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New Proposal Template - Mcu - November 22
New Proposal Template - Mcu - November 22
MEDICAL CHECK-UP
Greetings from Siloam Hospital Group. First of all we would like to thank you for the
opportunity to establish a cooperation with PT PAMAPERSADA NUSANTARA.
Siloam Hospitals Group (Siloam) is Indonesia’s most progressive and innovative healthcare
provider that has set the benchmark for high quality healthcare services in Indonesia.
Siloam’s medical team of more than 500 general practitioners, 2,200 specialist doctors, and
9,000 nurses, allied health, and support staff, offers international quality healthcare services
to nearly two million patients annually.
NO EXAMINATION PRICE
1 Physical Examination by Doctor
2 Full Blood Count
3 Blood Type & Rhesus
4 SGOT-SGPT
5 Ureum Creatine
6 Uric Acid
7 Glucose Fasting
8 Triglyceride
9 Total Cholesterol
10 LDL Cholesterol
11 HDL Cholesterol
12 VDRL or RPR
13 HBSAG Qualitative
14 Complete Urinalysis
15 Rontgen Thorax
16 EKG
17 Audiometry
18 Spirometry
19 Food and Beverage - Meal
TOTAL IDR 1,700,000
IDR 99,000/pax*
ANTIGEN Available at hospital units in Java Island and Bali
COVID-19
IDR 109,000/pax*
TEST
Available at hospital units outside Java Island and Bali
(*) Not Available at: Siloam Mampang, Kelapa Dua & Paal Dua Manado.
PCR Regular: Result in 1x24 hours calculated after sample arrived in Siloam
Laboratory
IDR 275,000/pax*
RT-PCR Available at hospital units in Java Island and Bali.
COVID-19
IDR 300,000/pax*
TEST
Available at hospital units outside of Java Island and Bali.
(*) Not available at: Siloam Mampang, Kelapa Dua & Paal Dua Manado.
Note:
The price for the Services mentioned above is valid for acceptance within seven (7)
working days from the date of this Proposal.
The price for the Services mentioned above shall remain fixed for 1 (one) year,
Day+1 upon the receival of the signed proposal via email by PT PAMAPERSADA
NUSANTARA.
The price for the Services mentioned above is only valid for employees and their
dependents that are covered by PT PAMAPERSADA NUSANTARA.
Temporarily, PT PAMAPERSADA NUSANTARA and its employees may receive
services from Siloam Hospitals Group in accordance with the applicable provisions as
mentioned in Appendix 1 of this proposal.
We look forward to an acceptance from PT PAMAPERSADA NUSANTARA on the above
offering.
If you have any queries regarding our proposal or any other issues in connection with this,
do not hesitate to contact me.
Sincerely yours,
Name : ____________________
Title : ____________________
Date : ____________________
APPENDIX I: SERVICE PROVISIONS
1. Siloam Hospitals Group and PT PAMAPERSADA NUSANTARA shall make a service
agreement which includes the terms and conditions in rendering the services at the
latest 90 (ninety) calendar days from the signing of this Proposal.
2. PT PAMAPERSADA NUSANTARA shall provide all the requested documents from
Siloam Hospitals Group and fill in the form sent by Siloam Hospitals Group.
3. Siloam Hospitals Group may provide services as mentioned in Proposal to PT
PAMAPERSADA NUSANTARA in the hospitals operated by Siloam Hospitals Group
(“Hospital”), in accordance with the following terms and conditions:
a. Siloam Hospitals Group may provide services to PT PAMAPERSADA NUSANTARA
who carry the Client's membership card or a service payment guarantee letter or a
letter issued by the Client for services will be rendered by Siloam Hospitals Group.
b. Tariff of the service is in accordance with this Proposal.
c. Reservation is required with minimum 3 (three) days prior to examination.
d. All cost incurred from the services will be borne by the PT PAMAPERSADA
NUSANTARA and the term of payment is 14 (fourteen) calendar days after the
receipt of the invoice.
e. The payment as mentioned in point d, shall be paid to Siloam Hospitals Group in
accordance with bank account as mentioned in Appendix III of this Proposal
(subject to the Hospital where the employees of the Client receive the services).
4. This proposal will automatically terminate once the service agreement as specified in
point 1 above is signed by both Siloam Hospitals Group and the Client or within 90
(ninety) calendar days as of the date the Client signs this proposal, whichever earlier.
