Health Connect Sdn Bhd (599302-D)

F-G-6, BLOCK F, PUSAT KOMERSIAL PARKLANE

N0.21, JALAN SS7/26, 47301 KELANA JAYA, SELANGOR
Tel : 03-7884 1919 Fax : 03-7809 9333

LETTER OF GUARANTEE
(Please Submit Invoice within 15days after treatment date)

Name of Patient Mohd. Azmi Bin Ismail GL No. EA10254272-AMINURIZA

Membership No. DCHB4920489-01 Date of Issuance 23/04/2019
Employee Name NOORLIZA BINTI ABD MALEK Treatment date 25/04/2019
BANK PERTANIAN MALAYSIA BERHAD
Company (AGROBANK) Coverage OUTPATIENT TREATMENT ONLY
Hospital SENTOSA MEDICAL CENTRE[S456] Fax number:
Diagnosis CERVICAL FACET SYNDROME IC Number 790121115269
Attending Dr. DR NIZAR-PAIN SPECIALIST
1. Maximum One (1) month medication that is related to illness
2. Any charges for MRI/ CT SCAN/ PHYSIOTHERAPY/ CHEMOTHERAPY/ DIALYSIS are NOT
cover under this GL. Please request a New GL for the above procedure if any.
Remarks 3. This GL valid for One (1) visit only within 7days from treatment date.
4. Medical providers to call Health Connect IMMEDIATELY If Limit is insufficient subject
to Annual Limit availability.
** Any treatment and medication related to Pregnancy are NOT COVERED **

This is to confirm that we guarantee the medical expenses in connection with the outpatient treatment of the above-mentioned patient
up to a limit of RM500

Our undertaking however does not cover the following: -

 Vitamin & Supplements

 Immunization & vaccination (Except Approved KKM Immunizations for infants)
 Psychotic/Psychological mental and emotional treatment
 Congenital Abnormalities & Development Disorder
 Infertility / HRT / Contraceptive related treatment
 Allergy test & blood profiles/screening for investigation purposes
 Cosmetic procedures & its related treatment (Treatment for acne, scar removal, skin tag, keloid & etc.)
 Dental Treatment
 Obesity & its related treatment including dietary supplement/ appetite suppressants etc.
 Refractive errors of the eyes & its related treatment
 Alternative therapies (Acupuncture, Chiropractic, Traditional Medicine & etc.)
 External Appliances/Prosthesis (Crutches, Pacemaker, Braces, Corset and Cervical Collar, Hearing Aid)
 Supplies & Services not related to the above diagnosis
 Non-Medical Items (Herbal cures, soaps, shampoo & etc.)
 Ambulance Charges

Kindly direct all bills with itemized pharmacy report stating a complete DIAGNOSIS to the above address.

The above medical cardholder is scheduled for consultation / treatment at your hospital on the above
mentioned date. We hereby guarantee payment of the charges for this consultation / treatment. Any late
sending of invoices to us (15days after treatment date) will not be entertained & paid.

Health Connect reserves the right not to make FULL payment to hospital if the above requirements are not fulfilled

Thank you.
Yours faithfully
Health Connect Sdn Bhd

Foo Sik Ngo

Assistant Vice President