Instrument Set 3 Set9 Sthethoscope Dewasa 1 UnitPoliklinik Penyakitdalam1 ECG 2 Unit2 Examination Lamp 2 Unit3 Examination Table 1 Unit4 Bedside Monitor 2 Unit5 Instrument Trolley 3 Unit6 Nebulyzer 2 Unit7 Diagnostic Set 2 Set8 Resucitation Set 2 Set9 Intubation Set 1 SetPoliklinik Kandungandan Kebidanan1 Baby Doppler Pocket 2 Unit2 Examination Lamp 2 Unit3 Gynecologycal Examination 1 UnitTable4 Obstetrical Examination Table 2 Unit5 Diagnostic Set 2 Set6 Minor Surgery Instrument Set 1 Set7 Dilatation

and Curetage 1 SetDiagnostic Set8 Sthethoscope Dewasa 1 UnitPoliklinik Anak1 ECG 1 Unit2 Instrument Trolley 1 Unit3 Oksigen Concentrator 1 Unit4 Paediatric Bed 1 Unit5 Suction Pump 1 Unit6 Diagnostic Set 1 Set7 Vena Section Set 1 Set8 Resucitation Set for Children 1 Unit9 Sthethoscope Anak 1 UnitPerawatan Bedah1 Autoclave 1 Unit2 Examination Table 2 Unit3 Sterilisator 2 Unit4 Suction Pump 2 Unit5 Minor Surgery Instrument Set 2 SetPerawatan PeenyakitDalam1 Infusion Pump 3 Unit2 Spirometer 1 Unit3

Diagnostic Set 1 Set4 Resucitation Set 1 Set Hal 16Putusan Pengadilan TIPIKORNo.07/Pid.Sus.K/2014/P N.Mdn 5 Vena Section Set 2 Set6 Laringoscope for Adult 1 SetPerawatanKandungan danKebidanan1 Gynecologycal Examination 1 UnitTable2 Infusion Pump 2 Unit3 Sterilisator 1 Unit4 Suction Pump 1 Unit5 Vacum Extractor 2 Set6 Minor Surgery Instrument Set 2 Set7 Resucitation Set for Adult 2 Set8 Resucitation Setfor Children 2 SetPerawatan Anak1 Paediatric Bed 5 Unit2 Patient Trolley 3 Unit3 Suction Pump 1

Kebidanan1 Baby Doppler Pocket 2 Unit2 Examination Lamp 2 Unit3 Gynecologycal Examination 1 UnitTable4 Obstetrical Examination Table 2 Unit5 Diagnostic Set 2 Set6 Minor Surgery Instrument Set 1 Set7 Dilatation and Curetage 1 SetDiagnostic Set8 Sthethoscope Dewasa 1 UnitPoliklinik Anak1 ECG 1 Unit2 Instrument Trolley 1 Unit3 Oksigen Concentrator 1 Unit4 Paediatric Bed 1 Unit5 Suction Pump 1 Unit6 Diagnostic Set 1 Set7 Vena Section Set 1 Set8 Resucitation Set for Children 1 Unit9 Sthethoscope Anak

1 UnitPerawatan Bedah1 Autoclave 1 Unit2 Examination Table 2 Unit3 Sterilisator 2 Unit4 Suction Pump 2 Unit5 Minor Surgery Instrument Set 2 SetPerawatan PenyakitDalam1 Infusion Pump 3 Unit2 Spirometer 1 Unit3 Diagnostic Set 1 Set4 Resucitation Set 1 Set5 Vena Section Set 2 Set6 Laringoscope for Adult 1 SetPerawatanKandungan danKebidanan1 Gynecologycal Examination 1 UnitTable2 Infusion Pump 2 Unit3 Sterilisator 1 Unit4 Suction Pump 1 Unit5 Vacum Extractor 2 Set6 Minor Surgery Instrument Set 2 Set7

