For Official use only
STANDARD CLAIM FORM
General Claim Form

PLEASE TYPE OR PRINT IN INK

Mail or deliver Office of Financial Management
No.
original claim Risk Management Division
General Administration Building, Room …..
………………………………………………….
………………………………………………….
Post Office Box ………………………………
…………………………………….., Malaysia
Business Hours: Mon. - Fri. 8:00 a.m. - 5:00 p.m.
Closed on weekends and official state holidays.

CLAIMANT INFORMATION
1. Claimant's name: ____________________________________________________________

________________________________

2. Date of birth (mm/dd/yyyy) [ _ _ - _ _ -_ _ _ _]

3. Current residential address: ____________________________________________________________

_______________________
____________________________________________________________

_______________________
____________________________________________________________

_______________________
____________________________________________________________

_______________________

4. Mailing address (if different):
____________________________________________________________

_______________________
____________________________________________________________

_______________________
____________________________________________________________

_______________________
____________________________________________________________

_______________________

5. Residential address at the time of the incident (if different from current address):
____________________________________________________________

_______________________
____________________________________________________________

_______________________
____________________________________________________________

_______________________
____________________________________________________________

_______________________

6. Claimant's daytime telephone number:
Home _____________________________
Mobile Phone _____________________________

7. Claimant’s e-mail address:
____________________________________________________________

________________

INCIDENT INFORMA TION

8. Reason of claim:
____________________________________________________________

_______________________
____________________________________________________________

_______________________
____________________________________________________________

_______________________
____________________________________________________________

_______________________

9. Date of the incident: ________________ Time:___________ a.m./ p.m. (check one) (mm/dd/yyyy)

9. If the incident occurred over a period of time, date of first and last occurrences: from ____________ Time: ____ a.m. / p.m. (check one) to ____________, Time:____ a.m . p.m. (check one) (mm/dd/yyyy) (mm/dd/yyyy)

9. Location of incident
____________________________________________________________

_________________
____________________________________________________________

_________________
____________________________________________________________

_________________
(State and county City, if applicable Place where occurred)

10. Names, addresses and telephone numbers of all persons involved in or witness to this incident: * ____________________________________________________________

__________________________
____________________________________________________________

__________________________
____________________________________________________________

__________________________
__________________ (hp) * ____________________________________________________________

__________________________
____________________________________________________________

__________________________
____________________________________________________________

__________________________
__________________ (hp) * ____________________________________________________________

__________________________
____________________________________________________________

__________________________
____________________________________________________________

__________________________
__________________ (hp)

11. Names, addresses and telephone numbers of any employees having knowledge about this incident:
____________________________________________________________

_________________________________
____________________________________________________________

_________________________________
__________________ (hp)

12. Names, addresses and telephone numbers of all individuals not already identified in #12 and #13 above that have knowledge regarding the liability issues involved in this incident, or knowledge of the Claimant’s resulting damages. Please include a brief description as to the nature and extent of each person’s knowledge. Attach additional sheets if necessary. (fill in if it necessary)
____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________
____________________________________________________________

____________________________________________________________

____________________________________________________________

______

13. Describe the cause of the injury or damages. Explain the extent of property loss or medical, physical or mental injuries. Attach additional sheets if necessary.(fill in if it necessary)
____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________
____________________________________________________________

_________________________________

14. Has this incident been reported to law enforcement, safety or security personnel? If so, when and to whom?____________________________________________________________

____________________________________________________________

___________________________________________________________ ____________________________________________________________

_________________________________
15. Names, addresses and telephone numbers of treating medical providers. Attach copies of all medical reports and billings. .(fill in if it necessary)
____________________________________________________________

_________________________________
____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________

16. If travelling purpose, where did you travel and on what reason did you travel?(fill in if it necessary)
____________________________________________________________

_________________________________
____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________

17. Who have knowledge regarding this official matter (as you mentioned in Q16) in this organization.
Please state their name, position, and their contact number.(fill in if it necessary)
____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________

18. Any relevant information that claimant wants to include :
____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________

19. Please attach documents which support the claim’s allegations.

20. I claim damages from the company in the sum of RM___________.

This Claim form must be signed by the Claimant, a person holding a written power of attorney from the Claimant, by the attorney in fact for the Claimant, by an attorney admitted to practice in Malaysia on the Claimant's behalf, or by a court-approved guardian or guardian ad litem on behalf of the Claimant.

I declare under penalty of perjury under the laws of the Malaysia state that the foregoing is true and correct.

____________________________________ _____________________________________________
Signature of Claimant Date and place (residential address)

Claim# ____________________

Authorization for Release of Protected Health Information (PHI)
To The Office of Financial Management (OFM) Risk Management Division

Name: ________________________________________________________
(Last, First, Middle Initial or Middle Name)

Date of Birth: Month _____ Day ____ Year _________

* I hereby authorize disclosure of my protected health information to the Office of Financial Management, Risk Management Division, for purposes of processing my claim for damages filed with the State of Malaysia. * I understand that by signing this document, I authorize the release of the following information:

* Complete medical record for all services, including history and physical exam; progress notes; x-ray reports; inpatient admissions; operative notes; physical or other therapy; laboratory and other test reports; physician and physician assistant orders; nursing notes; and all other records and references designated by the provider as part of its medical record.

* HIV Test Results and medical information related to HIV testing or treatment

* Psychiatric, mental and behavioral health records, including treatment notes, assessments, testing documents and results, and medical records related to mental health diagnosis and treatment

* Alcohol assessment, testing, referral or treatment records

* All other chemical dependency assessment of treatment records

* Pharmacy prescriptions and reports

* All letters and memos received or sent, including electronic mail, referencing my treatment,

* Information related to alleged sexual assault or sexually transmitted disease, including test results

* Urgent care, outpatient or other clinic visit information

* Gynecological and/or obstetrical information

* All client records generated for or by governmental programs of which I am a client. Identify the program(s) and agency: ___________________________________________________.

* Financial records related to my care and treatment

* I understand the following: (PLEASE READ AND INITIAL ALL STATEMENTS)

* I understand that my records are protected under HIPAA/PHI regulations (federal law) and the Malaysia State Health Care Information Act

* I understand that my health information may be subject to re-disclosure by OFM and not protected for purposes of evaluating and investigating the claim I have filed with the State of Malaysia.

* I understand that the specific information to be disclosed in my medical record may include information regarding alcohol, drug or other controlled substance use, counseling referrals and/or a history of testing or treatment of acquired immune deficiency syndrome.

* I understand that I may revoke this authorization at any time by notifying OFM in writing, and that the revocation will be effective as of the date OFM receives it. Any records obtained pursuant to this Authorization for Release of PHI prior to the revocation will be deemed authorized by me for release.

* I understand that this Authorization for Release will expire 90 days from the date I sign it. I can also authorize a different time frame for this release to be valid. This permission is valid until my claim is resolved or closed by OFM.

A Photostat of this Authorization carries the same authority as the original for purposes of releasing my records to OFM.
Signature of Authorizing Individual:
____________________________________________________________

________________

Date of Signature: ____________________________________________________________

_

Telephone number: ____________________________________________________________

Witness (where patient is over 13 and signing the release):
____________________________________________________________

________________

Where the signer is not the subject of the records:
I am authorized to sign this because I am the (attach proof of authority): Parent of minor Legal Guardian Personal Representative Other

To the Provider or Records Custodian
Please send legible copies of all records to:

Office of Financial Management
Risk Management Division
General Administration Building, Room …..
………………………………………………….
………………………………………………….
Post Office Box ………………………………
…………………………………….., Malaysia