• MEDICAL REPORT & INSURANCE APPLICATION FORM

    MEDICAL REPORT & INSURANCE APPLICATION FORM

    (VERSION 03/2025)

  • HEALTH INFORMATION MANAGEMENT (HIM)

    ALTY ORTHOPAEDIC HOSPITAL
    MENARA ALTY
    187, JALAN AMPANG
    50450 KUALA LUMPUR 

    Contact No: 
    1) 03-27870545 
    2) 03-27870603

    Please contact us if you have any questions about the application procedure or the status of the medical report and insurance claim application by clicking on the WhatsApp button below. 

  • MEDICAL REPORT OPERATION HOURS 

    • MONDAY - THURSDAY : 0900 - 1700 
    • FRIDAY : 0900 - 1200, BREAK, 1500 - 1700
    • SATURDAY, SUNDAY, & PUBLIC HOLIDAY : OFF

  • TERMS AND CONDITIONS. PLEASE READ BEFORE YOU APPLY

    To ensure a smooth application process for medical reports at ALTY Orthopaedic Hospital, please take note of the following guidelines: 

    ⏳ PROCESSING TIMELINE

    • Standard applications take a minimum of 14 working days (excluding weekends, public holidays, and doctor’s leave).
    • Processing may take longer due to unforeseen circumstances.
    • Legal, court, lawyer, and police-related requests require more than 14 working days. 

    🗂 REQUIREMENT DOCUMENT (FOR SOCSO)

    • For SOCSO applications, please attach:
    • Form 34
    • The official SOCSO Form. 

    • All applications must include a completed and signed:
    • “Consent to Release of Information” form.
    • If the patient is a minor, this must be signed by a parent or legal guardian.
    • If applying on behalf of the patient, an authorization letter may be required. 

    💰 FEES & CHARGES

    • Medical report fees vary based on the report’s length and complexity.
    • Fees must be communicated to and agreed upon by the patient or their authorized representative before processing.
    • Delivery fees apply (mail, courier, or email).
    • If the original report is lost or not delivered, no replacement will be issued. However, a photocopy can be provided for a fee of RM50.00. 

    📦 REPORT COLLECTION

    • Completed reports can be collected:
    • At the Hospital Business Office Counter (Level 5)
    • Or sent via mail, courier, or email (after full payment) 

    • If someone else is collecting the report, please provide a signed letter of authorization with the collector’s name and NRIC copy for verification. 

    📌 OTHER IMPORTANT NOTES

    • If the doctor is no longer practicing at ALTY Orthopaedic Hospital:
      • A formal letter will be issued stating this.
      • The discharge summary and investigation results (if available) will be enclosed.
      • No fees will be charged for this letter. 

    • If the patient’s record has been disposed:
      • A notification letter will be provided.
      • No charges will apply. 

    • Please ensure the patient’s details are filled in on the application form before submission.
    • Incomplete forms will not be processed. 

    ⏰ UNCLAIMED REPORT

    • Medical reports that are not collected within 3 months will be disposed of without further notice.
    • Only a scanned copy can be issued afterward, with a charge of RM50.00.

     

  • SUBMISSION

    In order to adhere to the requirements of the Personal Data Protection (PDP) Act 2010 (AMENDEMENT 2024), it is necessary to include the following documents when submitting medical reports:

    • IF THE APPLICANT IS A PATIENT:
      a) Insurance form / request letter
      b) Consent to Release of Information for Medical Report
      c) Patient copy of NRIC
      d) Processing fee (Please check from Medical Records Personnel) 

    • IF THE PATIENT IS BELOW 18 YEARS OLD (MINOR)
      a) Insurance form / request letter
      b) Consent to Release of Information for Medical Report
      c) Copy of Patient's NRIC or Birth Certificate
      d) Copy of Parent's NRIC (Either one)
      e) Child Custody Letter from the court (for divorce parent)
      f) Processing fee (Please check from Medical Records Personnel) 

    • IF THE PATIENT IS DECEASED
      a) Insurance Form/ Request Letter
      b) Copy of Relative's NRIC (Spouse / 3rd Party requester)
      c) Original Death Certificate (will be copied by hospital staff for verification)
      d) A letter of administration letter/ grant of probate/ grant of administration letter from the court.
          (apply to requester other than wife or husband)
      e) Original Marriage Certificate (will be copied by hospital staff for verification)
      f) Processing fee (Please check from Medical Records Personnel) 