PT.Esa Medika Mandiro :1. 3 (tiga) Unit Minor Surgery Set Merek Medicon @ Rp.21.660.800.= Rp64.982.400,00;2. 1 (satu) Unit THT Set Merek Medicom = Rp34.800.000,00;3. 2 (dua) Unit SP30 Suction Pump Merek Penlon @Rp.8.000.000.= Rp16.000.000,00;4.1 (satu) Unit D300 Mobile Examination Lamp Merek Bertchtold= Rp37.000.000,00;5. 1 (satu) Unit NEC28 Nebulizer Merek Riester= Rp 1.000.000,006. 1 (satu) Unit Lampu Kepala Merek Riester =Rp 2.500.000,007. 1 (satu) Unit Optima VS Infusion Merek Fresenius Vial=

Rp.16.300.000,1 UnitMinor Surgery Set Rp.43.500.000. Rp.130.500.000,3 UnitSuction Pump Rp.19.000.000. Rp.38.000.000,2 Unit1 Unit Vital Sign Monitor Rp.280.000.000 Rp.280.000.000,1 Unit Lampu Kepala Rp.7.400.000. Rp.7.400.000,1 Unit THT Set Rp.72.200.000. Rp.72.200.000,1 Unit Infusion Pump Rp.34.000.000. Rp.34.000.000,1 Unit Syring Pump Rp.34.000.000. Rp.34.000.000.1 Unit Meja Operasi Rp.549.000.000 Rp.549.000.000,1 Unit Lampu operasi mobil Rp.77.000.000.

Nomor 2410 K/Pid.Sus/2015 Minor Surgery Set 3 Set @Rp.45.800.000 Rp.137.400.000 Suction Pump 2 Unit @Rp.20.000.000 Rp.40.000.000 Vital Sign monitor 1 Unit @Rp.295.600.000 Rp.295.600.000 1 Unit @Rp.7.800.000 Rp.7.800.000Lampu Kepala THT Set 1 Set @Rp.76.000.000 Rp.76.000.000Infusion Pump 1 Unit @Rp.36.000.000 Rp.36.000.000Syringe Pump 1 Unit @Rp.36.000.000 Rp.36.000.000Meja Operasi 1 Unit @Rp.580.400.000 Rp.580.400.000 Lampu Operasi Mobile 1 Unit @Rp.81.700.000 Rp.81.700.000 Jumlah Rp.1.414.100.000

PT.Esa Medika Mandiro :1. 3 (tiga) Unit Minor Surgery Set Merek Medicon @ Rp21.660.800,00= Rp64.982.400,002. 1 (satu) Unit THT Set Merek Medicom = Rp34.800.000,003. 2 (dua) Unit SP30 Suction Pump Merek Penlon @Rp8.000.000,00= Rp16.000.000,004. 1 (satu) Unit D300 Mobile Examination Lamp Merek Bertchtold)= Rp37.000.000,005. 1 (satu) Unit NEC28 Nebulizer Merek Riester= Rp 1.000.000,006. 1 (satu) Unit Lampu Kepala Merek Riester = Rp 2.500.000,007. 1 (satu) Unit Optima VS Infusion Merek Fresenius Vial

Rp16.300.000,3 Unit Minor Surgery Set Rp43.500.000. Rp130.500.000,2 Unit Suction Pump Rp19.000.000. Rp38.000.000,1 Unit Vital Sign Monitor Rp280.000.000. Rp280.000.000,1 Unit Lampu Kepala Rp7.400.000. Rp7.400.000,1 Unit THT Set Rp72.200.000. Rp72.200.000,1 Unit Infusion Pump Rp34.000.000. Rp34.000.000,1 Unit Syring Pump Rp34.000.000. Rp34.000.000.1 Unit Meja Operasi Rp549.000.000. Rp549.000.000,1 Unit Lampu operasi mobil Rp77.000.000.