APPENDIX II: SILOAM HOSPITALS GROUP LIST IN
INDONESIA
No Hospital Unit Name of Entity Address
PT Siloam International
Jl. Raya Gubeng No.70, Surabaya 60281
4 Siloam Hospitals Surabaya Hospitals Tbk.
5 Siloam Hospitals Jambi PT Golden First Atlanta Jl. Soekarno Hatta, Paal Merah Jambi 36139
PT Siloam International
Jl. Sam Ratulangi No. 22 Manado 95111
8 Siloam Hospitals Manado Hospitals Tbk.
PT Siloam International
Jl. Metro Tanjung Bunga Kav 9, Makassar 90134
9 Siloam Hospitals Makassar Hospitals Tbk.
PT Siloam International
Jl. Sunset Road No. 818, Kuta, Bali 80361
11 Siloam Hospitals Bali (Denpasar) Hospitals Tbk.
Siloam Hospitals Cinere (RS Jantung PT Diagram Healthcare Jl. Cinere Raya No. 19, Kel. Pangkalan Jati, Kec.
12 Diagram Depok) Indonesia Cinere, Kota Depok, Provinsi Jawa Barat, 16514
PT Siloam International
Jl. RA Kartini No. 8 Cilandak, Jakarta Selatan 12430
13 Siloam Hospitals TB Simatupang Hospitals Tbk.
14 Siloam Hospitals Purwakarta PT Berlian Cahaya Indah Jl. Raya Bungursari No. 1 Purwakarta 41181
15 Siloam Hospitals Kupang PT Krisolis Jaya Mandiri Jl. RW Monginsidi RT. 014 RW. 004 Fatululi Kupang
16 Siloam Hospitals Asri PT Rashal Siar Cakra Medika Jalan Duren Tiga No. 20 Jakarta Selatan 12760
17 Siloam Hospitals Dhirga Surya Medan PT Gramari Prima Nusa Jl. Imam Bonjol No. 6, Kel. Petisah - Medan 20112
23 Siloam Hospitals Sentosa Bekasi PT Lishar Sentosa Pratama Jl Pahlawan No. 60 Duren Jaya, Bekasi Timur
Siloam Hospitals Mataram (RS Grha Jl. Majapahit No.10 Kota Mataram, Lombok – NTB
24 Ultima Medika) PT Grha Ultima Medika 83127
Siloam Hospitals Cirebon (RS Putera Jl. Ciremai Raya No. 114. Kel. Kecapi. Kec. Harjamukti,
29 Bahagia) PT Sumber Bahagia Sentosa Kota Cirebon
31 Siloam Hospitals Jember PT Kirana Puspa Cemerlang Jl. Gajah Mada 104, Kaliwates, Jember
32 Siloam Hospitals Semarang PT Sembilan Raksa Jl. Kompol Maksum 296 Kel. Peterongan, Kec.
Dinamika Semarang Selatan, Kota Semarang
PT Saritama Mandiri Jl. RTA Milono No.KM 4, RW.No. 425, Langkai, Kec.
