PROPOSAL

MEDICAL CHECK-UP

PREPARED FOR PREPARED BY

PAMAPERSADA NUSANTARA Antonio Martin Suhendra
2 Desember 2022 085890009775
antonio.suhendra@siloamhospitals.com
 TABLE OF CONTENTS
INTRODUCTION.....................................................................................................................................2
PRICE & TERMS.....................................................................................................................................3
APPENDIX I: SERVICE PROVISIONS.......................................................................................................7
APPENDIX II: SILOAM HOSPITALS GROUP LIST IN INDONESIA.............................................................8
APPENDIX III: SILOAM HOSPITALS BANK ACCOUNT..........................................................................11
APPENDIX IV: SILOAM HOSPITALS PERSON IN-CHARGE....................................................................15
APPENDIX V: MEDICAL CHECK-UP PREPARATION..............................................................................15
APPENDIX VI: MEDICAL CHECK-UP WORKFLOW................................................................................30
 INTRODUCTION
Dear dr. Agus,

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.

41 Hospitals all over Indonesia

Operating Hospitals (41)

Future Developments (12)

 PRICE & TERMS
With a commitment to provide the best service for patients, corporate and partners, Siloam
Hospitals would like to offer PT PAMAPERSADA NUSANTARA the following services
("Services"):

Medical Check-Up Package Pre-Employee (Without Lumbosacral)

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

Medical Check-Up Package Pre-Employee (With Lumbosacral)

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 Vert. Lumbosacral
16 Rontgen Thorax
17 EKG
18 Audiometry
19 Spirometry
20 Food and Beverage - Meal
TOTAL IDR 2,200,000

Covid-19 Test Package

 ITEMS

Swab Antigen Nasopharyngeal: Result in 15 minutes

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,

Antonio Martin Suhendra

Corporate Account Management Dept. Head

The offer in this proposal is accepted by PT PAMAPERSADA NUSANTARA.

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. Siloam No.6, Lippo Karawaci 1600, Tangerang

1 Siloam Hospitals Lippo Village Hospitals Tbk. 15811

PT Siloam International Jl. Raya Pejuangan Kav.08, Kebon Jeruk, Jakarta

2 Siloam Hospitals Kebon Jeruk Hospitals Tbk. 11530

Jl. M.H. Thamrin Kav.105, Lippo Cikarang, Bekasi

3 Siloam Hospitals Lippo Cikarang PT East Jakarta Medika 17550

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

Jl. MT. Haryono Dalam No. 23 RT. 30, Kelurahan

PT Balikpapan Damai Sungai Nangka Kecamatan Balikpapan Selatan
6 Siloam Hospitals Balikpapan Husada Balikpapan 76114

PT Siloam International Jl. Garnisun Kav. 2-3, Karet Semanggi-Setiabudi,

7 MRCCC Siloam Hospitals Semanggi Hospitals Tbk. Jakarta Selatan 12930

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 Rumah Sakit Siloam

Jl. POM IX Kel. Lorok Pakjo Kec. Ilir Barat I Palembang
10 Siloam Hospitals Sriwijaya Palembang Hospitals Sumsel

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

Jl. Sultan Hasanuddin No. 58 Kel. Batulo, Kec. Wolio

18 Siloam Hospitals Buton PT Bina Bahtera Sejati Kota Baubau Sulawesi Tenggara, 93717

Jl. Gabriel Gampur RT 013 RW 005, Dusun V, Kec

19 Siloam Hospitals Labuan Bajo PT Lintas Buana Jaya Komodo, Kab. Manggarai Barat. Labuan Bajo 86754

Kawasan ITDC Blok D, Jl. Nusa Dua, Benoa, Kabupaten

20 BIMC Hospital Nusa Dua PT Trisaka Reksa Waluya Badung, Bali 80363

Jl. Bypass Ngurah Rai No.100X, Kuta, Kabupaten

21 BIMC Hospital Kuta PT Medika Sarana Traliansia Badung, Bali 80361

Jl. Chairil Anwar Blu Plaza No. 27 RT 004/RW 009

PT Mulia Pratama Kelurahan Margahayu, Kec. Bekasi Timur, Bekasi
22 Siloam Hospitals Bekasi Timur Cemerlang 17113

