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The Health Care Reference Letter is a critical document in Malaysian healthcare practice, used when a patient requires transfer of care, specialist consultation, or additional medical services from another healthcare provider. This document, governed by Malaysian healthcare regulations including the Medical Act 1971 and Medical Council Guidelines, serves as an official communication channel between healthcare providers. It typically includes comprehensive patient information, medical history, current treatment details, and the specific reason for referral. The letter must comply with Malaysian personal data protection laws while ensuring all relevant medical information is accurately conveyed to facilitate continued patient care. It is particularly important in both public and private healthcare settings, serving as a formal record of referral and supporting documentation for insurance and administrative purposes.

1. Letterhead Details: Referring doctor's/facility's complete contact information, medical license number, and professional credentials

2. Date and Reference Number: Current date and unique reference number for tracking purposes

3. Recipient Details: Name, designation, and complete contact information of the receiving healthcare provider or facility

4. Patient Information: Patient's full name, IC number, date of birth, contact details, and any relevant identification numbers

5. Purpose of Referral: Clear statement of the primary reason for the referral and type of medical attention needed

6. Clinical Information: Relevant medical history, current condition, symptoms, and duration of illness

7. Current Medications: List of current medications, dosages, and duration of treatment

8. Investigations and Results: Summary of relevant tests, investigations performed, and their results

9. Current Treatment: Overview of treatments provided and patient's response

10. Closing and Authentication: Professional closing, referring doctor's signature, name stamp, and medical registration number