PT AA INTERNATIONAL INDONESIA

PANEL PROVIDER APPLICATION FORM

PART A: GENERAL INFORMATION

Provider Name : RSIA. RINOVA INTAN
Address : Jl. Raya Seroja No. 101 Kel. Harapan Jaya Bekasi Utara
City/Township/Village : BEKASI
Postal Code : 17124
State :INDONESIA
Country :INDONESIA
Website :-
Email Address :rinova.intan@yahoo.com
Telephone Number (office hour) :021 - 8849401
Telephone Number (after office hour) : 0813 8139 9365
Fax Number :-
Number of Bed (For Hospital) :30
Agree to be audited by AAI Indonesia : Yes
No
Please specify if No

PART B: OWNERSHIP (Please tick if applicable)

Ownership : Private limited Partnership
Other (please specify) Government
Does the Provider have any affiliation with
: (Please specify if yes)
Providers or Universities
Does the Provider belong to a group or network : (Please specify if yes)
Hospital built/construted since (year) :
Average equipment since (year) :
Last renovation (for Hospital) :
Operate since :

PART C: PROVIDER PROFILE CHECKLIST (Please tick if applicable)

Provider Introduction :
Services and Facilities :
Consultant List :
Price List :
MOH License (for Hospital) :
Other supporting document (please
specify)
:
PART D: CONTACT INFORMATION
Marketing Department :
HOD Name :
Position :
Mobile Number :
Fax Number :
Email Address :

Second Contact Person

Name :
Position :
Moile Number :
Fax Number :
Email Address :

PART E: MAILING UPDATE/ENQUIRIES

Attention to (Name) :
Position :
Fax Number :
Email Address :

PART F: BILLING INFORMATION

Person In Charge :
Contact Number :
City/Township :
Postal Code :
State :
Country :
Bank Account :
Account Ownership :
Bank Charges :
Currency :
Other (Please Specify) :

PART G: ADMISSION DEPARTMENT (for Hospital)

Operate 24 Hours : Yes
No. Please specify operating hours
Head of Department (Name) :
Staff Name(s) :
Contact Number :
Fax Number :

PART H: DISCHARGE DEPARTMENT (for Hospital)

Operate 24 Hours : Yes
No. Please specify operating hours
Head of Department (Name) :
Staff Name(s) :
Contact Number :
Fax Number :
THIS FORM IS COMPLETED BY
Name :
Position :
Email :
Phone Number :
Date of Completion :
Company Stamp :

FOR PT AA INTERNATIONAL INDONESIA PURPOSE

Notes :

Reviewed by Approved by

( ) (Head of Provider Network)