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

Jl.Soekarno Hatta Km 5 Kab Bangka Tengah 33684

25 Siloam Hospitals Bangka Belitung PT Mega Buana Bhakti Bangka Belitung

Jl. Pajajaran No. 27, Kel. Babakan, Kec. Bogor Tengah,

26 Siloam Hospitals Bogor PT Tataka Bumi Karya Kota Bogor

Jl. Laksda Adisucipto No.32-34 Kelurahan Demangan,

27 Siloam Hospitals Yogyakarta PT Taruna Perkasa Megah Kecamatan Gondokusuman, Yogyakarta

Siloam Hospitals Bekasi Sepanjang (RS

Jl. Pramuka No.12, Rawalumbu, Bekasi
28 Hosana Medica Bekasi) PT Anugerah Sentra Medika

Siloam Hospitals Cirebon (RS Putera Jl. Ciremai Raya No. 114. Kel. Kecapi. Kec. Harjamukti,
29 Bahagia) PT Sumber Bahagia Sentosa Kota Cirebon

Jl. Yos Sudarso RT.11. Kelurahan Taba Jemekeh.

Siloam Hospitals Silampari (Lubuk Kecamatan Lubuk Linggau Timur I. Kota Lubuk
30 Linggau) PT Lintang Laksana Utama Linggau

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

Jl. Magelang-Kopeng km. 08, Dusun Nuren, Kelurahan

RSU Syubbanul Wathon Tegalrejo PT RSU Syubbanul Wathon Purwosari, Kecamatan Tegalrejo, Kabupaten
34 (Magelang) Tegalrejo Magelang, Jawa Tengah

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

Jl. Mampang Prpt. Raya No.16, RT.2/RW.5, Duren

Tiga, Kec. Pancoran, Kota Jakarta Selatan, Daerah
37 Siloam Hospitals Mampang PT Sentra Sejahtera Utama Khusus Ibukota Jakarta 12760

Jl. Sultan Hasanudin No.Kel, Hative Kecil, Sirimau,

38 Siloam Hospitals Ambon PT Ambon Bangun Nusa Kota Ambon, Maluku

PT Sembilan Raksa Jl. A. Yani, Sungai Baru, Kec. Banjarmasin Tengah,

39 Siloam Hospitals Banjarmasin Dinamika Kota Banjarmasin, Kalimantan Selatan 70122

PT Siloam International Jl. Siloam No.6, Karawaci, Kec. Tangerang, Banten

RSU Siloam Lippo Village
40 Hospitals Tbk. 15811 (Gedung B)

Holland Village Jakarta, Jl. Letjen Suprapto Kav.60

41 Agora General Hospital PT Agora General Hospital No.1, Cempaka Putih Timur 10510
APPENDIX III: SILOAM HOSPITALS BANK ACCOUNT

Account
Hospital Unit Bank Name On The Name Swift Code
Number

Siloam Hospitals Lippo PT Siloam International

CIMB NIAGA 800110249200 BNIAIDJA
Village Hospitals

RSU Siloam Lippo PT Siloam International

CIMB NIAGA 800110256100 BNIAIDJA
Village Hospitals

Siloam Hospitals PT Siloam International

CIMB NIAGA 800110250900 BNIAIDJA
Kebon Jeruk Hospitals

Siloam Hospitals Lippo

CIMB NIAGA 800107938400 PT East Jakarta Medika BNIAIDJA
Cikarang

Siloam Hospitals PT Siloam International

CIMB NIAGA 800005671900 BNIAIDJA
Surabaya Hospitals

Siloam Hospitals PT Golden First Atlanta/Siloam

CIMB NIAGA 800110255900 BNIAIDJA
Jambi Hospitals Jambi

Siloam Hospitals
CIMB NIAGA 800076770400 PT Balikpapan Damai Husada BNIAIDJA
Balikpapan

MRCCC Siloam PT Siloam International

CIMB NIAGA 800110248000 BNIAIDJA
Hospitals Semanggi Hospitals

Siloam Hospitals PT Siloam International

CIMB NIAGA 800110247800 BNIAIDJA
Manado Hospitals

Siloam Hospitals PT Siloam International

CIMB NIAGA 800110251100 BNIAIDJA
Makassar Hospitals

Siloam Sriwijaya PT Rumah Sakit Siloam

CIMB NIAGA 800110254700 BNIAIDJA
Palembang Hospitals Sumsel

Siloam Hospitals CIMB NIAGA 800110253500 PT Siloam International BNIAIDJA

 Bali/Denpasar Hospitals

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 TB PT Siloam International

CIMB NIAGA 800110257300 BNIAIDJA
Simatupang Hospitals

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

BIMC Hospital Nusa

CIMB NIAGA 800112797400 PT Trisaka Reksa Waluya BNIAIDJA
Dua

BIMC Kuta CIMB NIAGA 800099903000 PT Medika Sarana Traliansia BNIAIDJA

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 Paal

CIMB NIAGA 800170819500 PT Sentra Sehat Sejahtera BNIAIDJA
Dua Manado

Siloam Hospitals CIMB NIAGA 800170894500 PT Sentra Sejahtera Utama BNIAIDJA

 Mampang

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)