Mayor Surgery .Medizintechnik 1 SetInstrument Set/ GermanyAS16. Minor Surgery .Medizintechnik 2 SetInstrument Set/ Germany17. Operating LampCombination Ceilling; Uzumcu Turkey 1 unitSurgical Camera &Monitoring System18. Operating TableUzumcu Turkey 1 unitElectric Hal. 11 dari 205 hal. Put. No. 2588 K/PID.SUS/2015 19. Resucitation Bag For Uzumcu Turkey 2 SetAdult20. Resucitation Bag ForUzumcu Turkey 1 SetChild21. Resucitation Bag ForUzumcu Turkey 1 SetInfant22.

Mayor Surgery Instrument Medizintechni 4 GeteSet k/ GermanyAS16. Minor Surgery Instrument Medizintechni2 SetSet k/ Germany17. Operating LampUzumcu Combination Ceilling Surgical 1 unitTurkeyCamera & Monitoring SystemUzumcu 18. Operating Table Electric 1 unitTurkeyUzumcu 19. Resucitation Bag For Adult 2 SetTurkeyUzumcu 20. Resucitation Bag For Child 1 SetTurkeyUzumcu 21. Resucitation Bag For Infant 1 SetTurkey Hal. 37 dari 205 hal.Put. No. 2588 K/PID.SUS/2015 Uzumcu 22.

Mayor Surgery Medizintec1 SetInstrument Set hnik/ GermanyAS16. Minor Surgery Medizintec2 SetInstrument Set hnik/ Germany17. Operating LampCombinationCeilling Surgical Uzumcu ;1 unitCamera & TurkeyMonitoringSystem18. Operating Table Uzumcu ;1 unitElectric Turkey19. Resucitation Bag Uzumcu 2 SetFor Adult Turkey20. Resucitation Bag Uzumcu 1 SetFor Child Turkey21. Resucitation Bag Uzumcu 1 SetFor Infant Turkey22. Surgical Sunction Uzumcu 2 UnitPump TurkeyAS23.

Set 56,522,4 56,522.40eInstrument Set 05 5Minor Surgery eet 69,238,5 138,477,0eInstrument Set 48 9756,450,0 282,250,0Oksigen Konsentrate Unit00 00 Hal. 69 dari 205 hal.

Mayor Surgery InstrumentSetASMedizintechnik/Germany1 Set 16. Minor Surgery Instrument SetASMedizintechnik/Germany2 Set 17. Operating Lamp CombinationCeilling Surgical Camera & Uzumcu Turkey 1 unit Hal. 89 dari 205 hal. Put.

., yang berpraktek pada Pusat OperasiPlastik Aestetik/ Pusat Operasi Rekonstruktif (Aestetic Plastic SurgeryCenter/ Reconstructive Surgery Center) yang beralamat di PAI Building898/1 Sukhumvit 55, KiongtonNua, Wattana Bangkok 10110, Thailand,Tel: +66 (0) 2715011112, +66 (0) 27121111, +66 (0) 27150113, email:consult@pai.co.th, yang menerangkan, antara lain:*.. Theodora Victory Divine Grace Is a patient that we have diagnosedas a naturally occurring transsexual with gender identity as male.

pemohondilahirkan sebagai seorang anak perempuan, namun setelah beranjak dewasapemohon mulai menunjukkan sifat seperti lakilaki, hal ini Nampak ketikapemohon lebih suka dengan rambut pendek seperti lakilaki, berpakaian sepertianak lakilaki dan suka bermain dan bergaul dengan lakilaki;Menimbang, bahwa menurut bukti P6 (Surat keterangan yangdikeluarkan oleh Ahli Bedah Plastik yaitu Sutin Khobunsongserm,M.D., yangberpraktek pada Pusat Operasi Plastik Aestetik/ Pusat Operasi Rekonstruktif(Aestetic Plastic Surgery

Center/ Reconstructive Surgery Center)) padapokoknya menerangkan bahwa pada tanggal 15 Agustus 2015, Pemohon telahmelakukan mastektomi (operasi pengangkatan payudara) dan metoidioplasty(phalloplasty/ prosedur bedah untuk merekayasa bentuk alat kelamin pria) yangdilakukan di PAI Building 898/1 Sukhumvit 55, KiongtonNua, Wattana Bangkok10110, Thailand, Tel: +66 (0) 2715011112, +66 (0) 27121111, +66 (0) 27150113, email: consult@pai.co.th;Menimbang, bahwa metoidioplasty (phalloplasty) direkomendasikanuntuk

