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    <title>Farrer Park Hospital Discharge eForms</title>
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                        Welcome , Dr. Chiew Kim Huat Richard.   <br>
                        Your last login was on 10 Nov 2019 12:01pm
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                                        <h3 class='page_title'>Letter of Certification</h3>
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                                                <span id="hour" class="timer bg-theme"></span> <b>h</b>
                                                <span id="min" class="timer bg-theme"></span> <b>m</b>
                                                <span id="sec" class="timer bg-theme"></span> <b>s</b>
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                                    <label>Name :</label>
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                                    <label class='p_name info'></label>
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                                    <label>Patient Acccount No. :</label>
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                                <div class="col-md-2">
                                    <label class="acc_no info"></label>
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                                    <label>Principal Doctor :</label>
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                                        <a class="nav-link" id="side-tab-procedures-tab" data-toggle="pill" href="#side-tab-procedures" role="tab" aria-controls="side-tab-procedures" aria-selected="false">Procedures</a>
                                        <a class="nav-link" id="side-tab-non-surgical-treatment-tab" data-toggle="pill" href="#side-tab-non-surgical-treatment" role="tab" aria-controls="side-tab-non-surgical-treatment" aria-selected="false">Non-Surgical Treatment</a>
                                        <a class="nav-link" id="side-tab-total-surgical-non-surgical-tab" data-toggle="pill" href="#side-tab-total-surgical-non-surgical" role="tab" aria-controls="side-tab-total-surgical-non-surgical" aria-selected="false">Total Surgical and Non-Surgical Charges</a>
                                        <a class="nav-link" id="side-tab-certification-tab" data-toggle="pill" href="#side-tab-certification" role="tab" aria-controls="side-tab-certification" aria-selected="false">Certification</a>

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                                <div class="col-md-10 lc_content">
                                    <div class="tab-content" id="side-tab-tabContent">
                                        <div class="tab-pane fade show active" id="side-tab-patient-particulars" role="tabpanel" aria-labelledby="side-tab-patient-particulars-tab">
                                            <div class='sub_page_title'>
                                                <h4>
                                                    A. Patient Particulars
                                                </h4>
                                                <div class="clear_fix"></div>
                                                <div class="container-fluid" style='padding:0;'>
                                                    <div class="row">
                                                        <div class="col-md-6">
                                                            <div class="container-fluid" style='padding:0;'>
                                                                <div class="row">
                                                                    <div class="col-sm-4">
                                                                        <label>Name :</label>
                                                                    </div>
                                                                    <div class="col-sm-8">
                                                                        <label class='p_name'></label>
                                                                    </div>
                                                                    <div class="col-sm-4">
                                                                        <label>NRIC / Passport No. :</label>
                                                                    </div>
                                                                    <div class="col-sm-8">
                                                                        <label class="nric"></label>
                                                                    </div>
                                                                    <div class="col-sm-4">
                                                                        <label>Patient Acccount No. :</label>
                                                                    </div>
                                                                    <div class="col-sm-8">
                                                                        <label class="acc_no"></label>
                                                                    </div>

                                                                </div>
                                                            </div>

                                                        </div>
                                                        <div class="col-md-6">
                                                            <div class="container-fluid" style='padding:0;'>
                                                                <div class="row">
                                                                    <div class="col-sm-4">
                                                                        <label>Date of Admission :</label>
                                                                    </div>
                                                                    <div class="col-sm-8">
                                                                        <label class='date_admission'></label>
                                                                    </div>
                                                                    <div class="col-sm-4">
                                                                        <label>Date of Discharge :</label>
                                                                    </div>
                                                                    <div class="col-sm-8">
                                                                        <label class="date_discharge"></label>
                                                                    </div>
                                                                    <div class="col-sm-4">
                                                                        <label>Case Type :</label>
                                                                    </div>
                                                                    <div class="col-sm-8">
                                                                        <label class="case_type"></label>
                                                                    </div>