Hospital Unit Address Phone PIC Mobile E-mail

Alexander
085693110990 Alexander.mutak@siloamhospitals.com
Mutak

+6221- Erika J 081281818085 Erika.Julistiana@siloamhospitals.com

Jl. Siloam No.6,
80646900;
Lippo
Siloam Hospitals ext. 29500,
Karawaci 1600, Frisca Isabella 087871322688 Frisca.isabella@siloamhospitals.com
Lippo Village 29501,
Tangerang
29503,
15811
29505 Anggi Jasica 081348029299 Anggi.jasica@siloamhospitals.com

Slamet Priyadi 08562661777 slametpriyadi@siloamhospitals.onmicrosoft.com

Jl. Siloam No.6,

Karawaci, Kec.
RSU Siloam Lippo Raymond
Tangerang, 089630298281 raymond.prayogo@siloamhospitals.com
Village Prayogo
Banten 15811
(Gedung B)

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

Jl. Cinere Raya 0812-9864-

Ruth Purba Ruth.purba@siloamhospitals.com
Siloam Hospitals No. 19, Kel. 1323
Cinere (RS Pangkalan Jati, +6221
Elisabeth 0815-8706-
Khusus Jantung Kec. Cinere, 50900100 Elisabeth.paramita@siloamhospitals.com
Paramita 500
Diagram Kota Depok, (Hunting)
Depok) Provinsi Jawa Dani 0812-2134-
Barat, 16514 dani.ferdiansyah@siloamhospitals.com
Ferdiansyah 5244
 +6221 Triana 087881725486 Triana.Tambunan@siloamhospitals.com
29531900 ext.
Siloam Jl. RA Kartini No. 8
22600 atau
Hospitals TB Cilandak, Jakarta Kezia Hana 081311653437 kezia.hana@siloamhospitals.com
+6221
Simatupang Selatan 12430
29531900 Ext.
29300 Amelia Thionimar 082126470122 amelia.thiominar@siloamhospitals.com

+6221-2783 Muharrik 0813 6458

Jalan Duren Tiga ci.shasri@siloamhospitals.com
Siloam 7900; Ext. Fathuddin 5966
No. 20 Jakarta
Hospitals ASRI 22001; 22002;
Selatan 12760
22003 ci2.shasri@siloamhospitals.com

Jl. Kelapa Dua Raya

RSU Kelapa
No. 1001,
Dua (Legok Indriyani 08161671632 Indriyani@siloamhospitals.com
Kabupaten
Karawaci)
Tangerang, Benten

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

Jl. Garnisun Kav. 2- Riduanwati

MRCCC Siloam 0818877708 riduanwati.ponidjo@siloamhospitals.com
3, Karet Semanggi- +6221 2996 Ponidjo
Hospitals
Setiabudi, Jakarta 2888 ext 20378
Semanggi
Selatan 12930 Astri Sianipar 085276926666 Astri.sianipar@siloamhospitals.com

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)

Hospital Unit Address Phone PIC Mobile E-mail

Tien Wenny 0812-9130-5657 tien.wenny@siloamhospitals.com

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

Megi Kurnia 087879486262 megi.kurnia@siloamhospitals.com

+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

22000; Astri Nuryanti 0822 270 600 99 astri.nuryanti@siloamhospitals.com

Jl. Chairil Anwar

Blu Plaza No. 27
RT 004/RW 009 +6221 806
Siloam Hospitals Kelurahan 11 900 Ext
Iswatul Auliyah 0857-7069-0373 iswatul.auliyah@siloamhospitals.onmicrosoft.c
Bekasi Timur Margahayu, 22600,
Kec. Bekasi 22602
Timur, Bekasi
17113