THT Set (Ent Surgery Set) 1 set 193.881.600 193.881.6005. Cataract Set 1 set 184.965.800 184.965.8006. Tonsillectomy Set 1 set 100.599.700 100.599.700Ts Basic Orthopaedic Set 1 set 508.720.100 508.720.1008. UV Room Sterillizer 4 unit 30.396.500 121.586.0009. Dental Unit 1 unit 221.608.400 221.608.40010. Meja Operasi 2 unit 977.534.700 1.955.069.40011. Pap Smear Test 1 set 18.271.700 18.271.70012. Meatotomy Set 1 set 314.014.000 314.014.00013.

Basic Eye Surgery Set 1 unit 176.410.500 176.410.500Total 9.595.000.000 e Bahwa tender/pelelangan Pengadaan AlatAlat KesehatanRumah Sakit tersebut diikuti oleh 12 (dua belas)perusahaan yang memasukkan dokumen penawaran, yakniPT. RAITI BROTHERS, PT. JAVERA TOBIAS, PT.DIMAS INTI MEDILAB, CV. SURYA INDAHPERKASA, PT. BINTANG HOE, PT. PUSAKA AMSALFARMA, CV. TUNAS AGUNG, PT. PANTE BIDADARI,CV. FAHYUSMA SAKTI, PT. KESUKA FARMA, PT.MEDICAL BANDAR DUA, dan PT.

THT Set (Ent Surgery Set) 1 set 193.881.600 193.881.6005. Cataract Set 1 set 184.965.800 184.965.8006. Tonsillectomy Set 1 set 100.599.700 100.599.7007. Basic Orthopaedic Set 1 set 508.720.100 508.720.1008. UV Room Sterillizer 4 unit 30.396.500 121.586.0009. Dental Unit 1 unit 221.608.400 221.608.40010. Meja Operasi 2 unit 977.534.700 1.955.069.40011. Pap Smear Test 1 set 18.271.700 18.271.70012. Meatotomy Set 1 set 314.014.000 314.014.00013.

Basic Eye Surgery Set 1 unit 176.410.500 176.410.500Total 9.595.000.000 Bahwa tender/pelelangan Pengadaan AlatAlat KesehatanRumah Sakit tersebut diikuti oleh 12 (dua belas)perusahaan yang memasukkan dokumen penawaran, yakniPT. RAITI BROTHERS, PT. JAVERA TOBIAS, PT.DIMAS INTI MEDILAB, CV. SURYA INDAHPERKASA, PT. BINTANG HOE, PT. PUSAKA AMSALFARMA, CV. TUNAS AGUNG, PT. PANTE BIDADARI,CV. FAHYUSMA SAKTI, PT. KESUKA FARMA, PT.Hal 49 dari 223 Hal. Put.

THT Set (Ent Surgery Set) 1 set 193.881.600 193.881.6005. Cataract Set 1 set 184.965.800 184.965.8006. Tonsillectomy Set 1 set 100.599.700 100.599.700ds Basic Orthopaedic Set 1 set 508.720.100 508.720.1008. UV Room Sterillizer 4 unit 30.396.500 121.586.0009. Dental Unit 1 unit 221.608.400 221.608.40010. Meja Operasi 2 unit 977.534.700 1.955.069.40011. Pap Smear Test 1 set 18.271.700 18.271.70012. Meatotomy Set 1 set 314.014.000 314.014.00013.

Elektro Surgery. Meja Operasi. Alat Operasi Bedah Mulut567. Lampu Operasi89.

Bor Orthopedi / electric Power System ForOrthopaedic Large Bone Surgery;192k. Anasthesi Machine 2 Flowmeter with 1 Vaporizer,Mounting and Integrated Ventilator the future ofAnasthesia Machine;.

