Download application for haemodialysis programme

PEMEGANG AMANAH YAYASAN KEBAJIKAN SSL HAEMODIALYSIS
修成林洗肾福利基金
No.9, Jalan 1/5, 46000 Petaling Jaya, Selangor.
Tel : 03-7782 2293 / 7782 4092 Fax : 03-7783 5092
APPLICATION FOR HAEMODIALYSIS PROGRAMME
(PERMOHONAN MENYERTAI PROGRAM HEMODIALISIS)
1. PERSONAL PARTICULARS
Full Name:
NRIC No:
Address:
Tel No. :
D.O.B :
Marital Status :
Age :
Sex:
Nationality :
Race :
M / F
Type of Accommodation:
OWN [ Fully Paid / On Installment : RM __________/month ]
Loan payment from _________ until ________ (attach loan agreement)
RENT [RM ____________/ month]
Low Cost Flat
Single Storey
Apartment
Double Storey
Condominium
Other __________
2. EDUCATION BACKGROUND
Level / Course
Primary
Secondary
STPM
University/College
Others
Year
Name of School
3. DETAILS OF EMPLOYMENT
Present Occupation
Employer Name
:
:
Income :
Address :
Tel
If unemployed, please state:
Since (date):
Reason:
Name of supporter:
[1]
:
Result
PEMEGANG AMANAH YAYASAN KEBAJIKAN SSL HAEMODIALYSIS
修成林洗肾福利基金
No.9, Jalan 1/5, 46000 Petaling Jaya, Selangor.
Tel : 03-7782 2293 / 7782 4092 Fax : 03-7783 5092
4. FAMILY INFORMATION
List of siblings staying together
No.
Name
Relationship Age
Occupation
Marital
Status
No. of
Children
Monthly
Income
TOTAL :
List of siblings NOT staying together
No.
Name
Relationship
Age
Occupation
Marital
Status
No.
Of
Children
Monthly
Income
TOTAL :
[2]
Contribution
To
Applicant
PEMEGANG AMANAH YAYASAN KEBAJIKAN SSL HAEMODIALYSIS
修成林洗肾福利基金
No.9, Jalan 1/5, 46000 Petaling Jaya, Selangor.
Tel : 03-7782 2293 / 7782 4092 Fax : 03-7783 5092
5. TOTAL MONTHLY HOUSEHOLD INCOME AND EXPENDITURE
Income
RM
1. Personal Income
2. Household Family Income
3. Contributions From Other Children
4. Other Income (Pls specify)
TOTAL INCOME
Expenditure
RM
1. EPF & SOCSO Contribution
2. Food
3. House Rental / Installment
4. Vehicle Installment
5. Utilities (water / electricity / telephone)
6. Schooling Expenses
7. Working Members’ Expenses (petrol / food)
8. Dialysis payment (Dialysis RM_______/month , EPO injection RM_____)
9. Others, pls specify,
TOTAL EXPENDITURE
BALANCE INCOME (Total Income – Total Expenditure)
Description
RM
Total Income
Total Expenditure
BALANCE
[3]
PEMEGANG AMANAH YAYASAN KEBAJIKAN SSL HAEMODIALYSIS
修成林洗肾福利基金
No.9, Jalan 1/5, 46000 Petaling Jaya, Selangor.
Tel : 03-7782 2293 / 7782 4092 Fax : 03-7783 5092
6.
Every applicant is REQUIRED to attach below listed supporting documents. The
admission process will be delayed if the patient fails to submit the complete required
documents.
a.
b.
c.
d.
e.
Photocopy of I/C & 2pcs Latest Passport Size Photo (Applicant only)
Latest Salary Slip or Certify letter from Employer (Applicant, spouse & children)
Income Tax Returns (Form J / EA) (Applicant, spouse & children)
Latest EPF Statement, or Proof of EPF withdrawal statement (if any) (Applicant, spouse & children)
Photocopy of saving account passbook, current account bank statements or FD slip (Applicant,
spouse & children)
f. House rental receipt or house installment statement (Applicant, spouse & children)
g. Vehicle installment statement, Insurance statement and Credit Card statement(Applicant, spouse &