Drg . Tina
087878271263 Tina.esadiarti@siloamhospitals.com
Esadiarti, MARS

Jl Pahlawan No. +621 Ahmad Facrizki 0813 60762434 ahmad.fachrizki@siloamhospitals.com

Siloam Hospitals
60 Duren Jaya, 8806140 ext.
Sentosa Bekasi
Bekasi Timur 119 Ruth
0856 8328866 ruth.kartikaningtyas@siloamhospitals.com
Kartikaningtyas

Marketing Support Insurance.SHST@siloamhospitals.com

Deka Febrian 08179007311 deka.febrian@siloamhospitals.com

Siloam Hospitals Jl. Pajajaran No. +62251-
 8303900;
27, Kel. ext. 22000,
Babakan, Kec.
Bogor
Bogor Tengah, 22104,
Kota Bogor 22103, Maurits 08119307789 ignatius.maurits@siloamhospitals.com
22102

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. Natasha 085353515566 CJ.Nathasa@siloamhospitals.com

Siloam
Jl. Ciremai Raya No.
Hospitals
114. Kel. Kecapi. +6231 -485654 0812
Cirebon (RS Irna Melviyana shcb.marcomm@siloamhospitals.com
Kec. Harjamukti, ext 116, 113 18122110
Putera
Kota Cirebon
Bahagia) 0813
Bagus Riadi shcb.marcomm@siloamhospitals.com
22478774

Jl. Kompol Maksum

Siloam 296 Kel.
+6224 0819
Hospitals Peterongan, Kec. Gabriella W gabriella.watulingas@siloamhospitals.com
86001900 09877188
Semarang Semarang Selatan,
Kota Semarang

RSU Jl. Magelang- 0813

Cantika Berliana cantika.berliana@siloamhospitals.com
Syubbanul Kopeng km. 08, 25710099
Wathon Dusun Nuren,
(Tegalrejo Kelurahan Dhesty 0858 marketing.rssw@siloamhopitals.com
Magelang) Purwosari, 04185609
Kecamatan
Tegalrejo,
Kabupaten
Magelang, Jawa
Tengah
 Hospital Unit Address Phone PIC Mobile E-mail

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

Agnes 082230249295 Corporate.SHSB@siloamhospitals.com

+62361-77 99
Epan Setiawan 085217367991 epan.setiawan@siloamhorpitals.com
00 Ext 22000

Ni Luh Putu Eka

22002 081353627642 Karmila.dewi@siloamhospitals.com
Karmila Dewi
Jl. Sunset Road
Siloam Hospitals Luh Putu Arianti
No. 818, Kuta, Bali 08175209222 pro.shdp@siloamhospitals.com
Bali Dhana Cristina
80361

Pande Sukarini 083114541992 pro.shdp@siloamhospitals.com

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. Gabriel 0812-9190-

+62385 238 Rianty Ontorael rianty.ontorael@siloamhospitals.com
Gampur RT 013 3950
1900 ext.
RW 005, Dusun V,
Siloam Hospitals 22001 atau 0852-3774-
Kec Komodo, Kab. Rosiana Rosiana.AmeiliaBeis@siloamhospitals.com
Labuan Bajo +62385 238 2007
Manggarai Barat.
1911 ext.
Labuan Bajo
29300 Marketing Team 081237836911 Info.shlb@siloamhospitals.com
86754

(Regional 3 : Jawa Timur & Bali)

 Akhmad Habsari
082147040468 Akhmad.Habsari@siloamhospitals.com
Siloam (Omy)
Jl. Majapahit No.10
Hospitals
Kota Mataram,
Mataram (RS +62370623999 Baiq Tessa '081805009711 Tessa.Ramadiyati@siloamhospitals.com
Lombok – NTB
Grha Ultima
83127
Medika) Andi Bunga
087888540113 Andi.septiani@siloamhospitals.com
Septiani

BIMC Nusa Dua : BIMC NUSA DUA -

081239531209 kadeklaksmi@bimcbali.com
Kawasan ITDC Blok Kadek Laksmi
D, Jl. Nusa Dua,
Benoa, Kec. Kuta
Sel., Kabupaten BIMC NUSA DUA -
081111077003 siska@bimcbali.com
Badung, Bali Fransiska
BIMC Hospital
80363.
Nusa Dua & +62 361 3000 911
Kuta
BIMC Kuta : Jl.
BIMC KUTA - Emy 085857130001 emy@bimcbali.com
Bypass Ngurah Rai
No.100X, Kuta,
Kec. Kuta, BIMC KUTA -Putu
Kabupaten 0812 3894627 putuhema@bimcbali.com
Hema
Badung, Bali 80361

