PERJANJIAN KERJASAMA PELAYANAN KESEHATAN / (COOPERATION AGREEMENT ON HEALTHCARE SERVICES amtarasbetwoon PT.TPA ASO TIRTA MITRA ADIHUSADA "TPA ASO TIRTA (os JTIRTA-DIRE./2018) danvand PT. ARTHA FAAD MEDIKA"ERATION AGREEMENT This COLLABORATION AGREEMENT (hereinafter refered as "CA" is made and entered into tis (day), (Sate and mont, year. (8d-mm-yyy) by and between: Kes a PERJANJIAN KERJASAMA ini (seinunys isebut PR) cust dan dlengsuncken pads hati (6ay) tanga! buian ‘aan (cemm-yyy) oleh dan arta PT. SUPRIMA MITRA ADIHUSADA, a Fegistorod company comiciod in Jakarta, Gis Nine Tower i 5. J.TB. Simatusang No2 Clandak KKO Jakarta selatan 12560, | was sabisned based on the Deed of Establishment NoS dated October 26%, | 2016, made before Rim Yulan SH, Notary | public n Jakarta, in ths mater represented By dr Fran, Subs MK as the Director who fais for and on behalf of the above Company, Hereinafter eferedas TPA ASOTRTA. | | PT. SUPRIMA MITRA_ADIHUSADA, | Porseroan yang berkocudukan di Jakarta ibis Nino Tower 8 JITB Smatupang No Gilancak KKO Jakarta eolatan 12560, iran Derdasarkan Aka Perubahan No.9 tangoal 25 | (Oxiober 2016 yang buat di hagapan Rin | Yuiiant SH, Notas Jakarta, dalam hal in| Ciwakiloloh oe Filan Suki MRK. selaky | Direktur dengan demikian berindsk unt dan alos nama Persoroan tersebut datas, Solanktrya disebut sebegal TPA ASO TIRTA. F i PT. Artha Faad Medika, 2 regi ‘company who. manages RSI. ‘Bunda Hospital Glin, domiciled in Hertasring RT & RW 001 Makassar, 5 ‘Sulawesi in this matter represented by ‘dr. Ardy’ Dahlan, - $P.0G,M.Kes. President Director basod on the Dood, 13 made before Niny Savity SH, Ne puble in Jakarta, thus esting for and behalf ofthe above Company, eal Hereinafter referred as PROVIDER. TPA ASO TIRTA and PROVIDER hereinafter willbe colectvely referred to 08, PARTIES. 4. RECITALS: {TPA ASO TIRTA is a healthcare administration company anda ‘Subsidiary “compary "of FULLERTON "HEALTHCARE CORPORATION LIMITED (200 ‘Appendix G) engages in the busmess of Thrd Party ‘Admiisrtion ‘TPA ASO TIRTA full he obligation 0 ts members of TPA ASO TTIRTA Programme and their famiios ‘and requres ‘healcare. facies inpatent andlor culpatort services Pant Page 1 of 38) Parfit jj PT. Artha Faad Medika , sebuah Persoroan “Terpatas yang mengeloia Rumah Saki / Kink SIA Sayang Bunda yang beraamet Harasning No. 52 RT 8 RW O01, Makassar ‘Sulawesi Selatan, dalam hal i val oleh dr. Ardy “Dahlan, $p.0G.,.N.Kes. selok Direktur Utama bordasarkan Akia NO. 13 dhadapan Nin Saviry, SH, Notars ‘lata, dengan demi berindak unk dan ‘alas nema Perseroan trsebut datas, Solanutnya dicobut sebagai PENYEDIA. ‘TPA ASO TIRTA don PENYEDIA secare bersame-same selanjuinya cisebul PARA PINAR. 1. PEMBUKAAN : 4.4 TPA ASO TIRTA adsloh sebush erusshaan administasi Kesehatan ‘dan morupekan anak perusahaan dari FULLERTON HEALTHCARE CORPORATION LIMITED (ahat Lampiren G) yang bergerak dalam ‘idang. usana’adminias! pk etiga TPA ASO TIRTA bertugas memenuhi kewajban kepada para _pocora Program TPA'= ASO TIRTA dan oluargarye dan karonarya16.3 Governing Law 16.3. Hukum yang mengatur This GA shall be construed and PK ini haus iatsikan dan enforced in accordance with the Slaksarakan merurut haku negara laws of Republic of Insonesia, Repubik nconesa, 164 Assignment Prohibited 164 Larangan Pemindahan This CA shall not be assignable by ini tidak dapat cipindahkan oleh either party without the writen salah satu phak lanpa.perseluuan Consent of the oho tents da pnak yang lan 165 Notices 165 Pemboritahuan Al polices and other ‘Semua pembertahuen dan komunikas! ‘communications requred ‘er Tain yang diperukan atau czinkan akan Dormitted wil be doomed to have langgap lsh berkan bid cantar eon culy gven if daivered langsung, cikrim melalui pos tercatat, personaly, sent by registered