DINAR RAYA MEGAH pernah terdapat kerusakan terhadap234barang atau item suction pump bagian dari suction surgery tetapi pada saat initelah mendapatkan perbaikan dari PT.

Suction Surgery..

Suction surgery kepada PT.CIMEKAR14. Operating Table Electric kepada PT.SANI15.

Basic Surgery Set AS lGennany 1 SetPT. MEGAH / Circumcisation Instrument Set AS lGennany 1 Set1 PERKASA8. Drainage Section Pump Uzumcu Turkey 2 Unit9. Elektro Surgical Ubit for OR Uzumcu Turkey 1 Unit10. Haemorroid Instrument Set ns ieee 1 Set41. Intubation Kit AS omen 4 Set12.Laparotomy Instrument Set AS lGennany 1 Set13. Large Suture Set AS lGennany 1 Set14. Mayyo Trolley for OR Uzumcu Turkey 3 unit15. Mayor Surgery Instrument Set AS lGennany 1 Set Hal. 9 dari 120 hal. Put.

1 Set 56,522,405 56,522,405Instrument Setgo Miner Surgery 2 Set 69,238,548 138,477,097Instrument Set Hal. 12 dari 120 hal.

Mayor Surgery Instrument Set Be Mearzintechnik 1 Setermany16. Minor Surgery Instrument Set AS Medizinectnik 2 Set/ Germany17. Operating Lamp CombinationCeilling Surgical Camera & Uzumcu Turkey 1 unitMonitoring System18. Operating Table Electric Uzumcu Turkey 1 unit19. Resucitation Bag For Adult Uzumcu Turkey 2 Set20. Resucitation Bag For Child Uzumcu Turkey 1 Set21. Resucitation Bag For Infant Uzumcu Turkey 1 Set22. Surgical Sunction Pump Uzumcu Turkey 2 UnitAS Medizintechnik23.

Mayor Surgery Instrument Set AS Modizintachnik 1 Set/ Germany16. Minor Surgery Instrument Set AS Menizinechnik 2 Set/ Germany17. Operating Lamp CombinationCeilling Surgical Camera & Uzumcu Turkey 1 unitMonitoring System18. Operating Table Electric Uzumcu Turkey 1 unit19. Resucitation Bag For Adult Uzumcu Turkey 2 Set20. Resucitation Bag For Child Uzumcu Turkey 1 Set21. Resucitation Bag For Infant Uzumcu Turkey 1 Set22. Surgical Sunction Pump Uzumcu Turkey 2 Unit23.

Mayor Surgery Instrument Set AS ic 1 Setermany16. Minor Surgery Instrument Set Be Mearzintechnik 2 Setermany17. Operating Lamp CombinationCeilling Surgical Camera & Uzumcu Turkey 1 unitMonitoring System18. Operating Table Electric Uzumcu Turkey 1 unit19. Resucitation Bag For Adult Uzumcu Turkey 2 Set20. Resucitation Bag For Child Uzumcu Turkey 1 Set21. Resucitation Bag For Infant Uzumcu Turkey 1 Set22. Surgical Sunction Pump Uzumcu Turkey 2 Unit23.

Major Surgery Instrument 2 set 90.938.000 181.876.000Set12. Minor Surgery Instrument 2 set 70.087.667 140.135.333Set13. Appendectomy Instrument 2 set 136.199.000 272.398.000set14. Haemorroid Intrument set 2 set 108.759.667 217.519.33315. Brush Disp. Small Comp 2 set 12.959.667 25.919.33316. Aseptic Hand Brus, 1 Box 2 bok 1.665.000 3.330.000@ 10 Pcs17.

