JASINDO HEALTH CARE

Menara MTH Lt. 15 Suite 1502-1505

Jl. Letjen MT Haryono Kav. 23 Jakarta 12820
Telp. (021) 83782490, Fax. (021) 8378 2460
http:///www.jasindo.co.id
Call Centre Swipe Card 24 Jam : Call Centre Show Card 24 Jam :
Telp +62 21 2927 5151 Telp +62 21 8378 2525 / 08118700022
Fax +62 21 351 0558 Fax +62 21 8378 2485

FORMULIR KLAIM
(CLAIM FORM)
CASHLESS* REIMBURSEMENT* *Pilih sesuai kebutuhan
(Select as needed)
1 DATA PESERTA (Patient’s Information))

Nama Karyawan : …………………......... Nama Pasien : …………………….........… Tanggal Lahir : …………………………... Jenis Kelamin : Pria Wanita
(Employee’s Name) (Patient’s Name) (date of birth) (Sex) (Male) (Female)
No. Peserta : ………………............... Nama Perusahaan : ……………………….….. No. Rekening : …………..…………......
(Membership Number) (Company’s Name) (Account Number)
Nama Pemilik Rekening : ……………………..…. No. Telpon Pemilik Rekening : ……………..…..…
(Account Owner Name) (Telephone Number Owner Account)

Status pasien : Pegawai Suami/Istri Anak

(Patient’s Status) (Employee’s) (Husband/Wife) (Child)

2 INFORMASI PEMBERI PELAYANAN KESEHATAN (Service’s Information)

Rumah Sakit/ Klinik Dr. : …………………................… Ruang Kelas : ………………….......………... Jenis Kelamin: Pria Wanita
(Hospital/Clinic/dr Name) (Room Class) (Sex) (Male) (Female)
Tanggal Masuk : ………………………............ Tanggal Keluar : ………………………..........
(Date of Admission) (Date of Discharge)

Jenis Pelayanan Medis : Rawat Jalan (Outpatient); [ ] Dr. Umum (General Practioner) [ ] Dr. Spesialis (Specialist) [ ] Dr. Gigi (Dentist) [ ] Kacamata (Spectacles)
(Medical Services Type) Rawat Inap (Hospitalization) [ ] Sebelum dan Sesudah Rawat Inap (Pre/Post Hospitalization)

RESUME MEDIS (Medical Resume)

1 Anamnesa (Anamnesis) 4 Diagnosa Tambahan jika ada (Additional Diagnosis, if any)
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a) Keluhan Utama (Main Complaint) ....................................................................................................................................................
……….............................................................................................................................................. ...................................................................................................................................................
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....................................................................................................................................................... 5 Pembedahan Jika ada (Surgery, if any)
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b) Keluhan Tambahan (Additional Complaint) Jenis Pembedahan (type of surgery)………..............................................................................
………............................................................................................................................................. ....................................................................................................................................................
....................................................................................................................................................... …..…................................................................................................................................................
.................................................................................................................................................... 6 Hasil Lab / Diagnostik (Diagnostic/Laboratory Result)
c) Sejak Kapan Peserta Mengalami Keluhan Tersebut (dated of complaint occur) .....................................................................................................................................................
.................................................................................................................................................... .....................................................................................................................................................
d) Riwayat Penyakit yang Diderita (History of illnes) ....................................................................................................................................................
....................................................................................................................................................... …….............................................................................................................................................
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2 Pemeriksaan Fisik (Physical Examination) 7 Terapi dan Tindakan (Procedure/Medication)
……….............................................................................................................................................. ...................................................................................................................................................
........................................................................................................................................................ ...................................................................................................................................................
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a) Tanda Vital (Vital Signs) :
Kesadaran : CM/Delirium/Stupor/Coma *) GCS :................................................. 8 Anjuran atau Saran Pengobatan Selanjutnya (Medication Advice)
(conscious : CM/Delirium/Stupor/Coma ) .....................................................................................................................................................
Tekanan Darah :.......................... Pernapasan : ....................................... .....................................................................................................................................................
(blood Pressure) (Respiration) ....................................................................................................................................................
Suhu Tubuh :......................... Nadi :........................................ .....................................................................................................................................................
(Body Temperature) (Pulse)
9 Diagnosa Medis Berhubungan dengan (beri tanda [v])
b) Pemeriksaan Gigi (Dental Examination) (is the diagnosis related to, give a [v] check list)
◻ Kelainan Bawaan (congenital) ◻ Kesuburan (fertility/infertility)
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8 ◻ Keturunan (Hereditary) ◻ PHS (Sexual Trasmitted Desease)
V IV III II I I II III IV V ◻ Kosmetik (Cosmetic) ◻ Kecelakaan Kerja/KKL (Accident)
◻ Psikis/Psikomatis ◻ Lainnya (Others) :..........................
8 7 6 5 4 3 2 1 12 3 4 5 6 7 8 (Psychiatric/psychosomatic)
V IV III II I I II III IV V
3 Diagnosa Kerja (Working Diagnosis)
………...........................................................................................................................................
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3 PERNYATAAN PESERTA (Authorization Statement)

Dengan ini Saya memberi kuasa kepada Jasindo Healthcare untuk mendapatkan dan menyimpan segala keterangan/catatan medis (diagnosa, hasil pemeriksaan laboratorium & penunjang medis, perincian biaya, dll) dari
klinik/Rumah Sakit atau pihak lain yang memberikan pelayanan medis kepada Saya sesuai ketentuan yang berlaku. Saya menyetujui bahwa biaya-biaya yang timbul sehubungan pelayanan kesehatan yang Saya terima akan
diperhitungkan kemudian oleh Jasindo Health Care dimana dalam hal ini Saya akan bertanggung jawab atas biaya pelayanan dan/atau perlengkapan kesehatan yang tidak disantun dan/atau biaya yang melebihi batas santunan
serta Saya tunduk pada ketentuan peraturan yang berlaku sehubungan dengan timbulnya biaya tersebut.
I Hereby Authorize to Jasindo Heatlh Care to get my medical data or my medical record needed to analyze my claim from health provider/hospital/physician. And i also authorize to Jasindo Heatlh Care to inform the claim or
medical care to my working place. If the medical care i have received is a part of employees health program benefit: and to insurance company, if the claims included in benefit that was covered by insurance policy. If the treatment
cost over my benefit limit, i will pay the excess of the benefit.

Tanda Tangan Pasien ……………., ………………………, 20….......

(Patient Signature)

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(Nama Jelas Pasien) ( Nama Jelas, Tanda Tangan & Cap Stempel Dokter yang merawat)
(Name of patient) (Name, & Attending Physician signature)

Lampiran 1 untuk Jasindo Health Care, Lampiran 2 untuk Klinik/Rumah Sakit,

Wajib Melampirkan
 Formulir yang diisi lengkap oleh Peserta dan Dokter yang memeriksa atau merawat dengan disertai tanda tangan dan stempel dokter beserta alamat dan No. telp yang bisa dihubungi
 Salinan Tes Hasil Lab dan Diagnostik (jika melakukan tes lab dan diagostik)
 Salinan Resep obat
 Kuitansi Pembayaran Asli dari RS/Klinik/Dokter/Apotik/Laboratorium
 Perincian Biaya Perawatan (Khusus untuk Rawat Inap)
FORM KLAIM JASINDO HEALTH CARE 151015