below)
Limit per Visit (RM)
Limit per Month (RM)
Limit per Year (RM)
Payment Terms
Pay and Claim (Pay at counter and claim directly with the company)
Monthly Invoicing (clinic send invoice on monthly basis)
Other Requirements (if any)
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