                                                                </div>
                                                            </div>
                                                        </div>
                                                        <div class="col-md-6">
                                                            <div class="container-fluid" style='padding:0;'>
                                                                <div class="row">
                                                                    <div class="col-sm-4">
                                                                        <label>Admitting Specialty :</label>
                                                                    </div>
                                                                    <div class="col-sm-8">
                                                                        <label class="admitting_speciality"></label>
                                                                    </div>
                                                                </div>
                                                            </div>
                                                        </div>
                                                    </div>
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                                            <div class='m_15'></div>
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                                        <div class="tab-pane fade" id="side-tab-diagnosis" role="tabpanel" aria-labelledby="side-tab-diagnosis">
                                            <div class='sub_page_title'>
                                                <h4>
                                                    B. Diagnosis
                                                </h4>

                                            </div>
                                            <div class="clear_fix"></div>
                                            <div class="container-fluid" style='padding:0;'>
                                                <div class="row">
                                                    <div class="col-md-12">
                                                        <div class="container-fluid" style='padding:0;'>
                                                            <div class="row">
                                                                <div class="col-md-3">
                                                                    <label><span style='color:red'>*</span> Principal Diagnosis :</label>
                                                                </div>
                                                                <div class="col-md-9">
                                                                    <label>D24 : Benign neoplasm of breast</label>
                                                                </div>
                                                                <div class='m_15'></div>
                                                                <div class="col-md-3">
                                                                    <label>Secondary Diagnosis :</label>
                                                                </div>
                                                                <div class="col-md-9">
                                                                    <div id='secondary_diagnosis_field'>
                                                                        <label>1) L720 : Epidermal Cyst</label>
                                                                        <br> <label>2) C501 : Malignant neoplasm of central portion of breast</label>
                                                                    </div>
                                                                </div>

                                                                <div class='m_15'></div>
                                                                <div class="col-md-3">
                                                                    <label>Other Diagnosis :</label>
                                                                </div>
                                                                <div class="col-md-9">
                                                                    <div id='others_diagnosis_field'>
                                                                        <label>1) K210: Gastro-oesophageal reflux disease with oesophageal</label>
                                                                    </div>
                                                                </div>


                                                            </div>
                                                        </div>

                                                    </div>

                                                </div>
                                            </div>
                                            <div class='m_15'></div>
                                        </div>
                                        <div class="tab-pane fade" id="side-tab-procedures" role="tabpanel" aria-labelledby="side-tab-procedures-tab">
                                            <div class='sub_page_title'>
                                                <h4>
                                                    C. Procedures
                                                </h4>
                                            </div>
                                            <div class="clear_fix"></div>
                                            <div class="container-fluid" style='padding:0;'>
                                                <div class="row">
                                                    <div class="col-md-12">
                                                        <div class="container-fluid" style='padding:0;'>
                                                            <div class="row">
                                                                <div class="col-md-3">
                                                                    <label>Date of Procedure : 17/07/19</label>
                                                                </div>
                                                                <div class="col-md-3">
                                                                    <label>Procedure Code : AT123</label>
                                                                </div>
                                                                <div class="col-md-2">
                                                                    <label>Table : 2A</label>
                                                                </div>
                                                                <div class="col-md-2">
                                                                    <label>Start time in OT : 09:20 </label>
                                                                </div>
                                                                <div class="col-md-2">
                                                                    <label>End time in OT : 15:00</label>
                                                                </div>
                                                                <div class='m_15'></div>
                                                                <div class="col-md-6">
                                                                    <label><span style='color:red'>*</span> Surgical Procedure :</label>
                                                                    <select class="form-control" id="surgical_procedure" name='surgical_procedure'>
                                                                          <option value=''>select ...</option>
                                                                          <option value='SA701S'>SA701S : Skin and Subcutaneous Tissue, Tumor/Cyst/Ulcer/Scar, Excision biopsy, removal of 2 or more or recurrent or complicated (adherent), excision</option>
                                                                          <option value='SA704B'>SA704B : Breasts, Lumps, imaging Guided Vaccum assisted Biopsy / Mammodome, Single lesion</option>
                                                                          <option value='SA824B'>SA824B : Breast, Tumor (malignant), Simple Mastectomy with Axiliary Clearance, with/without Sentinel Node Biopsy</option>
                                                                    </select>

