PT ARUTMIN INDONESIA

Medical_20_003

MEDICAL EXPENSE STATEMENT

Name of Employee : Birrul Walidain Position : Project Supervisor

I.D. Number : 573 - SSS Departement : Project

Cost Code : Location : Satui, Kintap, Asam-asam

Name Medical / Dental / Name of dr./ Date

Item of Optical /Hospital / Physician / of Cost Rp.
Patient Medicine / Other Dentist, etc. Treatment
1 Birrul Walidain Swab Antigen. Klinik Tirta Medical Center 3/16/2021 180,000
Tenggarong - Samarinda

Catatan :
Swab Antigen untuk tujuan naik
pesawat kembali ke site dari roster
periode 03 s/d 16 Maret 2021.

TOTAL RP. 180,000

I certify that the above expenses have been incurred by myself or members of my immediate family /
Saya menyatakan bahwa pengeluaran biaya perawatan kesehatan di atas adalah benar.

Employee's Signature __________________ D a t e : ___________________

Checked by H.R. Officer__________________ D a t e : ___________________

ed by Company's Doctor : __________________ D a t e : ___________________

Approved for Payment __________________ D a t e : ___________________

Notes :
As per the CLA article 9.3.d, attached are : / Sesuai dengan KKB pasal 9.3.d, saya lampirkan :
1. Receipt from the doctor / Kwitansi dari dokter.
2. Photocopy of prescription from the doctor / Fotokopy resep dari dokter.
3. Receipt of medicine from drug store / Kwitansi pembelian obat dari apotik.
4. Only claims less than two months old will be reimbursed / Pengajuan tidak lebih dari 2 bln sejak tgl berobat.
Medical Expense Statement

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