children)
h. Photocopy of electricity, water, telephone or hand phone bill (Applicant, spouse & children)
i. Medical Report from Nephrologist & ECG Report (if any)
j. Blood test report with VDRL (RPR), HIV I & II, Hepatitis A, B, C,Antigen and Antibody (must be within
6 months)
================>>>>>>>>>>>>>>>>>================<<<<<<<<<<<<<<<<<<<=============
Checklist (For Office Use Only)
Form
Date
Received
Applicant
Application Form
Medical Report
Latest Blood Test Report
(HHH, HIV & VDRL)
Latest 2 pcs Passport Size Photo &
photocopy of I/C
Latest Salary slip
Latest Income Tax Return
Latest EPF statement
Saving/current account statement
House Rental / Installment slip
Vehicle Installment slip
Utilities bill
Others (pls specify),
[4]
Spouse
Parent
Children
Sibling
Others
PEMEGANG AMANAH YAYASAN KEBAJIKAN SSL HAEMODIALYSIS
修成林洗肾福利基金
No.9, Jalan 1/5, 46000 Petaling Jaya, Selangor.
Tel : 03-7782 2293 / 7782 4092 Fax : 03-7783 5092
7. CONDITIONS FOR SELECTION INTO STAFF NURSE ASSISTANCE HAEMODIALYSIS PROGRAMME
a. Applicant is a Malaysian Citizen.
b. Applicant is aged 16 years and above.
c. Applicant is ambulant (able to move independently).
d. Applicant has a suitable functional vascular access.
e. Applicant is prepared to have regular blood test to assess the medical condition and quality condition.
f.
Applicant must be certified medically fit by SSL's appointed Nephrologist.
g. Applicant has no other recourse to regular Haemodialysis from charitable organisation.
h. Applicant is prepared to meet the SSL Committee Member before being considered for the programme.
i.
Applicant must agree to a Committee and Social Worker's visit to his/her home with a view to verify all
information given.
j.
Applicant is prepared to pay treatment fee of RM110.00 per dialysis session on admission until the approval
of government subsidy of RM50.00 is granted by the Ministry of Health (MOH). SSL will henceforth charge
RM60.00 per dialysis session. SSL will apply to MOH for approval of government subsidy on behalf of the
patient.
k. Applicant is prepared to pay a dialysis deposit of RM300.00 before starting the dialysis with SSL. It will be
forfeited if the patient fails to turn up for dialysis during that week.
l.
Applicant is prepared to pay treatment fee as stated above. This fee is subject to change by the SSL as and
when it deems necessary. This amount is payable prior to treatment.
m. Applicant who fails to obtain the government subsidy approval from MOH will have to pay RM110.00 or fee
set by SSL per dialysis while his appeal is referred to MOH for reconsideration. If the appeal to MOH is
rejected, the case will be referred to SSL Committee Member for its final decision to allow the patient to
continue dialysis or terminate his dialysis treatment in SSL.
n. The selected patient must be willing to undergo dialysis at the Centre at the dates and times fixed by the
Centre, three times per week, 4 hours per session.
o. Reselection-The patient is reviewed every 6 months with regards to his suitability to continue on the dialysis
programme.
p. The patient's programme can be terminated if :

