PUTRA CARE iDEAL MEMBERSHIP
Pendaftaran untuk iDEAL / iDEAL Member Registration
Nama/Name :
No.Tel/Contact Number :
Umur/Age :
Jantina/Gender : Male                      Female
Alamat/Address :
Pekerjaan/Occupation :
Status Perkahwinan/Marital Status : Single                     Married
Warganegara/Nationality :
NRIC No :
Passport No :
Tanggungan/Dependent : Yes                         No
Tarikh Daftar/Registration Date :
Pakej/Package : INDIVIDUAL Package               FAMILY Package
Tandatangan/Signature : ______________________________________

Keterangan Ahli Tanggungan / Dependent Details
No Nama / Name NRIC Gender / Jantina Hubungan/Relationship 
1       M  /  F  
2       M  /  F  
3       M  /  F   
4       M  /  F   
5       M  /  F  
6       M  /  F  
7       M  /  F  
8       M  /  F  
9       M  /  F  

Untuk Kegunaan Pejabat SAHAJA / For Office use ONLY
Account manager : _______________________  Tarikh : __________________
Union Leader : _______________________  Membership Number : __________________
Tandatangan : _______________________  CRC  Number  __________________










TERMS and CONDITIONS
  1. This plan is only allowed to be used in the POLIKLINIK PUTRA CARE and its branches.
  2. This plan is only entitled to be used for treatment purposes only.
  3. Any treatment process that requires further investigation are to be decided by medical professionals only.
  4. Payments are required to be collected up front 7 days before the start of the treatment month (Treatment month is defined as the month that plan is active)
  5. Any additional of child into family package requires
    • Additional payment RM12.00/ child if above 5 pax / family
    • Every child included into family package are mandatory to be LESS than 18 YEARS OLD
    • Proof of relationship
    • Complete dependent information
    • Maximum TEN(10) pax are allowed to be enrolled into Family Package
  6. Receipt voucher should be held as proof of payment.
  7. This plan does not entitle for abuse of health care benefit.
  8. The clinic personnel have the rights to reject the use of this plan in the event of discrepancy of information in our database detected.
  9. Any addition or cancelation of names contained in this agreement should be done in writing/email.
  10. Each visit to POLIKLINIK PUTRA CARE requires to present NRIC or PASSPORT copy for verification.
  11. The POLIKLINIK PUTRA CARE has the rights to alter and add from time to time the terms and conditions that deemed as necessary to be applied in this agreement.
  12. These packages are only allowed for returning customers of POLIKLINIK PUTRA CARE.
  13. Ideal Plan is only effective twenty four [24] hours after registration made into the system.
  14. Payment for union leader is to be given in the form of cash payment. This payment are to be collected from POLIKLINIK PUTRA CARE and its branches within the first seven[7] days of the month.
  15. Payment for account manager shall be made in the form of cheque payment. Payment shall be given during claims payment [15(±)3 days]. Account manager mandatory to be staff of POLIKLINIK PUTRA CARE

EXCLUSION CRITERIA
  1. Vaccination/ Pre-order Medication
  2. Executive Screening Profile
  3. Medical Examination (ME)
  4. Medical Report [MR = 1 X VL]
  5. Family Member *
  6. Purchasing Medication
  7. Specialist Consultation [SC] & medication
  8. Cosmetic [COS]
  9. Wellness & Aesthetic [WA]
  10. Elective Pre-planned surgery

MEDICAL CRITERIA
  1. Temporary Disablement due to acute illness
  2. Temporary Disablement due to post procedure
  3. Temporary Disablement due to trauma / injury
  4. Complication / Excacerbation from chronic disease
  5. Abnormality in vital signs or functional symptoms
  6. Overuse syndrome / musculoskeletal disorders [MSD]
  7. Psychological Trauma / Injury
  8. Contagious illness
  9. Requires bedrest as deemed necessary
  10. Pregnancy complications

REFERAL CRITERIA
  1. Moderate to severe illness
  2. Hemodynamically unstable
  3. Procedure under sedation
  4. Emergency surgery under general anasthesia
  5. Moderate to severe trauma / injury
  6. Severe abnormality of Vital signs
  7. Warning Signs or Signs of shock
  8. Require elective surgery
  9. Require Specialist consultation and medication
  10. Medicolegal cases or police jurisdiction

I hereby accept that I have read, understood the above Terms and Conditions (please sign below):


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