AIA Singapore Private Limited(REG.No.201106386R) 3 Tampines Grande #09-01, Singapore 528799 SECTION 1 To be completed by Policy Owner PATIENT S PARTICULARS Life Assured s Full Name: (Patient) Life Assured's NRIC/Passport No./FIN No: (Patient) Policy Number: SECTION 2 -SPECIALIST S PARTICULARS MEDICAL SPECIALIST REPORT Medullary Cystic Disease MEDICAL SPECIALIST REPORT (To be completed by the Patient s Specialist) Name of Specialist: MCR No: Field of Specialty: Name of Medical Institution: MEDULLARY CYSTIC DISEASE 1. Had the patient been diagnosed with medullary cystic disease? YES NO If NO is answer for question (1), please provide full diagnosis of patient s medical condition 2. When did the patient first consult a doctor for medullary cystic disease? Date of first consultation: dd/ mm/ yyyy *L4MEDRT* Page 1 of 6 *L4MEDRT*
3. What were the symptoms of medullary cystic disease presented during first consultation? Symptom presented during consultation date under question (2) Date patient first experience symptoms If date is unknown, please provide the duration that symptoms had lasted prior to consultation date under question (2). (Please circle duration in days, months or years) dd/ mm/ yyyy Duration: (days/months/years) 4. When was first diagnosis of medullary cystic disease established? Date of first diagnosis: dd/ mm/ yyyy 5. Please provide the date when patient or next of kin first informed of the diagnosis of medullary cystic disease: dd/ mm/ yyyy 6. Was diagnosis of medullary cystic disease confirmed by renal biopsy? YES NO If No is answer for question (6), please provide the clinical basis for diagnosis of medullary cystic disease confirmed by attending specialist: 7. Was there presence of multiple cyst in the renal medulla accompanied by the presence of tubular atrophy and interstitial fibrosis? YES NO 8. Was there clinical manifestation anemia and/or polyuria? YES NO Page 2 of 6
9. Was there progressive deterioration in kidney function? YES NO If YES is answer for question (9), please provide the result of renal function test reflecting progressive deterioration in kidney s function: Name of laboratory test Date of laboratory test investigate renal function dd/ mm/ yyyy Finding of renal function test reflecting progressive deterioration in kidney s function dd/ mm/ yyyy dd/ mm/ yyyy 10. Was the patient s medullary cystic disease in presence of HIV infection? YES NO If YES is answer for question (10), please answer question (10a) and (10b) 10a. Date of first diagnosis of HIV infection: dd/ mm/ yyyy 10b. Date the patient was informed diagnosis of HIV infection: dd/ mm/ yyyy 11. Was the patient s medullary cystic a congenital disease? YES NO If YES is answer for question (11), please answer question (11a) and (11b) 11a. Date of first appearance (or first detection) of congenital defect relevant to medullary cystic: dd/ mm/ yyyy 11b. Please provide detail of congenital defect that appeared or was detected on date mentioned on question (11a): Page 3 of 6
12. Had the patient been diagnosed with or treated for chronic disease other than medullary cystic disease? YES NO If YES is answer for question (12), please complete below: Diagnosis Date of diagnosis Name and Address of Doctor consulted dd/ mm/ yyyy dd/ mm/ yyyy dd/ mm/ yyyy 13. Please provide name and address of doctor who referred the patient to you for treatment of medullary cystic disease: Name of doctor Full address Page 4 of 6
14. Will you agree and authorize us to release this medical information if such disclosure is required by the Financial Industry Disputes Resolution Centre Ltd (FIDReC) of Singapore or any proper Government Authority? YES NO I hereby declare that the foregoing answers to each and all are true and to the best of my knowledge and belief. Name and Signature of the Medical Specialist Date : dd/ mm/ yyyy Practice Stamp of the Medical Specialist Page 5 of 6
SECTION 4 (Copy of Medical Document) Please attach the following reports where applicable: Renal biopsy supported for diagnosis of medullary cystic disease. Renal function test reelecting progressive deterioration in kidney s function Ultrasound, CT, MRI or other reliable imaging techniques investigated for medullary cystic disease Referral Letter (if there is any) Page 6 of 6