Schmidt Biomed Tech Indonesia untuk AlatAnesthesia Machine + Ventilator Machine, sedangkan faktur Pembelian dari PT.Megah Alkesindo adalah untuk alat Bandage Instrument Set, Major SurgeryInstrument Set, Minor Surgery Instrument Set, Appedectomy Instrumen Set,Haemorrid Instrument Set, Brush Disp Small comp dan Aseptic Hand Brush danfaktur pembelian dari kKedua perusahaan tersebut mencantumkan harga pembeliandalam satuan mata uang euro yang kemudian dikonversikan ke mata uang rupiahdengan menggunakan

Major Surgery 2 set 90.938.000 181.876.000Instrument Set12. Minor Surgery 2 set 70.087.667 140.135.3338Instrument Set13. Appendectomy 2 set 136.199.000 272.398.000Instrument set14. Haemorroid Intrument 2 set 108.759.667 217.519.333set15. Brush Disp. Small 2 set 12.959.667 25.919.333Comp16. Aseptic Hand Brus, 1 2 bok 1.665.000 3.330.000Box @ 10 Pcs17.

Adityakarya Perdana UtamaMedica dalam dokumen penawarannya memberikan atau melampirkan izinedaryang sudah tidak berlaku (Kadaluarsa), untuk Alat Anesthesia Machine + VentilatorMachine sedangkan untuk Bandage Instrument Set, Major Surgery Instrument Set,Minor Surgery Intrument Set, Appedectomy Instrument set, Brush Disp Small Comp,dan Aseptic Hand Brush tidakada Izin Edarnya Sama Sekali, namun oleh paraTerdakwa PT.

Megah Alkesindoadalah untuk alat Bandage Instrument Set, Major Surgery Instrument Set, MinorSurgery Instrument Set, Appedectomy Instrumen Set, Haemorrid Instrument Set, BrushDisp Small comp dan Aseptic Hand Brush dan faktur pembelian dari kedua perusahaantersebut mencantumkan harga pembelian dalam satuan mata uang euro yangkemudian dikonversikan ke mata uang rupiah dengan menggunakan kurs tengah BankIndonesia pertanggal Transaksi pembelian;Menimbang, bahwa Penuntut Umum telah mengajukan tuntutan

Alfa Sarana Belum ada ijin2 Vaporizer; MakmurMinor Surgery Set: PT. Alfa Sarana AKL 11603111626. Makmur tanggal 26 Juli 2011 Hal. 6 dari 56 hal. Putusan No. 1021 K/PID.SUS/2016 6 Autoclave single door manual 365 PT. Alfa Sarana Belum ada ijin liter; Makmur7 Bedside cabinet; PT. Alfa Sarana Belum ada ijinMakmurMoleculer resonance generator; PT. Sarana Medica Kemenkes RI AKL8. Optindo 2160390 tanggal 22Mei 2010Digital Radiography PT. Surya Jaya AKL 215012123799.

Minor surgery Sel, Algeier Germany /1 unit 10.000.000Various6. Autoclave single door manual 365 Ortosintese Brazil/liter; 1 unit 797.272.500AC3657. Bedside cabinet, ASM Indonesia/1 unit 4.681.800ASM0128. Moleculer resonance generator; TELEA Italy/1 unit 294.090.900Quantum9. Digital Radiography ASS. In SiemensChina ULS AGGermany/ Multy 1 unit 2.468.181.800Selec DR IncludeDry Printer10. USG 2D Ass.

Minor Surgery Set: PT. Alfa Sarana AKL 11603111626Makmur tanggal 26 Juli 2011 Hal. 15 dari 56 hal. Putusan No. 1021 K/PID.SUS/2016 6. Autoclave single door manual PT. Alfa Sarana Belum ada ijin365 liter; Makmur7. Bedside cabinet; PT. Alfa Sarana Belum ada ijinMakmur8. Moleculer resonance PT. Sarana Medica Kemenkes RI AKLgenerator; Optindo 2160390 tanggal 22Mei 20109. Digital Radiography PT. Surya Jaya AKL 21501212379Lestari tanggal 27 Juli 201210. USG 2D PT.