                                                                </div>
                                                                <div class="col-md-6">
                                                                    <label>Nature of Operation :</label>
                                                                    <select class="form-control" id="nature_of_operation" name='nature_of_operation'>
                                                                            <option>select ...</option>
                                                                            <option>Medical</option>
                                                                            <option>Cosmetic</option>
                                                                            <option>Repeated</option>
                                                                            <option>Staged</option>
                                                                          </select>
                                                                </div>
                                                                <div class="m_15"></div>


                                                                <div class="col-md-12 ">
                                                                    <div class="surgical_procedure_table">
                                                                        <p class='sp_title'></p>
                                                                        <div class="table-responsive">
                                                                            <table class="table table-bordered table-hover dashboard_table">
                                                                                <thead>
                                                                                    <tr>
                                                                                        <th scope="col">Doctor Type</th>
                                                                                        <th scope="col">Doctor Name</th>
                                                                                        <th scope="col">MCR No.</th>
                                                                                        <th scope="col">Professional Fees</th>
                                                                                        <th scope="col">Implant Fees</th>
                                                                                        <th scope="col">Other Fees</th>
                                                                                        <th scope="col">Total Surgical Fees</th>
                                                                                        <th scope="col">GST</th>
                                                                                        <th scope="col">Charges with GST</th>
                                                                                        <th scope="col"><span style='color:red'>*</span> Fees to be collected (NC/FC)</th>
                                                                                        <th scope="col">Status</th>
                                                                                    </tr>
                                                                                </thead>
                                                                                <tbody>
                                                                                    <tr>
                                                                                        <th scope="row">Principal Surgeon</th>
                                                                                        <td><label class='doctor_name'>Dr. Richard Chew Kim Huat </label></td>
                                                                                        <td><label class="mcr_no">01877E</label></td>

                                                                                        <td>
                                                                                            <div style='position:relative;'>
                                                                                                <span class='fee'>$</span>
                                                                                                <input class="form-control fee_unit" type="number" name="professional_fee1" step="0.01" value='0.00' required>
                                                                                            </div>
                                                                                        </td>
                                                                                        <td>
                                                                                            <div style='position:relative;'>
                                                                                                <span class='fee'>$</span>
                                                                                                <input class="form-control fee_unit" type="number" name="implant_fee1" step="0.01" value='0.00' required>
                                                                                            </div>
                                                                                        </td>
                                                                                        <td> <span id='other_fee1' value='0.00'>$0.00 </span> <button type="button" class='btn sub_form' data-toggle="modal" data-target="#sub_form_modal" data-id="1">sub-form</button></td>
                                                                                        <td> <span id='total_fee1' value='0.00'>$0.00 </span></td>
                                                                                        <td>
                                                                                            <select class="form-control gst" name='gst1'>
                                                                                                      <option value=''>select ...</option>
                                                                                                      <option value='charged'>Charged</option>
                                                                                                      <option value='waived'>Waived</option>
                                                                                                      <option value='not_registered'>Not Registered</option>
                                                                                                    </select>
                                                                                        </td>
                                                                                        <td> <span id='charged_gst_fee1' value='0.00'>$0.00 </span></td>
                                                                                        <td width='150px'>
                                                                                            <div style='position:relative;'>
                                                                                                <span class='fee'>$</span>
                                                                                                <input class="form-control fee_unit" type="number" name="fee_collected1" step="0.01" value='0.00' required>
                                                                                            </div>
                                                                                        </td>
                                                                                        <td> <select class="form-control status" name='status'>
                                                                                                    <option>Completed</option>
                                                                                                    <option>Saved as Draft</option>
                                                                                                  </select>
                                                                                        </td>
                                                                                    </tr>
                                                                                    <tr>
                                                                                        <th scope="row">Anaesthetist</th>
                                                                                        <td>Dr. Chong Kwan Yin</td>
                                                                                        <td>03792C</td>
                                                                                        <td>
                                                                                            <div style='position:relative;'>
                                                                                                <span class='fee'>$</span>
                                                                                                <input class="form-control fee_unit" type="number" name="professional_fee2" step="0.01" value='0.00' required>
                                                                                            </div>
                                                                                        </td>
                                                                                        <td>
                                                                                            <div style='position:relative;'>
                                                                                                <span class='fee'>$</span>
                                                                                                <input class="form-control fee_unit" type="number" name="implant_fee2" step="0.01" value='0.00' required>
                                                                                            </div>
                                                                                        </td>
                                                                                        <td> <span id='other_fee2' value='0.00'>$0.00 </span> <button type="button" class='btn sub_form' data-toggle="modal" data-target="#sub_form_modal" data-id="2">sub-form</button></td>
                                                                                        <td> <span id='total_fee2' value='0.00'>$0.00 </span></td>
                                                                                        <td>
                                                                                            <select class="form-control gst" name='gst2'>
                                                                                                      <option value=''>select ...</option>
                                                                                                      <option value='charged'>Charged</option>
                                                                                                      <option value='waived'>Waived</option>
                                                                                                      <option value='not_registered'>Not Registered</option>
                                                                                                    </select>
                                                                                        </td>
                                                                                        <td> <span id='charged_gst_fee2' value='0.00'>$0.00 </span></td>
                                                                                        <td width='150px'>
                                                                                            <div style='position:relative;'>
                                                                                                <span class='fee'>$</span>
                                                                                                <input class="form-control fee_unit" type="number" name="fee_collected2" step="0.01" value='0.00' required>
                                                                                            </div>
                                                                                        </td>
                                                                                        <td> <select class="form-control status" name='status'>
                                                                                                    <option>Completed</option>
                                                                                                    <option>Saved as Draft</option>
                                                                                                  </select>
                                                                                        </td>
                                                                                    </tr>