33 Siloam Hospitals Palangka Raya Zamrud Pahandut, Kota Palangka Raya
Siloam Hospitals Kelapa Dua (Legok PT Aryamedika Teguh Jl. Kelapa Dua Raya No. 1001, Kabupaten Tangerang,
35 Karawaci) Tunggal Banten
36 Siloam Hospitals Paal Dua Manado PT Sentra Sehat Sejahtera Jl. Yos Sudarso no 38 – 40, Paal Dua, Manado
Account
Hospital Unit Bank Name On The Name Swift Code
Number
Siloam Hospitals
CIMB NIAGA 800076770400 PT Balikpapan Damai Husada BNIAIDJA
Balikpapan
Siloam Hospitals Asri CIMB NIAGA 800170771200 PT. Rashal Siar Cakra Medika BNIAIDJA
Siloam Hospitals
Cinere (RS Khusus PT Diagram Healthcare
CIMB NIAGA 800171349800 BNIAIDJA
Jantung Diagram Indonesia
Depok)
Siloam Hospitals
CIMB NIAGA 800170838300 PT Berlian Cahaya Indah BNIAIDJA
Purwakarta
Siloam Hospitals
Medan (RS Dhirga CIMB NIAGA 800109365700 PT Gramari Prima Nusa BNIAIDJA
Surya)
Siloam Hospitals
CIMB NIAGA 800109366900 PT Krisolis Jaya Mandiri BNIAIDJA
Kupang
Siloam Hospitals
CIMB NIAGA 800170746700 PT Bina Bahtera Sejati BNIAIDJA
Buton
Siloam Hospitals
CIMB NIAGA 800170834500 PT. LINTAS BUANA JAYA BNIAIDJA
Labuan Bajo
Siloam Hospitals
Mataram (RS Grha CIMB NIAGA 800170821400 PT Grha Ultima Medika BNIAIDJA
Ultima Medika)
Siloam Hospitals
CIMB NIAGA 800170829000 PT.Mega Buana Bhakti BNIAIDJA
Bangka Belitung
Siloam Hospitals
CIMB NIAGA 800170825200 PT Tataka Bumi Karya BNIAIDJA
Bogor
Siloam Hospitals
CIMB NIAGA 800170822600 PT Mulia Pratama Cemerlang BNIAIDJA
Bekasi Timur
Siloam Hospitals
CIMB NIAGA 800170758600 PT. Lishar Sentosa Pratama BNIAIDJA
Sentosa Bekasi
Siloam Hospitals
CIMB NIAGA 800170833300 PT Taruna Perkasa Megah BNIAIDJA
Yogyakarta
Siloam Hospitals
Bekasi Sepanjang (RS
CIMB NIAGA 800116526500 PT Anugerah Sentra Medica BNIAIDJA
Hosana Medica
Bekasi)
Siloam Hospitals
Cirebon (RS Putera CIMB NIAGA 800170820200 PT Sumber Bahagia Sentosa BNIAIDJA
Bahagia)
Siloam Hospitals
CIMB NIAGA 800170756200 PT Lintang Laksana Utama BNIAIDJA
Lubuk Linggau
Siloam Hospitals
CIMB NIAGA 800170745500 PT Kirana Puspa Cemerlang BNIAIDJA
Jember
Siloam Hospitals
CIMB NIAGA 800170814500 PT Sembilan Raksa Dinamika BNIAIDJA
Semarang
Siloam Hospitals
CIMB NIAGA 800170869000 PT Saritama Mandiri Zamrud BNIAIDJA
Palangka Raya
RSU Syubbanul
CIMB NIAGA 800170851900 PT RSU Syubbanul Wathon BNIAIDJA
Wathon
Siloam Hospitals
CIMB NIAGA 800170827600 PT Arya Medika Teguh Tunggal BNIAIDJA
Kelapa Dua
Siloam Hospitals
CIMB NIAGA 800170891900 PT Ambon Bangun Nusa BNIAIDJA
Ambon
Siloam Hospitals
CIMB NIAGA 800170816900 PT Sembilan Raksa Dinamika BNIAIDJA
Banjarmasin
Agora General
16830118889 NOBUIDJA
Hospital NOBU BANK PT Agora General Hospital
APPENDIX IV: SILOAM HOSPITALS PERSON IN-
CHARGE
(Regional 1 : Jakarta & Tangerang)
Alexander
085693110990 Alexander.mutak@siloamhospitals.com
Mutak
Agnes Sartika
081703157005 agnes.husin@siloamhospitals.com
Husin
Jl. Raya
Pejuangan Sitti Noor
Siloam Hospitals +6221 536
Kav.08, Kebon Aisyah Farida 08121869845 sitti.farida@siloamhospitals.com
Kebon Jeruk 956 66
Jeruk, Jakarta (Ain)
11530
Andreas 087886688961 Andreas.putra@siloamhospitals.com
JI. Mampang
Perapatan XVI, Inggrid Herma 081299403046 inggrid.herma@siloamhospitals.com
Siloam Kelurahan Duren
Hospitals Tiga, Kecamatan
Mampang Pancoran, Kota 0859-4591-
Marta Ningrum martha.ningrum@siloamhospitals.com
Administrasi 2166
Jakarta Selatan
Holland Village
Jakarta, Jl. Letjen
Agora General Lusiana Dina
Suprapto Kav.60 0811168541 lusiana.dina@siloamhospitals.com
Hospital Avianti
No.1, Cempaka
Putih Timur 10510
(Regional 2 : Bekasi & Jawa Tengah)
Restiana Fuji
081222629982 restiana.fuji@siloamhospitals.com
Antika
Jl. M.H. Thamrin
Siloam Hospitals Kav.105, Lippo +6221 8990
Ditya 0822 1357 7070 ditya.kurnia@siloamhospitals.com
Lippo Cikarang Cikarang, Bekasi 1911
17550
Priska Debora 085210243832 priska.samosir@siloamhospitals.onmicrosoft.c
+62264-
8628900 ext: Mitha 081382700872 sasmita.nurdin@siloamhospitals.com
Jl. Raya 22002
Siloam Hospitals Bungursari No.
