Invoice Surgeon in Indonesia Jakarta –Free Word Template Download with AI
Specialized Surgical Services
Jl. Sudirman Kav. 52-53, SCBD Lot 10
Jakarta Selatan, DKI Jakarta 12190
Indonesia
Tax ID (NPWP): 01.234.567.8-901.000
Phone: +62 21 5555 8888
Email: [email protected]
Invoice #: INV-JKT-2023-0892
Date: October 24, 2023
Due Date: November 24, 2023
Status: Pending Payment
Bill To:Patient Name: Budi Santoso
Address: Jl. Gatot Subroto No. 12, Menteng, Jakarta Pusat, Indonesia
Insurance Provider: Allianz Indonesia (Policy #ALZ-ID-998877)
Contact: +62 812 3456 7890
Description of Surgical ServicesThis invoice details the professional fees and associated costs for the surgical procedure performed by Dr. Andi Wijaya, Sp.B., at our facility in Jakarta, Indonesia. The procedure was conducted in accordance with the highest standards of medical practice and Indonesian health regulations.
| Description | Quantity | Unit Price (IDR) | Total (IDR) |
|---|---|---|---|
| Surgeon Professional Fee: Laparoscopic Cholecystectomy performed by Dr. Andi Wijaya, Sp.B. Includes pre-operative consultation, surgical execution, and immediate post-operative assessment. | 1 | 15,000,000 | 15,000,000 |
| Anesthesiologist Fee: General anesthesia administration and monitoring during the surgical procedure. | 1 | 5,000,000 | 5,000,000 |
| Operating Room Charges: Use of sterile surgical suite, equipment, and nursing staff for 3 hours. | 3 | 2,500,000 | 7,500,000 |
| Medical Supplies & Implants: Laparoscopic instruments, sutures, and disposable surgical materials. | 1 | 3,200,000 | 3,200,000 |
| Post-Operative Care: Recovery room monitoring and initial wound care. | 1 | 1,500,000 | 1,500,000 |
| Diagnostic Tests: Pre-operative blood work and imaging (Ultrasound/CT Scan). | 1 | 1,800,000 | 1,800,000 |
Please remit payment to the following bank account in Indonesia:
Bank: Bank Central Asia (BCA)
Account Name: PT Medika Utama Surgical Center
Account Number: 123-456-7890
Reference: INV-JKT-2023-0892
Note: Please include the invoice number in your transfer reference to ensure proper allocation.
Terms and Conditions- Payment Terms: Payment is due within 30 days of the invoice date. Late payments may incur a penalty of 2% per month.
- Currency: All amounts are quoted in Indonesian Rupiah (IDR).
- Insurance Claims: If you are paying out-of-pocket and seeking reimbursement from your insurance provider, please contact our billing department for a detailed itemized statement.
- Disputes: Any discrepancies regarding this invoice must be reported within 14 days of receipt.
- Privacy: Your personal and medical information is handled in accordance with Indonesian data protection laws.
- Validity: This invoice is valid for 12 months from the date of issue.
Thank you for choosing Medika Utama Surgical Center for your healthcare needs in Jakarta, Indonesia. We are committed to providing exceptional surgical care and support.
Authorized Signature
Dr. Andi Wijaya, Sp.B.
Lead Surgeon
Billing Department
Siti Rahayu
Finance Manager
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