                                                                                </tbody>
                                                                            </table>

                                                                        </div>
                                                                    </div>

                                                                </div>
                                                                <div class="m_15"></div>
                                                                <div class="col-md-12">
                                                                    <button type="button" class='btn' id='addField'><i class="fas fa-plus"></i> Add Field</button>
                                                                    <button type="button" class='btn' id='removeField'><i class="fas fa-minus"></i> Remove Field</button>
                                                                </div>
                                                                <div class="m_15"></div>
                                                                <div class="col-md-2 offset-md-10">
                                                                    <button type="button" class="btn footer_btn_save save_surgical_info">Save</button>
                                                                </div>
                                                            </div>
                                                        </div>

                                                    </div>

                                                </div>
                                            </div>
                                            <div class='m_15'></div>
                                            <div class="clear_fix"></div>
                                        </div>
                                        <div class="tab-pane fade" id="side-tab-non-surgical-treatment" role="tabpanel" aria-labelledby="side-tab-non-surgical-treatment-tab">
                                            <div class='sub_page_title'>
                                                <h4>
                                                    D. Doctors' Non-Surgical Treatment
                                                </h4>
                                            </div>
                                            <div class="clear_fix"></div>
                                            <div class="table-responsive">
                                                <table class="table table-bordered table-hover non_surgical_table">
                                                    <thead>
                                                        <tr>
                                                            <th scope="col">Doctor Type</th>
                                                            <th scope="col">Doctor Name</th>
                                                            <th scope="col">MCR No.</th>
                                                            <th scope="col">Inpatient/Attendance Fees</th>
                                                            <th scope="col">Other Fees</th>
                                                            <th scope="col">Total Non-Surgical Fees</th>
                                                            <th scope="col">GST</th>
                                                            <th scope="col">Charges with GST</th>
                                                            <th scope="col"><span style='color:red'>*</span> Fees to be collected (NC/FC)</th>
                                                            <th scope="col">Status</th>
                                                        </tr>
                                                    </thead>
                                                    <tbody>
                                                        <tr>
                                                            <th scope="row">Principal Surgeon</th>
                                                            <td>Dr Richard Chew Kim Huat</td>
                                                            <td>01877E</td>
                                                            <td>
                                                                <div style='position:relative;'>
                                                                    <span class='fee'>$</span>
                                                                    <input class="form-control fee_unit" type="number" name="inpatient_fee1" step="0.01" value='0.00' required>
                                                                </div>
                                                            </td>
                                                            <td> <span id='non_surgical_other_fee1' value='0.00'>$0.00 </span> <button type="button" class='btn non_surgical_sub_form' data-toggle="modal" data-target="#sub_form_modal2" data-id="1">sub-form</button></td>
                                                            <td> <span id='non_surgical_total_fee1' value='0.00'>$0.00 </span></td>
                                                            <td>
                                                                <select class="form-control gst" name='non_surgical_gst1'>
                                                                  <option value=''>select ...</option>
                                                                  <option value='charged'>Charged</option>
                                                                  <option value='waived'>Waived</option>
                                                                  <option value='not_registered'>Not Registered</option>
                                                                </select>
                                                            </td>
                                                            <td> <span id='non_surgical_charged_gst_fee1' value='0.00'>$0.00 </span></td>
                                                            <td width='150px'>
