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    PT Aa International Indonesia: Panel Provider Application Form

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    rinova intan
    RSIA Rinova Intan hospital in Bekasi, Indonesia is applying to join the PT AA International Indonesia provider panel. The 30-bed hospital has been operating since [year] and provides general medical services and facilities. The application form collects contact details for billing, admissions, and discharge departments as well as ownership and affiliation information. RSIA Rinova Intan agrees to undergo audits by PT AA International Indonesia.

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    PT Aa International Indonesia: Panel Provider Application Form

    Uploaded by

    rinova intan
    37 views3 pages
    RSIA Rinova Intan hospital in Bekasi, Indonesia is applying to join the PT AA International Indonesia provider panel. The 30-bed hospital has been operating since [year] and provides general medical services and facilities. The application form collects contact details for billing, admissions, and discharge departments as well as ownership and affiliation information. RSIA Rinova Intan agrees to undergo audits by PT AA International Indonesia.

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    Original Title

    Cover Panduan Hpk

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    RSIA Rinova Intan hospital in Bekasi, Indonesia is applying to join the PT AA International Indonesia provider panel. The 30-bed hospital has been operating since [year] and provides general medical services and facilities. The application form collects contact details for billing, admissions, and discharge departments as well as ownership and affiliation information. RSIA Rinova Intan agrees to undergo audits by PT AA International Indonesia.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    37 views3 pages

    PT Aa International Indonesia: Panel Provider Application Form

    Uploaded by

    rinova intan
    RSIA Rinova Intan hospital in Bekasi, Indonesia is applying to join the PT AA International Indonesia provider panel. The 30-bed hospital has been operating since [year] and provides general medical services and facilities. The application form collects contact details for billing, admissions, and discharge departments as well as ownership and affiliation information. RSIA Rinova Intan agrees to undergo audits by PT AA International Indonesia.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 3

    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 :[email protected]
    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)

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