APPLICATION FORM (PDF File)

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SUPPORTING DOCUMENTS
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Medical Report Summary by Doctor
Supporting Documents Checklist for HD Programme by Dialysis Centre
Approval for HD Programme by Dialysis Centre – Welfare – HOM
Agreement for entry into for HD Programme by Dialysis Centre with patient

TERMS AND CONDITIONS FOR ADMISSION INTO NKF HAEMODIALYSIS PROGRAMME
SYARAT-SYARAT DAN PERATURAN UNTUK MASUK KE PROGRAM HEMODIALISIS NKF (YAYASAN BUAH PINGGANG KEBANGSAAN MALAYSIA)

1. Applicant is a Malaysian citizen or a Permanent Resident (subject to Terms & Conditions).
   Pemohon adalah warganegara Malaysia atau Penduduk Tetap (berdasarkan kepada Terma & Syarat tertentu).
2. Applicant is 18 years and above.
   Pemohon adalah berusia 18 tahun ke atas.
3. Applicant is ambulant (able to move about independently).
   Pemohon boleh bergerak secara berdikari.
4. Applicant has suitable functional vascular access.
   Pemohon mempunyai fistula yang berfungsi dengan baik.
5. Applicant has no other recourse to regular haemodialysis.
   Pemohon tiada tempat lain untuk menjalani dialisis.
6. Applicant is prepared to appear before the Patient Selection and Welfare Committee of NKF prior to being considered for the programme.
   Pemohon bersedia hadir di hadapan Jawatankuasa Pemilihan dan Kebajikan Pesakit NKF untuk dipertimbangkan memasuki program hemodialisis.
7. Applicant must agree to a visit to his / her home by the Welfare Manager / Officer or an Officer nominated by the NKF with a view to verifying all information given.
   Pemohon mestilah bersetuju dilawati oleh Pengurus / Pegawai Kebajikan atau seorang Pegawai yang dilantik oleh NKF untuk tujuan memastikan keterangan adalah benar.
8. Applicant is prepared to pay treatment fee of RM90.00 per dialysis session on admission until the approval of government subsidy of RM100.00 per dialysis session is given by the Ministry of Health (MOH). NKF will henceforth charge RM100.00 per dialysis session.
   Pemohon bersetuju membayar RM90.00 bagi setiap kali dialisis dari tarikh kemasukan sehingga mendapat kelulusan subsidi kerajaan sebanyak RM100.00 bagi setiap kali dialisis diberi oleh Kementerian Kesihatan Malaysia (KKM). NKF seterusnya akan mengenakan bayaran sebanyak RM100.00 bagi setiap kali dialysis.
9. Applicant is prepared to pay an advance of RM270.00 for a week’s treatment payable on the first session of each week before the approval of government subsidy of RM100.00 per dialysis is given.
   Pemohon bersetuju membayar wang pendahuluan sebanyak RM270.00 bagi rawatan untuk seminggu dan wang pendahuluan perlu dibayar pada hari dialisis pertama setiap minggu sebelum kelulusan subsidi kerajaan sebanyak RM100.00 bagi setiap kali dialisis diberikan.
10. Applicant may seek assistance from the Centre Manager / Staff Nurse In-Charge of the Dialysis Centre to apply for the government subsidy of RM100.00 from Ministry Of Health.
    Pemohon boleh meminta bantuan daripada Pengurus / Jururawat Yang Menjaga Pusat Dialisis untuk memohon subsidi kerajaan sebanyak RM100.00 daripada Kementerian Kesihatan Malaysia.
11. Applicant is prepared to pay treatment fee as stated above. This fee is subject to change by the NKF as and when it deems necessary. This amount is payable prior to treatment.
    Pemohon bersetuju membayar yuran rawatan seperti yang tersebut di atas. Bayaran ini adalah tertakluk kepada perubahan oleh NKF jika dan apabila perlu. Bayaran ini hendaklah dibayar sebelum rawatan.
12. Applicant who fails to obtain the subsidy approval from MOH will have to pay RM90.00 per dialysis while his appeal is referred to MOH for reconsideration. If the appeal to MOH is rejected, the case will be referred to the Patient Selection and Welfare Committee of NKF for its final decision to allow the patient to continue dialysis or terminate his dialysis treatment in NKF.
    Pemohon yang gagal mendapat kelulusan daripada KKM perlu membayar RM90.00 bagi setiap kali dialisis sementara menunggu keputusan rayuan daripada KKM. Sekiranya rayuan daripada KKM ditolak, pemohon akan dirujuk kepada Jawatankuasa Pemilihan dan Kebajikan Pesakit untuk pertimbangan dan keputusan muktamad sama ada membenarkan pesakit meneruskan dialisis atau memberhentikan pesakit daripada dialisis di NKF.
13. The selected patient must be willing to undergo 4 hourly dialysis 3 times a week at NKF Dialysis Centre at the dates and times fixed by the Centre.
    Pemohon yang dipilih hendaklah bersetuju menjalani dialisis 4 jam setiap kali sebanyak 3 kali seminggu di Pusat Dialisis NKF pada tarikh dan masa yang ditetapkan oleh Pusat Dialisis.
14. The patient shall be reviewed by NKF Welfare Manager / Officer as and when necessary at the discretion of NKF with regard to his / her suitability to continue the haemodialysis programme by regular payment of his / her dialysis fees.
    Pesakit akan dikajisemula untuk menentukan kesesuaian menjalani rawatan dialisis oleh Pengurus / Pegawai Kebajikan NKF pada masa-masa yang diperlukan mengikut budibicara NKF dengan membayar yuran rawatan dengan tepat.
15. No visitors are allowed into the Dialysis Centre without the consent of the Centre Manager / Staff Nurse In-Charge of the Centre.
    Pelawat-pelawat tidak dibenarkan memasuki Pusat Dialisis tanpa kebenaran Pengurus / Jururawat Yang Menjaga Pusat Dialisis tersebut.
16. The patient must be willing to sign a contract with the NKF before commencing the dialysis programme.
    Pesakit hendaklah bersetuju menandatangani perjanjian dengan NKF sebelum menjalani rawatan dialisis.
17. The patient must be willing to give his consent and/or explicit consent for NKF to use his personal data and/or sensitive personal data for the purposes and the parties stated in the Privacy Notice of NKF which is displayed in the NKF website at www.nkf.org.my.
    Pesakit hendaklah bersetuju memberi persetujuan dan/atau persetujuan eksplisit beliau untuk NKF menggunakan data peribadi dan/atau data peribadi sensitif beliau bagi tujuan dan pihak yang dinyatakan dalam Notis Privasi NKF yang dipaparkan di laman web NKF di www.nkf.org.my.
18. The witness to the patient’s signature should not be the spouse, sibling, children and parents of the patient.
    Seorang saksi yang menyaksikan tandatangan pesakit tidak boleh terdiri daripada suami atau isteri, adik beradik, anak-anak dan ibu bapa pesakit.