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English (UK)
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SOCSO RETURN TO WORK REFERRAL E-FORM
If you feel your patient/employee/SOCSO insured person could benefit from SOCSO Return To Work Program, kindly fill the form below. The eligibility to join return to work program subject to the insured person contribution upon examination by the case manager return to work
I want to refer myself for this program
*
Yes
No
State
*
PERLIS
KEDAH
PULAU PINANG
PERAK
TERENGGANU
KELANTAN
PAHANG
JOHOR
MELAKA
NEGERI SEMBILAN
SELANGOR
SABAH
SARAWAK
WILAYAH PERSEKUTUAN KUALA LUMPUR
WILAYAH PERSEKUTUAN PUTRAJAYA
Select your or Insured Person/Patient/Employee current State
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REFEREE INFO
*You need to complete the information below for our references
Q2. SOCSO State Office
*
KANGAR
Select the SOCSO State Office nearest to your or Insured Person/Patient/Employee location for the referral
Q2. SOCSO State Office
*
ALOR SETAR
KULIM
SUNGAI PETANI
Select the SOCSO State Office nearest to your or Insured Person/Patient/Employee location for the referral
Q2. SOCSO State Office
*
GEORGETOWN
SEBERANG JAYA
Select the SOCSO State Office nearest to your or Insured Person/Patient/Employee location for the referral
Q2. SOCSO State Office
*
IPOH
SRI MANJUNG
TAIPING
TAPAH
TELUK INTAN
KUALA KANGSAR
Select the SOCSO State Office nearest to your or Insured Person/Patient/Employee location for the referral
Q2. SOCSO State Office
*
KUALA TERENGGANU
KEMAMAN
Select the SOCSO State Office nearest to your or Insured Person/Patient/Employee location for the referral
Q2. SOCSO State Office
*
KOTA BHARU
KUALA KRAI
Select the SOCSO State Office nearest to your or Insured Person/Patient/Employee location for the referral
Q2. SOCSO State Office
*
BENTONG
KUANTAN
TEMERLOH
Select the SOCSO State Office nearest to your or Insured Person/Patient/Employee location for the referral
Q2. SOCSO State Office
*
BATU PAHAT
JOHOR BAHRU
KLUANG
MUAR
SEGAMAT
Select the SOCSO State Office nearest to your or Insured Person/Patient/Employee location for the referral
Q2. SOCSO State Office
*
MELAKA
Select the SOCSO State Office nearest to your or Insured Person/Patient/Employee location for the referral
Q2. SOCSO State Office
*
SEREMBAN
KUALA PILAH
Select the SOCSO State Office nearest to your or Insured Person/Patient/Employee location for the referral
Q2. SOCSO State Office
*
PETALING JAYA
KLANG
RAWANG
Select the SOCSO State Office nearest to your or Insured Person/Patient/Employee location for the referral
Q2. SOCSO State Office
*
KOTA KINABALU
SANDAKAN
KENINGAU
LAHAD DATU
TAWAU
Select the SOCSO State Office nearest to your or Insured Person/Patient/Employee location for the referral
Q2. SOCSO State Office
*
KUCHING
MIRI
SIBU
BINTULU
Select the SOCSO State Office nearest to your or Insured Person/Patient/Employee location for the referral
Q2. SOCSO State Office
*
KUALA LUMPUR
Select the SOCSO State Office nearest to your or Insured Person/Patient/Employee location for the referral
Q2. SOCSO State Office
*
PUTRAJAYA
Select the SOCSO State Office nearest to your or Insured Person/Patient/Employee location for the referral
Q1. Referee name (Doctor/ Employer's name/Workers/Public)
*
Q2. Hospital / Health Clinic / Company/ Others
*
Q3. Department
*
Q4. Referee Phone Number
*
-
Area Code
Phone Number
Q5. Referee Email
*
example@example.com
Q6. Referee Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Insured Person/Patient/Employee Info
*You need to complete the information of the insured person/patient/employee for our references.
Q1. Insured/Patient/ Employee's name
*
Q2. I/C Number
*
(xxxxxxxxxxxx)
Q3. Phone Number
*
-
Area Code
Phone Number
Q4. Email
*
example@example.com
Q5. Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Q6. SOCSO State Office
*
KANGAR
Select the SOCSO State Office nearest to your or Insured Person/Patient/Employee location for the referral
Q6. SOCSO State Office
*
ALOR SETAR
KULIM
SUNGAI PETANI
Select the SOCSO State Office nearest to your or Insured Person/Patient/Employee location for the referral
Q6. SOCSO State Office
*
GEORGETOWN
SEBERANG JAYA
Select the SOCSO State Office nearest to your or Insured Person/Patient/Employee location for the referral
Q6. SOCSO State Office
*
IPOH
SRI MANJUNG
TAIPING
TAPAH
TELUK INTAN
KUALA KANGSAR
Select the SOCSO State Office nearest to your or Insured Person/Patient/Employee location for the referral
Q6. SOCSO State Office
*
KUALA TERENGGANU
KEMAMAN
Select the SOCSO State Office nearest to your or Insured Person/Patient/Employee location for the referral
Q6. SOCSO State Office
*
KOTA BHARU
KUALA KRAI
Select the SOCSO State Office nearest to your or Insured Person/Patient/Employee location for the referral
Q6. SOCSO State Office
*
BENTONG
KUANTAN
TEMERLOH
Select the SOCSO State Office nearest to your or Insured Person/Patient/Employee location for the referral
Q6. SOCSO State Office
*
BATU PAHAT
JOHOR BAHRU
KLUANG
MUAR
SEGAMAT
Select the SOCSO State Office nearest to your or Insured Person/Patient/Employee location for the referral
Q6. SOCSO State Office
*
MELAKA
Select the SOCSO State Office nearest to your or Insured Person/Patient/Employee location for the referral
Q6. SOCSO State Office
*
SEREMBAN
KUALA PILAH
Select the SOCSO State Office nearest to your or Insured Person/Patient/Employee location for the referral
Q6. SOCSO State Office
*
PETALING JAYA
KLANG
RAWANG
Select the SOCSO State Office nearest to your or Insured Person/Patient/Employee location for the referral
Q6. SOCSO State Office
*
KOTA KINABALU
SANDAKAN
KENINGAU
LAHAD DATU
TAWAU
Select the SOCSO State Office nearest to your or Insured Person/Patient/Employee location for the referral
Q6. SOCSO State Office
*
KUCHING
MIRI
SIBU
BINTULU
Select the SOCSO State Office nearest to your or Insured Person/Patient/Employee location for the referral
Q6. SOCSO State Office
*
KUALA LUMPUR
Select the SOCSO State Office nearest to your or Insured Person/Patient/Employee location for the referral
Q6. SOCSO State Office
*
PUTRAJAYA
Select the SOCSO State Office nearest to your or Insured Person/Patient/Employee location for the referral
Q7. Purpose of referral / Support needed
*
Rehabilitation
Vocational
Refer to Rehabilitation Centre/Satellite SOCSO
Work modification (Work Integration)
Orthotic/ Prosthetic/ Assistive device
Work Support Integration (Job Coaching)
Psychology Support
Entrepreneurship
Q8. Diagnosis/Types of injury
*
Injury/ Illness
Q9. Remarks
Any additional information
Q10. Upload patient/employee's document (e.g.,memo/ letter/ medical report/ related documents)
*
Browse Files
Must not exceed 10MB
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