MRC English Form

HIM-PMR-H01
MEDICAL REPORT APPLICATION FORM

*Please refer to next page for guideline on how to fill in the form.
Requester:  Patient  Representative
 Part A. Patient Detail

Patient Name: MRN:
NRIC: Phone No:
 Part B. Representative Detail

Category:  Next of Kin  Agent  Court  PDRM  KKM  Others: ……………………………………………………...
Representative Name: NRIC: Phone No:
 Part C. Application Detail

No Description Fee (RM) (√)
Full Medical Report
Purpose:  Personal  Insurance  Legal  Second Opinion  Others: ………………..………………......

Content:  Default
 Patient identification data  Brief history  Results of investigations  Dates and time of admission or treatment
 Treatment  Diagnosis  Management plan  Significant examination findings
 With doctor’s opinion: ……………...…………………………………………………………………………………………………………….

1. Full medical report by Consultant 200
2. Full medical report by Consultant - with doctor’s opinion 250

3. Full medical report by Consultant - with second opinion for non-IJN patient 570
4. Full medical report by Clinical Specialist 100
5. Full medical report requested by Authority/Government Agencies (PDRM, MOH, Court) FOC
6. Others:  Patient confirmation letter  Referral letter  Reply letter (as per attached) FOC
Medical Report (Form prepared by external party)
7. Attending Physician Statement Form by Consultant 120

8. Attending Physician Statement Form by Clinical Specialist 100
9. Insurance Claim Form by Consultant 100
10. Insurance Claim Form by Clinical Specialist 80
11. EPF Incapacitation 100
12. EPF Health Withdrawal 50

13. SOCSO 50
14. Others:  Hajj Appeal Letter/ Hajj book  Baitulmal form  Welfare form  Zakat Form FOC
Copy of Report
15.  Referral Letter  Investigation Report  Discharge Summary  MC  Others: …………………………….
10 per unit
 Blood Test  Operation Report  ECHOcardiogram  ECG ………………………………………….
Administration Fee
16. Administration Fees (Applicable only to Item 1 - 4 and 7 - 13) 20
Collection/Delivery Preference
17.  Self-collect  Email  Post (Peninsular MY)  Post (East MY)  Post (International)
RM10 RM16 subject to courier charges
Total
For HIMS use

Assigned Doctor: Secretary Signature, Name, Date & Time:
Revision 3. Effective Date: 13th September 2021.

Institut Jantung Negara Sdn. Bhd. (245794-V) 145, Jalan Tun Razak, 50400 Kuala Lumpur, Malaysia Tel +603 2617 8200 Website www.ijn.com.my
HIM-PMR-H01
 Part D. Delivery Detail
Email: ………………………………………………………………………………………………………………...……………
Mailing Address: ………………………………………………………………………………………………………………...…………………
………………………………………………………………………………………………………………..………………...
Postcode: ……………………… City: ……………………..……………………….……………………...…...
State: …………………………………………………………………..………………….…………...…………………...
 Part E. Consent by Patient/Next of Kin

PERSONAL DATA PROTECTION ACT 2010
The Personal Data Protection Act 2010 (hereinafter referred to as “the Act”), which regulates the processing of personal data in commercial
transactions, applies to Institut Jantung Negara Sdn. Bhd. and its subsidiaries (collectively referred to as “our”, “us” or “we”). For the purposes of this
Notice, the terms “personal data” and “processing” shall have the same meaning as prescribed in the Act.
Notice and Consent Under the PDPA 2010 – Point No. 10
“10. If you give us personal data or information about another person, you must first confirm that he/she has appointed you to act for him / her, to
consent to the processing of his/her personal data and to receive on his/her behalf any data protection notices. We may request your assistance to
procure the consent of such persons whose personal data is provided by you to us and you agree to do so. You shall indemnify us in the event we
suffer any loss or damage as a result of your failure to comply with the same.”
1. I hereby declare and confirm that the information given above is accurate and true.
2. I agree that only the representative’s name appear in the authorization letter can claim the report on my behalf.
3. I hereby release Institut Jantung Negara (IJN) and its employees from all possible legal responsibilities arising out of this content.
Patient/Next of Kin Signature, Name, Date & Time:  Consent provided/given separately
For HIMS Use

Payment Acknowledgement
Payment Method:  Not Applicable  Cash  Credit  Debit  E-Wallet  Online Banking
Payment Reference No:
Episode No: Staff Signature, Name, Date & Time:
Receipt No:
Receipt Date:
Consent Verification
 Not Applicable Staff Signature, Name, Date & Time (if applicable):
 Patient/next of kin matched registry
 Called and verified with patient/next of kin
 How to fill the form
 If you are IJN patient: 1. Fill in Part A, C and E.

2. If you prefer delivery by post/email, please fill in Part D.
 If you are patient’s representative: 1. Fill in Part A, B, C and E.

2. Get the patient or registered next of kin to sign in Part E.
3. If you prefer delivery by post/email, please fill in Part D.
4. If patient is deceased, please attach a copy of patient‘s death certificate.
Revision 3. Effective Date: 13th September 2021.

Institut Jantung Negara Sdn. Bhd. (245794-V) 145, Jalan Tun Razak, 50400 Kuala Lumpur, Malaysia Tel +603 2617 8200 Website www.ijn.com.my

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HIM-PMR-H01

MEDICAL REPORT APPLICATION FORM

Requester:  Patient  Representative

 Part A. Patient Detail

NRIC: Phone No:

 Part B. Representative Detail

Representative Name: NRIC: Phone No:

 Part C. Application Detail

Purpose:  Personal  Insurance  Legal  Second Opinion  Others: ………………..………………......

 With doctor’s opinion: ……………...…………………………………………………………………………………………………………….

2. Full medical report by Consultant - with doctor’s opinion 250

4. Full medical report by Clinical Specialist 100

Medical Report (Form prepared by external party)

7. Attending Physician Statement Form by Consultant 120

12. EPF Health Withdrawal 50

For HIMS use

Revision 3. Effective Date: 13th September 2021.

 Part D. Delivery Detail

Mailing Address: ………………………………………………………………………………………………………………...…………………

Postcode: ……………………… City: ……………………..……………………….……………………...…...

 Part E. Consent by Patient/Next of Kin

For HIMS Use

 How to fill the form

 If you are IJN patient: 1. Fill in Part A, C and E.

 If you are patient’s representative: 1. Fill in Part A, B, C and E.

Revision 3. Effective Date: 13th September 2021.

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