Purwakarta 1 Purwakarta 22001; Tedi Tarmedi 0821 21223227 tedi.tarmedi@siloamhospitals.com
41181
Drg . Tina
087878271263 Tina.esadiarti@siloamhospitals.com
Esadiarti, MARS
Jl. Laksda
Elita Dwi 082211802988 elita.dw@siloamhospitals.com
Adisucipto No.32-
Siloam 34 Kelurahan +62 274-
0822-4211-
Hospitals Demangan, 4600900 ext Sara Ayu sara.ayu@siloamhospitals.com
4709
Yogyakarta Kecamatan 22100
Gondokusuma,
Risca Nina 081215908887 Timorinda.RiskaNina@siloamhospitals.com
Yogyakarta
Drg . Tina
087878271263 Tina.esadiarti@siloamhospitals.com
Siloam Esadiarti, MARS
Hospitals
Jl. Pramuka No.12, +621 8221570- 0852
Bekasi Selfry Hutahaean selfry.hutahaean@siloamhospitals.com
Rawalumbu, Bekasi 72 62874033
Sepanjang
Jaya 0813
Shanti Gultom shanti.gultom@siloamhospitals.com
27782317
dr. Chandra
22601 081365544332 Chandra.wijaya@siloamhospitals.com
Wijaya
Jl. Raya Gubeng
Siloam Hospitals
No.70, Surabaya 22604 Rista 085730442462 insurance.shsb@siloamhospitals.com
Surabaya
60281
+62361-77 99
Epan Setiawan 085217367991 epan.setiawan@siloamhorpitals.com
00 Ext 22000
Adit 081239148234
Elfridus Utomo
+62380 – 8530 0811 3810 589 Elfridus.deRosari@siloamhospitals.com
Jl. RW Monginsidi De Rosari
Siloam Hospitals 900 atau +62
RT. 014 RW. 004
Kupang 380 - 8530
Fatululi Kupang 0813 3701
911 Gede gede.wiratma@siloamhospitals.com
8147
Jl. Sultan
Tashia Schuurman 081288200492 tashia.schuurman@siloamhospitals.com
Siloam Hasanuddin RT
Hospitals 005, RW 05 Hative
Ambon Kecil, Kecamatan Franklin Silawa 08111521968 franklin.silawa@siloamhospitals.com
Sirimau, Ambon
(Regional 4 : Kalimantan & Sulawesi)
Jl. Sultan
Hasanuddin No.
Siloam Hospitals 58 Kel. Batulo, +62402- Randi
085385509898 Randi.Agusmalar@siloamhospitals.com
Buton Kec. Wolio Kota 2825555 Agusmalar
Baubau Sulawesi
Tenggara, 93717
Charles
081344585993 Charles.tinangon@siloamhospitals.com
Siloam Hospitals Jl. Yos Sudarso +62431- Tinangon
Paal Dua Manado no 38 - 40 7100900
Selfianus Runtu 081356012270 Selfianus.Runtu@siloamhospitals.com
+624113662900;
Putri Amelia 6,28124E+12 Putri.amelia@siloamhospitals.com
ext. 27000
Siloam Jl. Metro Tanjung
+62852 5580
Hospitals Bunga Kav 9, 22603 Asrini Restu Asrini.indah@siloamhospitals.com
3545
Makassar Makassar 90134
+62853 9822
Hendrik Nabun Hendrik.nabun@siloamhospitals.com
2608
(Regional 5 : Sumatera)
+6261-8888
Fauziah Bachtiar 0811610112 Fauziah.bachtiar@siloamhospitals.com
1900; ext. 22601
Jl. Imam Bonjol
Rumah Sakit
No. 6, Kel. Effi Efiliana
Siloam Dhirga 22602 082273739109 Effi.efiliana@siloamhospitals.com
Petisah - Medan Tamba
Surya
20112
21000 Dita Anggreni 085277113448 dita.anggreni@siloamhospitals.com
+62711-
Jl. POM IX Kel. 5229100; ext. Lawren S 6,28128E+12 lawren.sitompul@siloamhospitals.com
Siloam Sriwijaya 27100, 27102,
Lorok Pakjo Kec.
