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 :