NCCE Saha Hosa A. Garnsun Kay, 28, Seman kat Slaton 12990 Tolp. 6221 208 ann, e168 9020 277% INVOICE aes as. Admission No/MR.: 1PA2205110033 /00-41-78-19 lrvolce Ho: tvzaust7o0zo Name + CHRISTIAN WILFANDIO REWAH Invoice Dato: 17Aay 20201610 Address + JLMAYJEN SUTOYO RT 1/11 Admission Dato: 11-May-2022 1924 Patient Type : PAYER Discharge Date: 47-May-2022 0640 Payer + ASURANS! ALLIANZ - ADMEDIKA Primary Doctor: dr. Trza Gwendoline Matulessy, SpPD Bed/ Ward 3310 / Ward 33TH FLOOR Class VIP DELUXE (Cie ane : _— a [1 CONSULTATION AND VST a 307.000 To a | 2. |tasoratory 3271055} | Ba1085 0 | 3 reoq.osy er ‘ 4 | PROCEDURE ANDTHERAPY 75000) | s7s00) ' | 5 lors sons) oa 8 CONSUMABLES AND MEDICAL SUPPLES so of amin 7 [OTHER seRVCE ANO CHARGE 3.000 | sox @ |beoReNTAL 2s000%0 o| seston 8 _[caREPACKAGE [__sason 0 s1zs0%0| Ga} "SUBTOTAL: 220024 0 2.240244 Ao CHARGE: somn000 ROUKDING: 4 TOTAL: e028 PAYMENT: 9 BALANCE: 82028 INWORDSPATIENT: —_Notrupah INWORDSPAYER: —_Empatpulh oa NOTES: CAPROSES BAYU (EKSES DUAMINKAN DAHULU ) jut dua rats empat pun rbu dua ras empath 6 ich CASHIER TERRE) Suara Anda sanga berart. Bantu kami mewujudkan pelayanan yang bererienast pada pasien. Scan barcod i FIN 1510. 35103: Dypinda dengon CamScannerCL Date 3 May 2022 Letter No, Mochtar Rindy Comprehensive Cancer Center-200820220509999 rime Bin No. MR Patient Name Bill Amoont 1 TS20as 11V2205170020 —arzaip CURISTIAN WitFaNDio Sama REWAN E Grand Total Rp 43,240,24309) Dipindo dengan CamStonnerDipindot dengan CamSianner Letter No, Subject KOM STO GAMIIR, ¢ : JAKARTA PUSAT PUDONG G |-5, JL. MEDAN MERDEKA SPLATAN NO. 12 cost for patient hospitalization. the payment of this outstanding amount is made within 30 days of the date Due Date + 24 June 2022 Beneficiary : ASURANSI ALLIANZ - ADMEDIKA No. Account: 9880000820700022 Bank BANK BNI 46 Amount Rp 43,240,243, Should you have made the payment, please fax the transfer receipt and details of payment to: Accounting & Finance Department Fi 19962888 ext 20418 attn. Okaria Nathalie Email: Reconciliation. MRCCC@siloamhospitals.com Ifyou have any questions regarding the bill, please do not hesitate to contact us at 021.29962888 ext 20736 or Fax with: . /. Billing Email; /illing.mrece@siloamhospitals.com For any further medical clarification please contact 021.29962888 ext 20198 or Fax (No Fax Information) witl dr. Vony Saputra(vony.saputra@siloamhospitals.com) Thank you for your cooperation. Sincerely yours, 8 Else) Teme 2EGAJXB46040969 .