GCF APPLICATION FORM (ENG)

Name

Gender

Age

Identity card number

For patient/client above 18 years old, please complete the following section.

Marital status

Occupation

Number of Children

Age of Children

Source of Financial Support for Living

Self Parents Children Government subsidy

Others

Monthly Income

No Income

Less than RM1,499

RM1,500-2, 499

RM2,500-3,499

RM3, 500 and above

Address

Contact

Primary

Secondary

GUARDIAN INFORMATION

ONLY for patient/client who is unemployed, not eligible for employment (e.g. elderly or individual below 18 years old)

Name

age

Identity card number

Contact

Primary

Secondary

Address

Relation with the patient/client:

Spouse

Father/ Mother

Children

Other

Other, please specify

Marital status

Number of Children

Age of Children

Occupation

Monthly Income

No Income Less than RM1,499 RM1,500-2, 499 RM2,500-3,499 RM3, 500 and above

DECLARATION & SIGNATURE OF PATIENT/CLIENT OR GUARDIAN

Name

Date

AUDIOLOGIST/SPEECH-LANGUAGE PATHOLOGIST INFORMATION
(to be completed by the attending audiologist/speech-language pathologist)

Name

Current MASH membership:

Yes No

Email address

Contact number

Institution name & department

Institution address

PATIENT/CLIENT CLINICAL INFORMATION

Hearing and/or speech-language related diagnosis (including statement of severity)

Medical history

Medical expenses (describe medical needs and other related needs)

Therapy history (e.g. where and when was the hearing or speech-language disorder first diagnosed, how long has the patient/client been in therapy service and frequency of therapy received thus far)

Provisional therapy goals

Prognosis

Commitment to therapy session (e.g. session attendance rate and commitment to home practice)

Good Fair Poor

Additional information (e.g. particulars that would help the fund application review panel to understand the urgency of this application)

Amount of fund applied

For intervention fees (please indicate frequency, duration of intervention session and total amount, e.g. RM100/session x 12 sessions (one session weekly) = total RM 1200)

For assistive device (please attach a quotation from vendor)

DECLARATION AND SIGNATURE OF CLINICIAN

Name

Date

APPLICATION SUBMISSION CHECKLIST

Copy of applicant’s Identity Card/ Birth Certificate

Copy of applicant’s Pay Slip, latest KWSP/EPF Statement (4 or 6 months prior to date of application) and EA Form (all related proof of income documentation) For applicants without the required financial statements/proofs, please provide an Employer Verification Letter.

For unemployed applicants, the attending/supporting clinician has to be the referee.

Quotation of assistive hearing/speech-language devices (if relevant)

Copy of the clinician’s professional qualification (only applicable to clinicians who are not a member of the MASH)

GCF APPLICATION FORM (ENG)

Applicant Information

Contact us
Today!

GCF APPLICATION FORM (ENG)

Applicant Information

Contact us Today!

Contact us
Today!