Please complete all required fields!
To be completed by Doctor/Clnic Administrator
A.1 CLINIC PARTICULARS
A.2 OWNER MEMBERSHIP DETAILS
A.3 CONTACT DETAILS
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)
A.5 GROUP/AFFILIATE PRACTICE DETAILS
Please submit a separate registration for each branch to be included in the panel.
B. BANK DETAILS
C. COMPUTERIZATION DETAILS
D. WORKING HOURS
Clinic Services Type
Long Term Medication Fees
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:
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Level 2 MMA Building 124 Jalan Pahang 53000 Kuala Lumpur Malaysia
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