IBU - Medical Reimbursement R

Payment Currency
IDR - Ind. Rupiah

Expenses Paid by Employee

1

Date
DD / MM / YY

Please read the instructio

2
3
Other Medical Expenses

Local Transport

Medical Package
Assistance

Perdiem

.00

.00

.00

5
Medical Expenses

Others

Doctor, Medicines, Lab, etc

.00

Patient Name

.00 =================>
316334162.xlsx

Employee Name :

Department :

Badge No :

Office Location :

CTN :

Office Room :

IDR - Ind. Rupiah

Employee Signature

Filled by Health & Medical

Cost Center

Account Code

Currency

Verification & Ap

Approved Amount

Medical Expenses

684911

IDR - Ind. Rupiah

.00

Other Medical Expenses

684911.J01

IDR - Ind. Rupiah

Name:

Name :

Date:

Date:

0.00

316334162.xlsx

Please read the instructions before you fill out this form.

Description (for Column 1, 4, and 5 if pertinent)

Attached receipts for all expenditures as applicable
DO NOT DISCLOSURE MEDICAL CONFIDENTIAL INFORMATION

.00 Grand total of all expenses

316334162.xlsx

Less: CASH ADVANCE received from Company

.00 Est. AMOUNT DUE COMPANY (Attach Refund Receipt)
.00 Est. AMOUNT DUE EMPLOYEE

Verification & Approval

Final Approval

Name :
Date :

DOA Limit : < USD

316334162.xlsx