PERJANJIAN BAGI KEMASUKAN SEMENTARA KE PROGRAM HEMODIALISIS
YAYASAN BUAH PINGGANG KEBANGSAAN MALAYSIA (NKF)
AGREEMENT FOR TEMPORARY ADMISSION TO THE HAEMODIALYSIS PROGRAMME OF THE NATIONAL KIDNEY FOUNDATION OF MALAYSIA (NKF)

Saya / I

No K.P / I.C Num:

mewakili diri saya atau pesakit bernama / representing myself or patient named)
No K.P / I.C Num:
bersetuju dirawat sebagai pesakit sementara di Pusat Dialisis / agree to be treated as a temporary patient at the Dialysis Center
--Select--Pusat Rawatan Dialisis Tuanku Syed Putra – NKF, Kangar, PerlisPusat Dialisis NKF – Kelab Lions Alor Star, KedahPusat Dialisis NKF – Superkids Trinity, Alor Setar, KedahPusat Dialisis NKF – Yayasan Sultanah Bahiyah, Kulim, KedahPusat Dialisis Amal FOYI – NKF (Unit I) Batu Maung, Pulau PinangPusat Dialisis Amal FOYI – NKF (Unit II) Batu Maung, Pulau PinangPusat Dialisis NKF – Yayasan Dialisis Pendidikan Akhlak Perak, IpohPusat Dialisis NKF – Yayasan Dialisis Pertubuhan Pendidikan Akhlak, TaipingPusat Dialisis NKF – Chempaka, Jalan SS 3/39, Petaling Jaya, SelangorPusat Dialisis NKF – Dato Dr. G.A.Sreenevasan, Jalan 14/29, Petaling Jaya, SelangorPusat Dialisis NKF – Kelab Apex, Meru, Klang, SelangorPusat Dialisis NKF - Rotary Damansara, SelayangPusat Dialisis NKF – Bakti, Klang, SelangorPusat Dialisis NKF – Fungates Superflow, Kepong, Kuala LumpurPusat Dialisis NKF – Charis, Taman Billion, Cheras, Kuala LumpurPusat Dialisis NKF – Calvary, Cheras, Kuala LumpurPusat Dialisis NKF – Good Health, Kampung Pandan, Kuala LumpurPusat Dialisis NKF – Nanyang, Batu 4 Jalan Gombak, Kuala LumpurPusat Dialisis NKF – Bonuslink , Kota BahruPusat Dialisis NKF – Tun Abdul Razak, Kuantan, PahangPusat Dialisis NKF – Sang Riang, Triang, PahangPusat Dialisis NKF – Yayasan Buah Pinggang Kemaman, TerengganuPusat Dialisis NKF – Kuala TerengganuPusat Dialisis NKF – Rotary Club Nilai SentralPusat Dialisis NKF – Che Luan Khor, Kluang, JohorPusat Dialisis NKF – Yayasan Pembangunan Keluarga Darul Tazim, Masai, JohorPusat Rawatan Dialisis MUIS – NKF, Kota Kinabalu, SabahPusat Dialisis MUIS – NKF , Menggatal, SabahPusat Dialisis NKF – Bonuslink, Sarikei, SarawakPusat Dialisis NKF – Kidney Association of Sarawak/Rotary (Unit 2), Kota Samarahan, Sarawak
untuk suatu tempoh masa tertentu atau sehingga permohonan kemasukan tetap saya atau pesakit diluluskan oleh Yayasan Buah Pinggang Kebangsaan Malaysia, dan akan mematuhi syarat - syarat berikut / for a certain period of time until my or patient’s application for permanent admission is approved by the National Kidney Foundation of Malaysia, and will comply with the following requirements:

[Tandakan Yang Berkaitan]/ [Tick Where Relevant]

Bersetuju membayar kos rawatan sebanyak RM90 tunai bagi setiap rawatan hemodialisis dengan mengemukakan wang pendahuluan RM270 setiap awal minggu sehingga permohonan kemasukan tetap diluluskan oleh Yayasan Buah Pinggang Kebangsaan Malaysia. (Agree to pay RM90 cash for each haemodialysis treatment by submitting advance payment of RM270 at the beginning of each week until the application for permanent admission is approved by the National Kidney Foundation of Malaysia)Mengemukakan laporan perubatan (submit medical report)Laporan ujian makmal yang lengkap dan terkini bagi ujian Hepatitis B, Hepatitis C dan HIV (Complete and most recent laboratory test reports for Hepatitis B, Hepatitis C and HIV)Borang Maklumat Keluarga (Family Information form)Salinan slip gaji dan borang Cukai Pendapatan terkini bagi pemohon dan semua ahli keluarga yang bekerja (A copy of the latest pay slip and income tax returns of applicant and all family members who are working)Salinan penyata KWSP terkini pemohon dan semua ahli keluarga yang bekerja (A copy of the latest EPF statement of applicant and all family members who are working)Salinan slip bayaran terkini dari Jabatan Pencen PERKESO (jika ada) bagi pemohon (A copy of the latest payment slip from the Pensions Department Social Security Organisation (SOCSO) (if any) for applicant;Salinan penyata akaun tetap atau simpanan (jika ada) bagi pemohon dan semua ahli keluarga yang bekerja (Copies of fixed deposits or savings accounts (if any) of applicant and all family members who are working)Bil elektrik, air, telefon & Astro (electricity, water, telephone and Astro bills)Gambar rumah pesakit (photos of patient’s house)Surat jaminan daripada majikan - tertakluk kepada terma dan syarat (Letter of guarantee from the employer -subject to terms and conditions)

Saya faham bahawa semua dokumen yang tersebut di atas diperlukan untuk pemprosesan kemasukan tetap ke Program Hemodialisis NKF dan permohonan subsidi Kementerian Kesihatan Malaysia. Jika saya gagal mematuhi syarat - syarat di atas atau gagal mengemukakan dokumen yang berkaitan dalam tempoh [4] empat minggu dari tarikh perjanjian ini, NKF berhak memberhentikan rawatan kepada saya / pesakit tanpa sebarang notis.

I understand that all the above-mentioned documents are required for the processing of my/ patient’s application for admission to the NKF Haemodialysis programme and the Ministry of Health subsidy for dialysis treatment. If I fail to comply with the conditions above or fail to submit the relevant documents within [4] four weeks of the date of this agreement, NKF reserves the right to discontinue treatment to me / patient without prior notice.