DocuSign Envelope ID: 7E4BA2AE-EAA5-497F-87C4-82531152F7A2
P.T. AstraZeneca Indonesia
MEDICAL REIMBURSEMENT CLAIM FORM
(NOTE : Please give full details in section, original bills
must be attached)
Claimants Name : Andrean Sopianto DEPT. : SALES
Claimed on behalf of (state names and relationships) :
Name Age Relationships Symptoms Treated
1 Andrea Zahra Salsabila. 5 tahun Daughter Covid 19
2 Afif Sulthan Farraas. 2 Bulan Son Covid 19
3 Ade Maya Azkiyati. 31 tahun Spouse Covid 19
4 Andrean Sopianto. 32 tahun Employee Covid 19
Company Reimbursement A/C
EXPENDITURE
% Amount Code
Name of Doctors
DOCTORS Amount
as per bill
23-Jun Dr. Anita Isabella G, [Link]+SWAB PCR Rp 670,852 100% Rp 670,852
24-Jun Dr Teda Faadhila+obat2an Rp 416,500 80% Rp 333,200
26-Jun Dr. Anita Isabella G, [Link]+SWAB PCR Rp 950,000 100% Rp 950,000
26-Jun Dr. Anita Isabella G, [Link]+SWAB PCR Rp 950,000 100% Rp 950,000
26-Jun Dr. Anita Isabella G, [Link]+SWAB antigen Rp 200,000 100% Rp 200,000
26-Jun Dr. Anita Isabella G, [Link]+SWAB PCR Rp 950,000 100% Rp 950,000
26-Jun Dr. Anita Isabella G, [Link]+SWAB PCR Rp 950,000 100% Rp 950,000
27-Jun Dr Mirza Artati+obat2an Covid 19 Rp 1,084,000 80% Rp 867,200
10-Jul Dr. Medityas Winda K, [Link]+SWAB antigen Rp 140,000 100% Rp 140,000
10-Jul Dr. Medityas Winda K, [Link]+SWAB antigen Rp 140,000 100% Rp 140,000
10-Jul Dr. Medityas Winda K, [Link]+SWAB antigen Rp 140,000 100% Rp 140,000
12-Jul Dr. Anita Isabella G, [Link]+SWAB antigen Rp 150,000 100% Rp 150,000
Rp -
DENTAL Name of Dentists Rp -
OPTICAL Total (A) Rp 6,441,252
MATERNITY
Other fees
1 Cek Darah SGOT+SGPT+Trombosis ######## 80% Rp 317,600
2 USG 80% Rp -
3 Medicines
4 Others (Tes Mantoux+suntik) 80% Rp -
HOSPITALIZATION/SURGERY
Hospital Total Days Rate/Day
Total (B) Rp 317,600.00
Signature of claimant Total (A + B) Rp 6,758,852.00
Advances taken on :
B.V./C.A.V. No. ____________
from Company
Balance due ____________
16-Jul-21 to Company
Date :
APPROVAL FOR PAYMENT Paid on voucher/cheque number ….…………………………………
Dated …………………………...………………………………………..
Received ……………………...…………………………………..……..
Date : ……………………….
19-Jul-21 Date …………………………...………………………….……………..
$cee41a133d9c$[Link]/es/aug'04
DocuSign Envelope ID: 7E4BA2AE-EAA5-497F-87C4-82531152F7A2
DocuSign Envelope ID: 7E4BA2AE-EAA5-497F-87C4-82531152F7A2
DocuSign Envelope ID: 7E4BA2AE-EAA5-497F-87C4-82531152F7A2
DocuSign Envelope ID: 7E4BA2AE-EAA5-497F-87C4-82531152F7A2
DocuSign Envelope ID: 7E4BA2AE-EAA5-497F-87C4-82531152F7A2
DocuSign Envelope ID: 7E4BA2AE-EAA5-497F-87C4-82531152F7A2
DocuSign Envelope ID: 7E4BA2AE-EAA5-497F-87C4-82531152F7A2
DocuSign Envelope ID: 7E4BA2AE-EAA5-497F-87C4-82531152F7A2
DocuSign Envelope ID: 7E4BA2AE-EAA5-497F-87C4-82531152F7A2
DocuSign Envelope ID: 7E4BA2AE-EAA5-497F-87C4-82531152F7A2
DocuSign Envelope ID: 7E4BA2AE-EAA5-497F-87C4-82531152F7A2
DocuSign Envelope ID: 7E4BA2AE-EAA5-497F-87C4-82531152F7A2
DocuSign Envelope ID: 7E4BA2AE-EAA5-497F-87C4-82531152F7A2
DocuSign Envelope ID: 7E4BA2AE-EAA5-497F-87C4-82531152F7A2
