Dear Mr./Mrs.

/Ms MOHAMAD NORAZUAN BIN MOHD NOR,

Kindly be informed that NUR DIANA AZ ZAHRA BINTI MOHAMAD NORAZUAN has made a visit to KLINIK PERUBATAN LITA
ALIS on 16/05/2016 10:31:00 a.m. The information of the visit as stated below.

PATIENT INFORMATION
Patient name : NUR DIANA AZ ZAHRA BINTI MOHAMAD NORAZUAN
Employee name : MOHAMAD NORAZUAN BIN MOHD NOR
Relationship: DAUGHTER
Membership no. : 880125355015-C1
Authorization no. : 20160514P001656
Company name : BANK KERJASAMA RAKYAT MALAYSIA BERHAD (BANK RAKYAT)
Date of visit : 16/05/2016 10:31:00 a.m.

DIAGNOSIS MEDICATION DETAILS QTY RM

1 OTHER AND UNSPECIFIED LESIONS OF ORAL TRIAMCINOLONE ACETONIDE, LIGNOCAINE 1
MUCOSA (LIDOCAINE) HCL & CHLORHEXIDINE HCL ORAL 10.00
LIQUID
TOTAL FOR MEDICATION: RM 10.00
TREATMENT SUMMARY
Consultation : RM 15.00
Medication : RM 10.00
X-ray: RM 0.00
Surgical procedures : RM 0.00
Others (Diagnosis, procedure, lab tests) : RM 0.00
Medical Certificate (MC): 0 Days
TOTAL : RM 25.00

Kindly revert to us should you require further clarification or to higlight any discrepencies in respect to your to your visit
at members.support@pmcare.my. We would consider the statement is good if we did not hear from you after 7 days from the
date of this notification.

Disclaimer: The amount reported is the amount claimed by the clinic/provider. This amount is subject to revision after the
claim is processed to a final amount to be finally stated in your utilisation ledger

This document is computer-generated and therefore does not require any signature.
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