emas logo 160x60 a   PANEL CLINIC ENROLMENT FORM

 To be completed by Doctor/Clnic Administrator


 

A.1  CLINIC PARTICULARS

 

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A.2  OWNER MEMBERSHIP DETAILS

 

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A.3  CONTACT DETAILS

 

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A.4  eMAS SERVICES SUBSCRIPTION

In addition to the eMAS TPA Services for claims processing, do you wish to subscribe to the following services (please contact eMAS Support for more details)

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A.5  GROUP/AFFILIATE PRACTICE DETAILS

 

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Please submit a separate registration for each branch to be included in the panel.

 

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B. BANK DETAILS

 

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C. COMPUTERIZATION DETAILS

 

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D. WORKING HOURS

 

Morning Hours

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Evening Hours

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National Holidays

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Clinic Services Type

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E. CHARGES

 

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Long Term Medication Fees

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By submitting this form, I/we hereby confirm that all information provided in this submission are true.

Please submit copies of  the following documents subsquent to the submission of this form:

  1. MMC Registration
  2. MOH Registration
  3. Panel Clinic Membership Agreement
  4. Advanced Primary Care Services Agreement
  5. Company Registration Forms 24 & 49

 

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Level 2 MMA Building
124 Jalan Pahang
53000 Kuala Lumpur
Malaysia

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Telephone: +603 4041 3627
Facsimile:   +603 4041 8627
Whatsapp: +6018 788 3627

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