    • IF FROM AN INSURANCE COMPANY / RELATIVE/ LEGAL FIRM
      a) Insurance Form / request letter
      b) Consent to Release of Information for Medical Report
      c) Authorization letter appointed of 3rd party (for legal) to request medical information / medical report
      d) A Copy of Patient's and Requestor NRIC
      e) A copy of the police report (for accident cases)
      f) Processing fee (Please check from Medical Records Personnel) 

    • IF FROM POLICE OFFICER / JABATAN KEBAJIKKAN MASYARAKAT
      a) Request letter
      b) Copy of police officer ID

     

    REMINDER

    • It is important to have all relevant documents ready before submitting.
    • Incomplete submissions will not be sent to the doctor until all necessary documents are provided.
    • Patient information on the application form must be filled out before submission.
    • Medical records personnel and doctors will not fill out the patient information on their behalf.
    • It is essential to ensure completeness and accuracy before submitting any medical documents.

  • MEDICAL REPORT FEE STRUCTURE 

    The completed medical report could be released to the requester or a party authorized by the requester at the service counters, via mail, courier, or by email after the medical report fee has been paid.

    INSURANCE CLAIM TYPE MAX CHARGES
    Attending Physician Statement RM91.00
    Critical Illness Form
    Death Claim Form 
    Disability Form 
    Hospitalization & Surgical Claim
    Personal Accident Form
    Questionnaire 
    Comprehensive (FreeText) for Insurance company / Legal Firm / Employee / Personal Reference

    RM200.00 - RM2,000.00
    Clarification report (FreeText) for Insurance company / Legal Firm / Employee / Personal Reference
    Court Attending Fee (charge perday) RM570.00
    SOCSO / EPF RM75.00
    Police Report  Free of Charge
    Jabatan Kebajikkan Masyarakat
    Ministry of Health (MOH)
    Medical Administration Report (MAR): Specialist RM570.00
    Medical Administration Report (MAR): Non-Specialist RM230.00
    Expert Witness (Medico Legal Cases): Specialist RM5,000.00
    Expert Witness (Medico Legal Cases): Non-Specialist RM1,000.00
    Medical Board perdoctor RM1,500.00
    Registration Fee RM5.00
    Courier Charges (Domestic) RM15.00
    Courier Charges (Sabah & Sarawak) RM30.00
    Photocopying Report (>10 pages and above) / page RM0.50

    Reference: 

    • MMC Guide Line 002-2006 Medical Records and Medical Report Fee
    • Medical Fee Act 1951 
    • https://www.msgh.org.my/files/39f67c7b459fcc3479132585009d6598.pdf 

  • PATIENT INFORMATION

  • REQUESTOR INFORMATION

  • PATIENT INFORMATION

  • UPLOAD SUPPORTING DOCUMENT(S)

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  • CONSENT TO RELEASE OF PATIENT INFORMATION FOR MEDICAL REPORT & INSURANCE CLAIM

    CONSENT TO RELEASE OF PATIENT INFORMATION FOR MEDICAL REPORT & INSURANCE CLAIM

  • DECLARATION & AUTHORIZATION

  • I, the above-named * patient / next of kin / legal representative of the above named patient, declare that the information provided above is true and correct to the best of my knowledge, and where applicable, do hereby expressly authorized ALTY ORTHOPAEDIC HOSPITAL to release the patient's medical report(s) as well as any / all information pertaining to the diagnosis and / or treatment given and / or received at ALTY ORTHOPAEDIC HOSPITAL to the requester stated above through the preferred method of release I have choose above. In the event. | choose of release other than self-collection, I accept the following terms:-

    1. That the hospital advice me to collect the medical report(s) in person but choose to have the medical report(s) sent / release by the means I selected above. 

    2. That I understand and accept that the risk of my personal and confidential information being delivered to unintended recipients.

    3. That I shall not hold ALTY ORTHOPAEDIC HOSPITAL responsible for consequential losses, damages, loss of reputation or any other types of losses as a result of my choice of delivery / release of the medical report(s).

    I have read and agree that my personal information set out in this form will be collected and processed in accordance to ALTY ORTHOPAEDIC HOSPITAL. I further undertake to settle all the cost and expenses incurred therein and release ALTY ORTHOPAEDIC HOSPITAL and its employee from any liabilities howsoever arising thereto.

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