NOMOR : PIM-SKP-LP-001

SURAT INTERN Tanggal 03 Juli 2017

Revisi 00

Kepada : VP PSDM
Dari : Osman Mohammad Saftari (5180012)
Tanggal : 25 Desember 2020
Nomor : Istimewa
Lampiran : 2 eks
Perihal : Laporan Kegiatan dan Reimbursement Biaya Pengurusan Visa Australia

Menindaklanjuti surat dari Departemen PSDM No. 693/DL0201/3320 tertanggal 30 November 2020
perihal penugasan program tugas belajar 2020, dengan ini saya sampaikan rangkaian kegiatan
sehubungan dengan pengurusan visa di kedutaan Australia di Jakarta sebagai berikut:

No Tanggal Rincian Kegiatan

1. 16 Desember 2020 Medical check up sesuai dengan referral letter HAP 2567933 sebagai
salah satu persyaratan pembuatan Visa Student (subclass 500)

2. 20 Desember 2020 Penerbitan Visa Student (subclass 500) atas nama Osman Mohammad
Saftari oleh Kedutaan Australia

Sehubungan dengan kegiatan nomor 1 (satu) di atas, dengan ini saya sampaikan rincian reimbursement
biaya tersebut sebagai berikut:

1. MCU di RS Premier Jatinegara: Rp1.050.000,00

Referral Letter dan bukti pembayaran untuk medical check up tersebut saya sertakan juga pada
lampiran.

Demikian saya sampaikan, atas bantuan dan persetujuan Bapak saya ucapkan banyak terima kasih.

Hormat Saya,

Osman Mohammad Saftari

5180012
 HAP 25679933

Referral letter
Client personal details Client identity details
Family name: SAFTARI Identity document presented: Original Passport
Given names: OSMAN MOHAMMAD Identity document number: B4885024
Gender: MALE Issuing country: INDONESIA
Date of birth: 23 Jan 1988 Date of issue: 26 Aug 2016
Country of birth: INDONESIA Date of expiry: 26 Aug 2021
Source: Australia

Client visa details

Visa: TU 500 Student

Instructions to the client

Please proceed to make an appointment to undergo the required immigration health examinations listed in this letter
with an approved panel physician if you are outside AUSTRALIA or the Department of Home Affairs (Home Affairs)’s
migration medical service provider if you are in Australia. You may also subsequently be referred to a specialist for
additional health examinations. Specific requirements for arranging your health examination are explained on Home
Affairs’ website at https://immi.homeaffairs.gov.au/help-support/meeting-our-requirements/health/arrange-your-health-
examinations.

If an examination is listed as Completed this means that there is an existing examination that can be re-used for this visa
application. You will not be asked to complete this examination again unless a repeat examination is required because
your medical circumstances have changed or the examination has since expired. More information about when re-use
is allowed is available at https://immi.homeaffairs.gov.au/help-support/meeting-our-requirements/health/arrange-your-
health-examinations. If you believe that you have additional examinations for re-use contact your case officer before you
attend your appointment.
When making your appointment, please provide the clinic with your health identifying number (HAP ID) indicated at the
top of this letter. Please also make sure that you bring with you to your appointment:

• this referral letter

• your prescription spectacles or contact lenses, if applicable

• existing specialist and/or other relevant medical reports for known medical conditions

• any previous chest x-rays

• a valid passport OR an agreed form of alternative documentation to confirm your identity.

Note: a copy of any health information that you have already provided to Home Affairs online is
included below for your information. This information will also assist staff at the panel clinic that you
select to visit.

Examinations required for this visa application

Generated: 14 Dec 2020 08:04 PM HAP: 25679933 Page 1 of 2

 Referral letter

Exam Status Clinic

501 Medical Examination Required
502 Chest X-ray Examination Required

Consent provided
On 14 DEC 2020 you consented online to using eMedical to process your health examinations where available.

Tuberculosis (TB), treatment for tuberculosis? No

Close household contact with Tuberculosis (TB)? No
Prolonged medical treatment and/or repeated hospital admissions for any reason, including a No
major operation or psychiatric illness
Psychological/Psychiatric Disorder (including major depression, bipolar disorder or No
schizophrenia)
An abnormal or reactive HIV blood test No
An abnormal or reactive Hepatitis B or Hepatitis C blood test? No
Hepatitis B -
Hepatitis C -
Cancer or Malignancy in the last 5 years No
Diabetes No
Heart condition including coronary disease, hypertension, valve or congenital disease No
Blood condition (including thalassemia) No
Kidney or Bladder Disease No
An ongoing physical or intellectual disability affecting your current or future ability to function No
independently or be able to work full-time (including autism or developmental delay)
An addiction to drugs or alcohol No
Are you taking any prescribed pills or medication (excluding oral contraceptives, over-the No
counter medication and natural supplements)? Please list

Client declaration

The client has provided true and correct medical history information.
Doctor declaration
-

Generated: 14 Dec 2020 08:04 PM HAP: 25679933 Page 2 of 2

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