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CI-01 - Cancer (Kanser)

The document is a medical report form for a critical illness claim related to cancer. It requests information about the patient's cancer diagnosis including: (1) The full and exact diagnosis, date of first diagnosis, details of any recurrence including dates and prior treatment history. (2) Details of the site and organ involved, histology of the tumor, staging information, whether it was borderline, pre-malignant, invasive, or involved lymph nodes or distant metastasis. (3) Confirmation from the attending physician that the statements are true to the best of their knowledge, including their signature and date.

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399 views2 pages

CI-01 - Cancer (Kanser)

The document is a medical report form for a critical illness claim related to cancer. It requests information about the patient's cancer diagnosis including: (1) The full and exact diagnosis, date of first diagnosis, details of any recurrence including dates and prior treatment history. (2) Details of the site and organ involved, histology of the tumor, staging information, whether it was borderline, pre-malignant, invasive, or involved lymph nodes or distant metastasis. (3) Confirmation from the attending physician that the statements are true to the best of their knowledge, including their signature and date.

Uploaded by

jijiq
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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CI-01 DOCTOR’S STATEMENT - CRITICAL ILLNESS - CANCER

MEDICAL REPORT TO BE COMPLETED BY THE ATTENDING PHYSICIAN/ SPECIALIST CI-01


Name of Patient (Person Covered) New NRIC No.

- -

1 Diagnosis

(i) Please describe the full and exact diagnosis. (i)

(ii)
(ii) Date when the Cancer was FIRST diagnosed
/ / (dd/mm/yyyy)

2 For recurrence cancer, please complete below:

(i) Date when recurrence cancer was diagnosed: (i)


/ / (dd/mm/yyyy)
(ii) Details of diagnosis:
(a) Has patient completed treatment and (ii) (a) Yes No
declared as cancer-free previously?

(b) If Yes, please state the date when cancer


treatment was completed:
(ii) (b)
/ / (dd/mm/yyyy)

(c) Date MRI/ CT done that confirmed


complete cancer remission:
(ii) (c)
/ / (dd/mm/yyyy)

3 (i) What was the site or organ involve? (i)

(ii) What was the precise histology of the tumour? (ii)

(iii) What was the stage of the tumour? (iii)


Please provide full details using appropriate
staging classification (e.g. TNM, Ann Arbor,
Duke's etc.)

(iv) It is classified as: (iv) borderline malignancy non-invasive

pre-malignant invasive

carcinoma in-situ

(v) The disease was: (v) invasive to adjacent tissues completely localized
You may tick ( ) more than one.
involved regional lymph nodes

distant metastatic. If so, please give details

CLM-B40DSCI01-V01-022020-TAKAFUL

Great Eastern Takaful Berhad 201001032332 (916257-H)


Head Office: Menara Great Eastern 303 Jalan Ampang 50450 Kuala Lumpur Page 1 of 2 3597369899
mySalam CareLine: 1-300-888-938 E-mail: [email protected]
mySalam Portal: www.mysalam.com.my
4 Is the Cancer associated with HIV or AIDS? Yes No

If "Yes", please state the date HIV was first diagnosed / detected.

/ / (dd/mm/yyyy)

DECLARATION: TO BE COMPLETED BY THE ATTENDING PHYSICIAN/ SPECIALIST

I, the undersigned, certify that I have examined the above Person Covered and all statement made and answers given are true and to the
best of my knowledge and belief.

Name:

Address:

Signature and Official Stamp Date: / / (dd/mm/yyyy)

Page 2 of 2 1186369891

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