9.0 DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (Relate items 7.1 to 7.8 to items by row in item 9) Diagnosa atau Penyakit atau Kecelakaan (yang berhubungan dgn item 7.1 sampai 7.8 pada baris dalam item 9 )

10.0 Current Physician Information (Informasi Dokter Sebelumnya) 10.1 Name of Physician (Nama Dokter)

10.2 Hospital or Clinic Name (Nama Rumah Sakit atau Klinik)

Table of Diagnosis Codes (Tabel Kode Diagnosa) 9.1

9.5

9.2

9.6

9.3

9.7

9.4

9.8

Date of Service (Tanggal Pelayanan) Procedure, Services, Supplies (Prosedur, Tindakan, Alat-alat)

To (Dari) From (Sampai

Dengan)

Place of Service(Tempat

Pelayanan)

Type of Service (Tipe Pelayanan)

Treatment Code (CPT,HCPCS, etc)

(Kode Pengobatan)

Treatment Code Description

(Penjelasan Kode Pengobatan)

Modifiers (Perubahan)

Diagnosis Code (Kode Diagnosa)

Unit/ Days (Unit/Hari)

Billed Amount (Jumlah Tagihan)

COB (Koordinasi Benefit)

TOTAL CHARGE (Total Tagihan) AMOUNT PAID (Jumlah yang Dibayarkan) BALANCE DUE (Sisa Tagihan)

MEMBER/PROVIDER REMITTANCE DETAILS (Detail Rekening) (Provide member details if the claim is a reimbursement. Otherwise, please input physician/hospital/clinic details).

PAYEE NAME (Nama Pemilik Rekening): BRANCH (Cabang): SWIFT CODE (Kode Pentransferan):

ROUTING NUMBER (Nomor Pentransferan) ACCOUNT NAME (Atas Nama): ACCOUNT NUMBER (Nomor Rekening):

Mailing Address (Alamat Surat-menyurat):

Street Address (Nama Jalan) City / Province (Kota/Propinsi) Postal Code (Kode Pos)

Telephone Number (Nomor Telepon):

Country Code / Prefix / Number (Kode Negara/ Prefix/Nomor)

SIGNATURE OF DOCTOR (Tanda-tangan Dokter) SIGNED(Tanda-tangan): DATE(Tanggal):

NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE RENDERED(Nama dan Alamat Fasilitas Pelayanan) (If other than home or office)(Selain Rumah atau Kantor)