Siloam Jl. Gajah Mada Rahajeng 085211650404 rahajeng.animas@siloamhospitals.com

Hospitals 104, Kaliwates, +62331-286 1900
Jember Jember Roni 08123472335 Roni.Papilaya@siloamhospitals.com

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)

Hospital Unit Address Phone PIC Mobile E-mail

Jl. MT. Haryono 0 812-7131-

Bakti Yudhistira bakti.yudhistira@siloamhospitals.com
Dalam No. 23 9247
RT. 30,
Kelurahan Martha 0813 7724
+62542 886 martha.hutabalian@siloamhospitals.com
Siloam Hospitals Sungai Nangka, Hutabalian 2284
2999; ext.
Balikpapan Kecamatan
22600
Balikpapan
Selatan, 0812-2530-
Enda Pandia enda.pandia@siloamhospitals.com
BALIKPAPAN 9671
76114

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

Jl. RTA Milono +0536 800

KM 4 No.425 1100 ext dr. Kevin C 082248048105 Kevin.Chrisanta@siloamhospitals.com
Kel. Langkai, 22100
Siloam Hospitals Kec. Pahandut
Palangka Raya Kota Palangka 22101 Christine 081331915522 Christine.iswantho@siloamhospitals.com
Raya,
Kalimantan
Windhiati 081615379328 windhiati.pratitis@siloamhospitals.com
Tengah 73111

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

Jl. Ahmad Yani Dea Andrienda 0822-2111-

dea.nasution@siloamhospitals.com
Km.2, Sungai Nasution 3369
Baru,
Siloam Hospitals 0878-1484-
Banjarmasin Patricia Devina patricia.devina@siloamhospitals.com
Banjarmasin 3560
Tengah,
Kalimantan
Selatan Elena Sucitra elena.sucitra@siloamhospitals.com

Siloam Hospitals Jl. Sam Ratulangi +62431 888

Reza Lonardy 08114518072 reza.lonardy@siloamhospitals.com
Manado No. 22 Manado 3131

Melissa +62811 4333 Melissa.walandouw@siloamhospitals.com

 Walandouw 003

95111 Corp Insurance corporateinsurance.mdo@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)

Hospital Unit Address Phone PIC Mobile E-mail

Supriyatun 0815 8681 4541 Supriyatun@siloamhospitals.com

Jl. Soekarno
+62741
Siloam Hospitals Hatta, Paal
5919000; ext. Tunggul Purba 0813 6880 7079 Tunggul.Purba@siloamhospitals.com
Jambi Merah Jambi-
22301, 22304
36139
Inda Marbun 081278672387 Inda.marbun@siloamhospitals.com

+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

Jl.Soekarno Yohan Krisandy

081513261198 yohan.gusanto@siloamhospitals.com
Hatta Km 5 Kab +62717 9190900 Gusanto
Siloam Hospitals
Bangka Tengah ext 22100;
Bangka Belitung
33684 Bangka 22101; 22300
Kian 081272158735 kiannardi.sutopo@siloamhospitals.com
Belitung

Jl. Yos Sudarso +627333035900

Sri Mahyuningsih 081958636524 Sri.Mahyuningsih@siloamhospitals.com
RT.11. ext 22101
Kelurahan Taba
Siloam Hospitals
Jemekeh.
Silampari Lubuk
Kecamatan
Linggau Achmad
Lubuk Linggau 22102 082378900 133 Achmad.muslihun@siloamhospitals.com
Muslihun
Timur I. Kota
Lubuk Linggau

+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

Siloam Hospitals Kebon Jeruk

Siloam Hospitals TB Simatupang

Siloam Hospitals ASRI

Siloam Hospitals Cinere - Jantung

Joyce Kusumariyadi 08119202529 joyce.kusumariyadi@siloamhospitals.com
Diagram

MRCCC Siloam Hospitals Semanggi

Siloam Hospitals Kelapa Dua

RSU Siloam Lippo Vilage (Gedung B)

Siloam Hospitals Mampang

Agora General Hospital

REG 2 BEKASI & JAWA TENGAH :