He/She fails to turn up for more than 3 successive dialysis.

He/She is no longer ambulant.
[5]
PEMEGANG AMANAH YAYASAN KEBAJIKAN SSL HAEMODIALYSIS
修成林洗肾福利基金
No.9, Jalan 1/5, 46000 Petaling Jaya, Selangor.
Tel : 03-7782 2293 / 7782 4092 Fax : 03-7783 5092

His/Her condition has deteriorated with complications such as heart disease, infection, stroke etc
or need to be transferred to CAPD.

He/She is uncooperative and fails to keep within the terms of the contract drawn up.
o. The patient must be willing to sign a contract with SSL before commencing the dialysis programme.
p. Applicant with HIV positive and Hepatitis B+C positive will not be accepted by SSL.
8. DECLARATION
I declare that :
a. I have read,understood and agreed to comply with the terms and conditions.
b. All the particulars given in this form are true & I have not suppressed any information required.
c. I am aware that if my application is successful, I will be accepted for dialysis for only 6 months. Thereafter
my application will be reconsidered.
d. Upon acceptance, I agree to obey all the rules & regulations set by Pemegang Amanah Yayasan Kebajikan
SSL Haemodialysis Berdaftar.
e. If I have suppressed or given any incorrect information, Pemegang Amanah Yayasan Kebajikan SSL
Haemodialysis Berdaftar reserves the right to discontinue providing treatment to me and I will not take
any legal action against the centre.
___________________________
________________
Applicant's Signature / Right Thumb Print
Date
WITNESSED BY,
Name
:
I/C No.
:
Relationship
:
Tel No.
:
Address:
[6]
PEMEGANG AMANAH YAYASAN KEBAJIKAN SSL HAEMODIALYSIS
修成林洗肾福利基金
No.9, Jalan 1/5, 46000 Petaling Jaya, Selangor.
Tel : 03-7782 2293 / 7782 4092 Fax : 03-7783 5092
To the Doctor incharge,
 Kindly complete the questionnaire in full. The report should indicate the period for which the patient was put under
care of the referring physician and provide an adequate resume of the patient’s clinical history.
 If the referring physician has specific reservations about the medical suitability of the patient for the treatment
applied for, these should be clearly declared.
 The referring Nephrologist should undertake to continue to treat the patient jointly with Pemegang Amanah
Yayasan Kebajikan SSL Haemodialysis Berdaftar after the patient is accepted for dialysis.
Patient’s Name :
Physician’s Name :
Patient I/C No. :
Physician’s Clinic/Hospital :
Diagnosis
Primary
Secondary
1. SUMMARY OF MEDICAL REPORT :
2. SPECIFIC QUESTIONS
(SPECIFY)
a) Is the patient mentally or educationally normal ?
Yes
No
b) Is the patient ambulant ?
Yes
No
c) Does the patient suffer any vision,hearing or physical disability?
Yes
No
d) Has the patient had any previous surgery (including
transplantation) ?
Yes
No
[7]
PEMEGANG AMANAH YAYASAN KEBAJIKAN SSL HAEMODIALYSIS
修成林洗肾福利基金
No.9, Jalan 1/5, 46000 Petaling Jaya, Selangor.
Tel : 03-7782 2293 / 7782 4092 Fax : 03-7783 5092
e) Does the patient have other significant disease(s) that would
Yes
No
Yes
No
Yes
No
h) Is the patient likely to be medically fit to work ?
Yes
No
i) Allergy :
Yes
No
mitigate against response to treatment ?
If so, please specify :

Coronary artery disease
Yes
No

Cerebrovascular disease
Yes
No

Peripheral vascular disease
Yes
No

Chronic pulmonary disease
Yes
No

Diabetes mellitus
Yes
No

Malignancy
Yes
No

Other systemic disease
Yes
No
f) Has the patient undergone peritoneal dialysis?
If yes, please specify :
Acute
Long Term
g) Has the patient been considered for transplantation ?
If yes, please specify :
Living related
Cadaveric
j) Other medical illness :
3. VASCULAR ACCESS
AV Fistula
AV Graft
Others,_________________
Date Created : __________________Location : _____________
In Use :
Yes
4. CURRENT TREATMENT :
Conservative
IPD
CAPD
Haemodialysis
Date of first dialysis : __________________________ Place of dialysis : __________________________
[8]
No
PEMEGANG AMANAH YAYASAN KEBAJIKAN SSL HAEMODIALYSIS
修成林洗肾福利基金
No.9, Jalan 1/5, 46000 Petaling Jaya, Selangor.
Tel : 03-7782 2293 / 7782 4092 Fax : 03-7783 5092
5. INVESTIGATIONS (Please attach a copy of latest blood test result)
HbsAg
:
positive
negative
not done
Anti HBS
:
positive
negative
not done
Anti HCV
:
positive
negative
not done
HIV
:
positive
negative
not done
VDRL
:
positive
negative
not done
MRSA Screen :
positive
negative
not done
Creatinine (umol/l) :
Urea (mmol/l) :
Potassium (mmol/l) :
HCO3 (mmol/l) :
Calcium (mmol/l) :
Phosphate (mmol/l) :
ALT (iu/l) :
AST (iu/l) :
Albumin (g/l) :
HB (g/dl) :
6. CURRENT MEDICATIONS :
7. OTHER COMMENTS :
_______________________________
Signature of Nephrologist / Physician
Date
Chop :
[9]