                                                                <div style='position:relative;'>
                                                                    <span class='fee'>$</span>
                                                                    <input class="form-control fee_unit" type="number" name="non_surgical_fee1" step="0.01" value='0.00' required>
                                                                </div>
                                                            </td>
                                                            <td> <select class="form-control status" name='status'>
                                                                <option>Completed</option>
                                                                <option>Saved as Draft</option>
                                                              </select>
                                                            </td>
                                                        </tr>
                                                        <tr>
                                                            <th scope="row">Anaesthetist</th>
                                                            <td>Dr Chong Kwan Yin</td>
                                                            <td>03792C</td>
                                                            <td>
                                                                <div style='position:relative;'>
                                                                    <span class='fee'>$</span>
                                                                    <input class="form-control fee_unit" type="number" name="inpatient_fee2" step="0.01" value='0.00' required>
                                                                </div>
                                                            </td>
                                                            <td> <span id='non_surgical_other_fee2' value='0.00'>$0.00 </span> <button type="button" class='btn non_surgical_sub_form' data-toggle="modal" data-target="#sub_form_modal2" data-id="2">sub-form</button></td>
                                                            <td> <span id='non_surgical_total_fee2' value='0.00'>$0.00 </span></td>
                                                            <td>
                                                                <select class="form-control gst" name='non_surgical_gst2'>
                                                                  <option value=''>select ...</option>
                                                                  <option value='charged'>Charged</option>
                                                                  <option value='waived'>Waived</option>
                                                                  <option value='not_registered'>Not Registered</option>
                                                                </select>
                                                            </td>
                                                            <td> <span id='non_surgical_charged_gst_fee2' value='0.00'>$0.00 </span></td>
                                                            <td width='150px'>
                                                                <div style='position:relative;'>
                                                                    <span class='fee'>$</span>
                                                                    <input class="form-control fee_unit" type="number" name="non_surgical_fee_collected2" step="0.01" value='0.00' required>
                                                                </div>
                                                            </td>
                                                            <td> <select class="form-control status" name='status'>
                                                                <option>Completed</option>
                                                                <option>Saved as Draft</option>
                                                              </select>
                                                            </td>
                                                        </tr>
                                                    </tbody>
                                                </table>
                                            </div>
                                            <div class="col-md-2 offset-md-10">
                                                <button type="button" class='btn footer_btn_save save_non_surgical_info'>Save</button>
                                            </div>
                                            <div class='m_15'></div>
                                        </div>
                                        <div class="tab-pane fade" id="side-tab-total-surgical-non-surgical" role="tabpanel" aria-labelledby="side-tab-total-surgical-non-surgical-tab">
                                            <div class='sub_page_title'>
                                                <h4>
                                                    E. Total Surgical and Non-Surgical Charges
                                                </h4>
                                            </div>
                                            <div class="clear_fix"></div>
                                            <div class="table-responsive">
                                                <table class="table table-bordered table-hover non_surgical_table">
                                                    <thead>
                                                        <tr>
                                                            <th scope="col">Doctor Name</th>
                                                            <th scope="col">MCR No.</th>
                                                            <th scope="col">Total Surgical Charges</th>
                                                            <th scope="col">Total Non-Surgical Charges</th>
                                                            <th scope="col">Total Charges</th>

