Invoice Doctor General Practitioner in Indonesia Jakarta –Free Word Template Download with AI
Klinik Pratama Sehat Sentosa
Jl. Sudirman No. 45, Karet Tengsin
Jakarta Selatan, Indonesia Jakarta 12920
Phone: +62 21 555 0199
Email: [email protected]
NPWP: 01.234.567.8-901.000
INVOICE
Invoice Number: INV-JKT-2023-10-0042
Date of Issue: October 24, 2023
Date of Service: October 24, 2023
Due Date: October 31, 2023
Status: UNPAID
Patient & Insurance Information Patient Name Mr. Ahmad Wijaya Date of Birth 15 March 1985 Address Jl. Gatot Subroto Kav. 10Jakarta Pusat, Indonesia Jakarta 10270 Phone Number +62 812 3456 7890 Insurance Provider BPJS Kesehatan (National Health Insurance) Policy / Member ID BPJS-9876543210 Group Number PESERTA-PRIHATIN-001 Authorization Code AUTH-JKT-2023-8899 Services Rendered by Doctor General Practitioner
| No. | Description of Service | ICD-10 Code | Qty | Unit Price (IDR) | Total (IDR) |
|---|---|---|---|---|---|
| 1 | Consultation with Doctor General Practitioner (Initial Visit) | R50.9 | 1 | 350,000 | 350,000 |
| 2 | Physical Examination (Vital Signs, Auscultation, Palpation) | - | 1 | 150,000 | 150,000 |
| 3 | Laboratory Test: Complete Blood Count (CBC) | - | 1 | 125,000 | 125,000 |
| 4 | Laboratory Test: Blood Glucose Level (Fasting) | - | 1 | 75,000 | 75,000 |
| 5 | Prescription Medication: Amoxicillin 500mg (10 Capsules) | - | 1 | 45,000 | 45,000 |
| 6 | Prescription Medication: Paracetamol 500mg (10 Tablets) | - | 1 | 25,000 | 25,000 |
| 7 | Medical Certificate Issuance (Sick Leave) | - | 1 | 50,000 | 50,000 |
Please remit payment for the outstanding balance of IDR 244,200 (Two Hundred Forty-Four Thousand Two Hundred Indonesian Rupiah) by the due date indicated above.
Bank Transfer (BCA) Account Name: Klinik Pratama Sehat SentosaAccount Number: 123-456-7890 Bank Transfer (Mandiri) Account Name: Klinik Pratama Sehat Sentosa
Account Number: 987-654-3210
Please include the Invoice Number (INV-JKT-2023-10-0042) as the transfer reference. For cash payments, please visit our clinic in Indonesia Jakarta during business hours (Monday - Saturday, 08:00 - 20:00 WIB).
Terms and Conditions
- This Invoice is issued in accordance with the medical services provided by the Doctor General Practitioner at Klinik Pratama Sehat Sentosa, located in Indonesia Jakarta.
- Payment is due within 7 days from the date of issue. Late payments may be subject to a penalty fee of 2% per month.
- For BPJS Kesehatan members, this invoice serves as a supplementary bill for services not fully covered by the insurance scheme. Please present your BPJS card and this invoice at the clinic's administrative desk for verification.
- All medical services are performed by licensed healthcare professionals registered with the Indonesian Medical Council (Konsil Kedokteran Indonesia).
- In case of any discrepancies regarding the charges, please contact our billing department within 14 days of receiving this invoice.
- This document is valid as a tax invoice for business expense claims in Indonesia.
Important Notice
This Invoice is generated electronically and is legally binding. No signature is required for validity. However, a physical copy with a clinic stamp can be obtained upon request at our facility in Indonesia Jakarta.
[Clinic Stamp Area] Dr. Budi Santoso, Sp.PDDoctor General Practitioner
Klinik Pratama Sehat Sentosa ⬇️ Download as DOCX Edit online as DOCX
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