Siloam Hospitals Sentosa Bekasi

Siloam Hospitals Bekasi Timur

Siloam Hospitals Bekasi Sepanjang

Jaya

Siloam Hospitals Lippo Cikarang

Siloam Hospitals Bogor Juli Tjong 08118902250 juli.tjong@siloamhospitals.com

Siloam Hospitals Purwakarta

Siloam Hospitals Cirebon (RS Putera

Bahagia)

RSU Syubbanul Wathon Magelang

Siloam Hospitals Yogyakarta

Siloam Hospitals Semarang

REG 3 JAWA TIMUR & BALI : Sally Danayani 081234888411 sally.danayani@siloamhospitals.com

Siloam Hospitals Surabaya

Siloam Hospitals Jember

Siloam Hospitals Denpasar

Siloam Hospitals Mataram

Siloam Hospitals Kupang

Siloam Hospitals Labuan Bajo

BIMC Nusa Dua & Kuta

Siloam Hospitals Ambon

REG 4 KALIMANTAN & SULAWESI :

Siloam Hospitals Makassar

Siloam Hospitals Buton

Siloam Hospitals Manado

Anastasia Lolita 0811466265 anastasia.lolita@siloamhospitals.com
Siloam Hospitals Paal Dua

Siloam Hospitals Palangka Raya

Siloam Hospitals Balikpapan

Siloam Hospitals Banjarmasin

REG 5 SUMATERA :

Siloam Hospitals Medan (RS Dhirga

Surya)

Siloam Hospitals Jambi

Yooseplin 087888487708 yooseplin@siloamhospitals.com
Siloam Hospitals Palembang

Siloam Hospitals Lubuk Linggau

Siloam Hospitals Bangka Belitung

 Head Office

dr.Hartono Salim 081292892067 Hartono.Salim@siloamhospitals.com

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)

Head Office : Jeanitha Kharisma 0821-1975-

jeanitha.kharisma@siloamhospitals.com
Jl. Boulevard (Corporate) 3935
Sudirman No.
Felin Gunawan 0819 0803
15 Lippo Felin.gunawan@siloamhospitals.com
(Insurance) 2093
Karawaci. FK
Univ. Pelita The Margareta
Harapan – 0812-2626-
Sentosa margareta.sentosa@siloamhospitals.com
Lt.29 0898
(Insurance)
Tangerang
15811 (+6221
Online Aggregator Fransiska Kesuma 0811-1719-123 fransiska.kesuma@siloamhospitals.com
2566 8000 ext
24004)
Lisa Budd 08123811505 lisa.budd@siloamhospitals.com

0877-8449-
International Referral Vinka vinka.lo@siloamhospitals.com
7756

0815-2365-
Rilly Richard M. rilly.mamahit@siloamhospitals.com
6613

dr. Laura Leandra 081802402501 laura.leandra@siloamhospitals.com

Medical Check Up Team
dr. Josephine
0817817739 Josephine.Darmawan@siloamhospitals.com
Darmawan
APPENDIX V: MEDICAL CHECK-UP PREPARATION
PT PAMAPERSADA NUSANTARA

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

3. Laboratory (Fasting Blood Sugar & Fat Profile)

 Mandatory fasting 10-12 hours before taking blood
 Only drinking water is allowed
 No alcohol consumption for 48 hours
 No smoking
 Not taking supplements / vitamins

4. Electrocardiography and treadmill test

 At least 24 hours before the examination, do not do strenuous exercise, take medication (unless
known to the doctor), drink coffee, alcohol
 Please bring sports shoes and socks if you feel more comfortable in your own shoes
 Stop certain heart medications such as 3-day beta blockers (Example: imdur, bisoprolol, propranolol,
digoxin)
 Not performed on severe heart problems, balance disorders, pinched nerves with severe disorders,
and impaired mobility in the extremities

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

8. Mammography / ultrasound of the mammary (female)

 Not pregnant or breastfeeding
 Avoid mammography a week before and during menstruation
 Avoid using deodorants, powders, lotions, perfumes on the armpits or around the breasts

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

11. Head CT Scan without Contrast / MRI Head without Contrast

 Not pregnant
 Removing metal objects, such as watches, jewelry, glasses, belts so that the imaging results are not
disturbed
 Do not use excessive hair spray / hair gel / make up.

TERMS & CONDITION OF MEDICAL CHECK UP SILOAM HOSPITALS GROUP

1. Operating hours:
a. Monday-Saturday 7.00 - 14.00

b. Sundays or National Holidays the MCU is close for business

2. Registration / arrival hours: 7.00 - 9.00

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