                                                        </tr>
                                                    </thead>
                                                    <tbody>
                                                        <tr>
                                                            <td>Dr Richard Chew Kim Huat</td>
                                                            <td>01877E</td>
                                                            <td>
                                                                <label class='Total_Surgical_Charges1'></label>
                                                            </td>
                                                            <td>
                                                                <label class='Total_Non_Surgical_Charges1'></label>
                                                            </td>
                                                            <td>
                                                                <label class='Total_Charges1'></label>
                                                            </td>
                                                        </tr>
                                                        <tr>
                                                            <td>Dr Chong Kwan Yin</td>
                                                            <td>03792C</td>
                                                            <td>
                                                                <label class='Total_Surgical_Charges2'></label>
                                                            </td>
                                                            <td>
                                                                <label class='Total_Non_Surgical_Charges2'></label>
                                                            </td>
                                                            <td>
                                                                <label class='Total_Charges2'></label>
                                                            </td>
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                                                <h4>
                                                    F. Certification
                                                </h4>
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                                            <div class="clear_fix"></div>
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                                                <p>I certify and declare that : </p>
                                                <ol class='order_list'>
                                                    <li>
                                                        I am the principal surgeon who performed the surgeries listed above. Procedures performed by other principal surgeons are not included in this Letter of Certification (LC).
                                                    </li>
                                                    <li>
                                                        Taking into consideration the patient's safety and medical condition, it was reasonable and approriate for the patient to be treated as an inpatient, to receive the surgeries and treatments provided, and for all the equipment, consumablesm, etc used in
                                                        the surgery to be used.
                                                    </li>
                                                    <li>
                                                        I am responsible for the accuracy of all information provided in this LC (including any Annexes), and it was completed in accordance with prevailing guidelines and rules on MediSave and MediShield Life claims. Inaccurate information submitted or breaches
                                                        of guidelines/rules may result in regulatory/legal action, including the imposition of financial penalties and the suspension or revocation of my approval under the MediSave and MediShield Life schemes.
                                                    </li>
                                                    <li>
                                                        I agree to the medical institution set out above making MediSave and MediShield Life claims for the patient, in respect of the surguries and other items listed in this LC. I further acknowledge and agree that I am responsible for all such claims which
                                                        may be made by the medical institution based on the information that I have provided in this LC.
                                                    </li>
                                                </ol>
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                                                    <p class='principal_name'>
                                                        <span>Dr Richard Chew Kim Huat </span>

                                                    </p>
                                                    <p class='mcr_num'>01877E</p>

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                                                <div class='signature_box'>
                                                    <p class='principal_name_field'>
                                                        <span>Name of Principal Surgeon</span>

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                                                    <p class='mcr_field'>MCR Number</p>

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                                                <div class='signature_box'>
                                                    <p style='text-align:center;'>This is an electronically signed copy and does not require signature.<span style='color:red;'>*</span></p>
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                                                <div class='m_15'></div>
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                                                        <td>CM0004</td>
                                                        <td>Chemotherapy</td>
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                                                        <td>CT</td>
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                                                        <td>MR003F</td>
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                                        <label class='start_ot'></label>
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                                                    </tr>
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                                                        <td>CM0004</td>
                                                        <td>Chemotherapy</td>
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                                                        <td>CT</td>
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                                                        <td>MR003F</td>
                                                        <td>Ultrasound</td>
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                                                            <input class="form-control" type="number" step="0.01" name="other2_fees6" value='0.00'>
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