Purchase Order Surgeon in Indonesia Jakarta –Free Word Template Download with AI
| Field | Details |
|---|---|
| Provider Name | Dr. Hendra Wijaya, Sp.B, Subsp. Onk(K) — Lead Surgeon |
| Professional License | SIP No. 110/2024/KEP/DINKES-JKT — Registered with the Indonesian Medical Council (IDI), Jakarta Chapter |
| Specialization | General Surgery with Subspecialty in Surgical Oncology |
| Practice Location | Medika Nusantara Hospital, Jakarta Selatan, Indonesia Jakarta |
| Contact | Phone: +62-21-555-0147 | Email: [email protected] |
| Bank Account | BCA — Account No. 2210-4567-8901 — a.n. Dr. Hendra Wijaya |
This Purchase Order is issued by RS Medika Nusantara Hospital, located in Indonesia Jakarta, to formally engage the services of the named Surgeon for a defined period of surgical procedures, consultations, and related professional duties. The engagement is governed by the terms and conditions outlined in this document and the supplementary service agreement dated 10 June 2025.
3. Line Items — Surgeon Service Breakdown| No. | Description of Surgeon Service | Qty | Unit Rate (IDR) | Amount (IDR) | Period / Schedule |
|---|---|---|---|---|---|
| 1 | Elective Surgical Oncology Procedures (laparoscopic and open) performed by the assigned Surgeon in the operating theatre of Medika Nusantara Hospital, Indonesia Jakarta | 12 | 45,000,000 | 540,000,000 | July 2025 – September 2025 |
| 2 | Pre-operative Patient Consultation and Surgical Planning Sessions conducted by the Surgeon at the hospital clinic, Indonesia Jakarta | 24 | 3,500,000 | 84,000,000 | July 2025 – September 2025 |
| 3 | Post-operative Follow-up and Wound Assessment by the Surgeon (minimum 3 visits per patient) | 36 | 2,000,000 | 72,000,000 | July 2025 – October 2025 |
| 4 | Emergency Surgical Intervention Call-out (on-call Surgeon availability, 24/7 coverage for the surgical ward) | 90 | 1,500,000 | 135,000,000 | July 2025 – September 2025 |
| 5 | Multidisciplinary Tumor Board Participation and Surgical Case Review by the Surgeon | 6 | 5,000,000 | 30,000,000 | Monthly, July–September 2025 |
| 6 | Medical Training and Mentoring of Junior Surgical Residents supervised by the Lead Surgeon | 12 | 4,000,000 | 48,000,000 | July 2025 – September 2025 |
| Subtotal | 909,000,000 | ||||
| VAT (PPN) 11% | 99,990,000 | ||||
| Total Purchase Order Value (IDR) | 1,008,990,000 | ||||
4.1 This Purchase Order constitutes a binding agreement between RS Medika Nusantara Hospital (hereinafter "the Hospital") and the named Surgeon (hereinafter "the Provider") for the delivery of surgical and related professional services within the premises and jurisdiction of Indonesia Jakarta.
4.2 All surgical procedures performed under this Purchase Order shall comply with the standards set forth by the Indonesian Ministry of Health (Kementerian Kesehatan RI), the Indonesian Medical Council (IDI), and the hospital's internal clinical governance policies applicable in Indonesia Jakarta.
4.3 The Surgeon shall maintain valid professional licensure (SIP), malpractice insurance coverage of no less than IDR 5,000,000,000 per claim, and all requisite certifications throughout the duration of this engagement.
4.4 Payment shall be processed within thirty (30) calendar days from the date of invoice submission, via bank transfer to the account specified in Section 1. Invoices must reference this Purchase Order number (PO-JKT-SRG-2025-0047).
4.5 The Surgeon is classified as an independent professional contractor for the purposes of this Purchase Order and is not an employee of the Hospital. All tax obligations, including Personal Income Tax (PPh Pasal 21) where applicable, shall be handled in accordance with Indonesian tax regulations.
4.6 Any modification, extension, or cancellation of this Purchase Order must be executed in writing and signed by both parties. Verbal agreements are not recognized under this document.
4.7 Disputes arising from this Purchase Order shall be resolved through mediation in Indonesia Jakarta, and if unresolved, through the Jakarta District Court (Pengadilan Negeri Jakarta Selatan).
For and on behalf of RS Medika Nusantara Hospital
Dr. Sari Kusuma, MARSDirector of Medical Services
Date: _______________
Accepted by the Surgeon (Service Provider)
Dr. Hendra Wijaya, Sp.B, Subsp. Onk(K)Lead Surgeon
Date: _______________ ⬇️ Download as DOCX Edit online as DOCX
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