Palembang
Ilir Barat I
27200 Martha Purba +628116927013 martha.purba@siloamhospitals.com
Business REG 1 JAKARTA :
Regional
Heads Siloam Hospitals Lippo Village
REG 5 SUMATERA :
Antonio Martin
085890009775 Antonio.suhendra@siloamhospitals.com
(Corporate)
Aileen Hidajat
081298718093 aileen.hidajat@siloamhospitals.com
(Corporate)
dr. Feliciana
Business Account Management - Amelinda 08128761589 feliciana.amelinda@siloamhospitals.com
Commercial (Corporate)
0877-8449-
International Referral Vinka vinka.lo@siloamhospitals.com
7756
0815-2365-
Rilly Richard M. rilly.mamahit@siloamhospitals.com
6613
1. Participant Data
Fill out the registration form & identity
Fill out a medical information release form
Bring an identity card / ID card
2. Physical Examination
Bring glasses if wearing glasses and do not use contact lenses
Please tell the nurse if you are taking medication
Enough rest, no strenuous physical activity or overtime before the MCU
5. CT Calcium Scoring
Not under pregnancy
Inform our medical staff if there is a history of placing a heart stent / ring, or other heart surgery
Removing metal objects, such as watches, jewelry, glasses, belts, and so on so that the image results
are not disturbed
Do not use deodorant / perfume
6. Urine Examination
Participants who are menstruating are not allowed to perform examinations and can be checked at
least on the 5th day after menstruation is complete
Taking urine samples midstream (middle beam).
7. Papsmear (female)
Do not have sexual intercourse 3 days before the examination
Have finished menstruating for at least 5 days (not menstruating)
Do not clean the vagina with douches, use tampons or vaginal pills at least 3 days before the
examination
Not under pregnancy or recently had other procedures related to the vagina, cervix, or vulva
9. Spirometry
2-4 hours before the examination is prohibited: smoking, drinking alcohol, eating full and strenuous
activities
It is prohibited to wear tight clothes and or pants during the inspection
Avoid consuming lozenges or cold medicines
10. Audiometry
Prior to examination the patient must be free from noise exposure for at least 16 hours
3. Screening for COVID-19 before entering the hospital area, in the form of checking the
temperature and filling in the screening ormular (*)
Note: (*) Several units of Siloam Hospitals Group impose mandatory rapid tests before conducting Medical Check-ups
[Attachment VI]
APPENDIX VI: MEDICAL CHECK-UP WORKFLOW
D-2 (Pre-registration) Submit payor booking template list (attached) for pre-registration to Siloam PIC
Patients will get booking confirmation and link to pre-assessment form via email. Please fill in the pre-
assessment form prior to hospital arrival.
D-Day (Arrival at hospital) Patient come to hospital destination of choice at allotted time slot (*)
Patient head to Medical Check Up Front Office to do Re-registration (**). Please bring ID Card (KTP) and
Guarantee Letter (GL)
MCU Examination
Patient head to Nurse Station, MCU nurse will explain the MCU examination flow to patient
Patients go through the MCU examination processes based on assigned MCU package and queue
Post MCU
Softcopy of MCU Result will be available and sent via email to PIC (H+3 if no pending result)
Hardcopy of MCU Result will be sent to designated mailing address if needed (H+5 if no pending result)
MCU Result Consultation will be scheduled as agreed ***
Corporate MCU Analysis MCU result tabulation will be given to corporate PIC H+14 after the MCU Period is done
(Annual MCU) Corporate Health Index analysis will be given H+7 after MCU result tabulation is available
Additional Program
Customized wellness program based on corporate health index result will be designed (****)
Note:
* Patient must do rapid test prior of MCU at Several Hospital Units (list attached) or show valid COVID-19 testing result
within the last 3 (three) and 7 (seven) days
** Some hospital units MCU front office is combined with Out-Patient Department
*** Result consultation will be done after CHI analysis, time and place to be confirmed
**** Customised Corporate Wellness program will be charged as agreed