post, iposkan atau skim mala fast ks fmaled sent by fecsimis lama yang dtentucan beckut Iransmission, to the aderesses Set forth boiow. {tte PROVIDER: ‘ila untuk PENYEDIA PT. Atha Fas Medika (for PT. Arha Faad Medka (untuk ‘exonsion of CA) perpanjangan PK) MARKETING DIVISION DIVISI PEMASARAN PIC: Aldayari Darian PIC: Aldayani Dahlan ‘Acoress: 52 Herasning RT 8 RW ‘Alamat: Hertasring No 52 RT 8 RW 001 (001 Makassar, Sout Sulawes! Makassar Sulawesi Selatan ep: 041 aer1a82 Toip: 0811 4671352, Fax: 0491 4671332 Fax O41 4671382 Ito TPA ASO TIRTATPA ASO. Bila untuk TPA ASO TIRTA (TPA RTs ‘ASO TIRTA) Cibs Nine Tower 85. J.T ibis Nine Tower 5. J.TB Simatupang Simatupang No.2 Cilandak KKO 'No2 Gilandak KKO .akarta selatan Jakara selatan 12560 12560, ‘At: Dr Fin Suk MK Ain Dr Fiiani Sub MK (Diecton) (Die) “Tolp, 021-296 35333 Telp. 021-206 33593, Fae 021-296 33534 Fax: 021 ~ 296 33334 168 Entire Agreement 166. Kesoluruhan Pecanjian This CA constitutes the enti PK iei_merupakan kesulurihan Understanding between PARTIES, engertan antara para PIHAK dan fand itis understood and agreed that Spahami sorta disetjui babwa PK in this CA supersedes ary prior writen menggantkan —peranjan dan oral agreement and Pemahsman secara isan’ maupun Understanding elated fo the subject fertuis sebelumnya menyangkut mater hareat, and. that all prior kok ponjanian in, an’ bahwa Lnderskings, negotiations ‘and semua" janj, negosiasi dan 2greements between PARTIES are Dersetuisan sebelumya entara para merged herein PIMAK tolan digabungkan dalam PK Par Porat t Page 28 of 38NOW, THEREFORE the PARTIES ‘signed on the date frst mentioned th GA. made in 2 (two) exact cuptcates, {ach with suit stamp duty ana have the same legal Binding force. mn wines whereof the PARTIES have hed thew uly authorized ofcers execute this CA, {28 of the above writen ‘Untuk dan atasramaifor and on behat of PT. SUPRIMA MITRA ADIMUSADA/ ‘TPAASO TIRTA iriani Sukr,.MKK ‘Director Part Port Page 32 of 38, DEMIKIANLAH PARA PIHAK telah menandatangani PK irs peda hart dan tanggal sebagamana Gisebutkan ot aas, “dual dalam rangkap 2 (dua) yang seme bunyinya dan masing-masing bermaterl ccukup Serta mempuryal kexutan uk yang same, Untuk dan atas nama /for and on behalf of PT. Artha Faad MedikaAPPENDIX F (LAMPIRAN F) PAYMENT METHODICARA PEMBAYARAN [PAYMENT METHOD FOR HEALTHCARE SERVICES, Payient PROVIDER'S account se otows. ‘Name of Account: PT. Artha Faad Media ‘Account Number:2295552290 Bank Namo: BNI ‘Branch: Matioangin ‘andioe PROVIDER account at other banks if atfed in wring to TPA ASO TIRTA atthe latest = {thirty working cays in advance ‘of the effective uzation date of te other account ‘ASO TIRTA wil emai to PROVIDER & Payment Statement wit all details of each ciins pad | Ths wil be e-maiied to te folowing Nomitod Biling Contact pereon ct PROVIDER'S staf ‘A the tine of making each bank transfers, TPA Phone number: 0411 4571932 Fax Number: 0411 4671332 Email: rsiasayangbunda04@gmai.com Pere Page 38 of 38 Pera mal: rsiasayangbundadd@gmal.com ‘CARA PEMBAYARAN UNTUK LAYANAN KESEHATAN ibe made by TPA ASO TIRTA To | Pambayaran akan” diokukan oleh TPA~ASO ‘TIRTA Ke rekering PENYEDIA sebagai beri | Nama pemegang rekening: PT. Ariha Faad | Meaika ‘Nomor rokening:2293552290 Nama Bank: BNI Cabang: Mattoangin lanfatau rekening PENYEDIA di bank Jin ‘pabila dbertanukan secara torus kepada TPA. ASO TIRTA solambetiambatnye 30 (hgapelsn) hari kerla sebelum diberakukannya Romar rekening yang, Pade waktu melaksanakan transfer pembayaren melalui bank, TPA ASO TIRTA shan mengrin BuktiPembayaran mola surat clekvonk Deserta rncian dan setap taginan yang dbayar hepade PENYEDIA. Bust Permbayaran tu tar) «dicrim kepada petugas PENYEDIA Baglan: Bendahara No. Telepon: 0411 4671332 | Nama: Ansari Nur | Nomor Fax: 0817 4871332