Sangha Medical Aid Application Form

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Step 1 of 2

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Application Date

A. Personal Details

Name (Chinese/English)*

Pali Name (Chinese/English)*

Gender*

Male

Female

Date of Birth*

Mobile Phone Number*

Email Address*

Residential Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Correspondence Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Name of Brother Monastery*

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Brother Monastery Address

B. Compulsary Attachments (Soft Copy)

NRIC / Passport (Both Sides)*

Drop files here or

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 10 MB, Max. files: 2.

Monk Certificate*

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Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 10 MB.

Please upload photos of your medical documents, including official receipts and medical reports.*

Drop files here or

Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 10 MB.

C. Details of Expenses

Name of Medical Institution/Doctor*

Diagnosis & Treatment Plan*

Total Medical Cost (RM)*

Amount Paid (RM)*

Amount Requested for Assistance (RM)*

D. Eligibility Criteria

Assistance is strictly for the 39 Critical Illnesses listed below:

Bacterial Meningitis
Benign Brain Tumour
Blindness
Brain Surgery
Cancer
Cardiomyopathy
Chronic Aplastic Anaemia
Coma
Deafness
Encephalitis
End-Stage Liver Failure
End-Stage Lung Failure
Full-Blown AIDS
Fulminant Viral Hepatitis
Heart Attack
Heart Valve Surgery
HIV Infection Due to Blood Transfusion
Kidney Failure
Loss of Independent Existence
Loss of Speech
Major Head Trauma
Major Organ / Bone Marrow Transplant
Medullary Cystic Disease
Motor Neurone Disease
Multiple Sclerosis
Muscular Dystrophy
Paralysis of Limbs
Parkinson’s Disease
Primary Pulmonary Hypertension
Serious Coronary Artery Disease
Stroke
Surgery to Aorta
Systemic Lupus Erythematosus with Severe Kidney Complication
Terminal Illness
Third Degree Burns
Alzheimer’s Disease / Severe Dementia
Severe Bacterial Infection with Septic Shock
Progressive Scleroderma
Severe Myasthenia Gravis

E. Disbursement

Disbursement: RM5,000 (subject to UBOM’s approval)

F. Contact Person Details

Name of Contact Person*

Relationship with Applicant*

Telephone*

Email*

G. Important Notice

Approval of this fund is solely at the discretion of the UBOM Exco members, and applicants shall not dispute the decision.

H. Applicant Declaration

The information provided in this form is true and complete.
I will notify UBOM promptly of any change to any of my information.
My membership is subject to fulfilling the eligibility criteria.
I consent to your disclosure of my personal data to third parties as you may deem necessary.

If you are currently not a member of UBOM, please register now.

Consent*

I agree with all of the above*

Sangha Medical Aid Application Form

A. Personal Details

B. Compulsary Attachments (Soft Copy)

C. Details of Expenses

D. Eligibility Criteria

E. Disbursement

F. Contact Person Details

G. Important Notice

H. Applicant Declaration

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