OWLEXA HEALTHCARE

MENARA THAMRIN GD ARCADIA LT 2

JL. MH THAMRIN KAV 3
JAKARTA SELATAN 10250

To : Advice Date : 19 June 2019

GRAHA HUSADA JEPARA Page :1

We have transferred to your account for the following transaction :

Date : 19 June 2019
Your Account : 1430011242706 (IDR) GRAHA HUSADA JEPARA,
BANK MANDIRI,
Transaction Amount : IDR 30,229,758.00
Remark : 10161/C/099//IP/05/2019
Extended Payment Detail : 5119/PAY/099/06/2019
Invoice No. : 262.I/DIR/RSGH/VI/2019

No Claim Number Member Name Card Number Client Name Group Name Admission Discharge Paid To Provider
1 58328/C/099/IP/04/ SUHARTO 1000620990241452 PT. ASURANSI PT TJB POWER 26-04-2019 04-05-2019 Rp. 16.082.306,00
2019 JIWA INHEALTH SERVICES
INDONESIA
2 62828/C/099/IP/04/ ENDANG 1000620990241930 PT. ASURANSI PT TJB POWER 28-04-2019 30-04-2019 Rp. 4.061.452,00
2019 PURWATI JIWA INHEALTH SERVICES
INDONESIA
3 06233/C/099//IP/05 MUHAMMAD 1000620990015593 PT. ASURANSI PT. KOMIPO 04-05-2019 09-05-2019 Rp. 6.913.700,00
/2019 DHAFRAN JIWA INHEALTH PEMBANGKITAN
RADHIANSYAH INDONESIA JAWA BALI
4 10161/C/099//IP/05 IRSYAD HANIEF 1000620990223595 PT. ASURANSI PT. KOMIPO 06-05-2019 08-05-2019 Rp. 3.172.300,00
/2019 KURNIAWAN JIWA INHEALTH PEMBANGKITAN
INDONESIA JAWA BALI

This advice is printed by computer and required no signature from bank officer
Jl. Jendral Gatot Subroto Kav. 36-38
Jakarta 12190 Indonesia
Telp: 14000, +62-21-52997777
Fax: +62-21-52997735