Minor surgery Sel, Algeier Germany /1 unit 10.000.000Various6. Autoclave single door manual 365 Ortosintese Brazil/liter; 1 unit 797.272.500AC3657. Bedside cabinet; ASM Indonesia/1 unit 4.681.800ASM0128. Moleculer resonance generator; TELEA Italy/1 unit 294.090.900Quantum9. Digital Radiography ASS. In SiemensChina ULS AGGermany/ Multy 1 unit 2.468.181.800Selec DR Include DryPrinter10. USG 2D Ass.

Minor Surgery Sek; Algeier Germany / Various 1 unit4. Bedside cabinet; ASM Indonesia/ ASM012 1 unit5. Moleculer resonance geberator; TELEA Italy/ Quantum 1 unit6. Digital Radiography ASS. In Siemens China ULSAG Germany/ Multy Selec DR 1 unitInclude Dry Printer7. USG 2D Ass. In Siemens Korea ULSMedical Solution USA, Inc/ 1 unitAccuson V150Sedangkan 3 (tiga) item barang yang belum diterima adalah sebagai berikut: ; Volume/No. Jenis Barang Merek / Type Satuan1.

tr>

11

Diagnostic Radiographic & Floroscope TV-X-Ray System

Merk: Hyunday

Model: HD 5125-AD

1

PERALATAN THT

12

THT SET ( Ent Surgery

MerkLeica Swistswerland .model : M 620 F 20. anit7. 1.690.310.000, 1.690.310.000,THT SET (ENT SURGERY Halaman 13 Putusan No.5/Pid.SusTPK/2016/PT.JMB 10.11.12.13.14.

Keke Indah Abadi memberitahu PT SindangMuda Serasan untuk pembayaran uang muka.Adapun 14 (empat belas) Jenis alat kesehatan tersebut, yaitu : NO NAMA ALAT MERK/TYPE HARGA / UNIT UNIT JUMLAH HARGA1 ANASTHESI MACHINE HERSILL SPAIN / REGINA 510,000,000 UNIT 2,550,000,000g SERUB STATION:2 POLYJAYA INDONESIA / POLY 076 114,863,400 UNIT 229,726,8003 DENTALUNIT ANDINI INDONESIA / SOLUSI 72,000,000 UNIT 144,000,0004 ELECTRO CAUTER ECLERIS ARGENTINA / HF 400 132,000,000 UNIT 528,000,0005 MINOR SURGERY SET

L 253319.Surat tanda pengiriman barang Minor Surgery Set dari PT.Sindang Muda Serasan ke RSUD Raden Mattaher.Packing List Minor Surgery Set.1 (satu) kartu garansi Foto Fundus Camera serial number321022.COO Ophthalmic Instruments.Foto Fundus Camera.Manual book Foto Fundus Camera.Halaman 43 Putusan No.5/Pid.SusTPK/2016/PT.JMB71.72.73.74.75.76.77.78.79.80.81.82.83.84.85.86.87.88.89.90.91.92.93.94.95.1 (satu) kartu garansi Operating Microscope Floor Stand ForOphthalmology.COO Leica M620 F20 Surgical

L 253319.Surat tanda pengiriman barang Minor Surgery Set dari PT.Sindang Muda Serasan ke RSUD Raden Mattaher.Packing List Minor Surgery Set.1 (Satu) kartu garansi Foto Fundus Camera serial number321022.COO Ophthalmic Instruments.Foto Fundus Camera.Manual book Foto Fundus Camera.1 (satu) kartu garansi Operating Microscope Floor Stand ForOphthalmology.Halaman 68 Putusan No.5/Pid.SusTPK/2016/PT.JMB72.73.74.75.76.V7.78.79.80.81.82.83.84.85.86.87.88.89.90.91.92.93.94.95.96.97.COO Leica M620 F20 Surgical

L 253319.Surat tanda pengiriman barang Minor Surgery Set dari PT.Sindang Muda Serasan ke RSUD Raden Mattaher.Packing List Minor Surgery Set.Halaman 100 Putusan No.5/Pid.SusTPK/2016/PT.JMB68.69.70.71.72.73.74.75.76.V7.78.79.80.81.82.83.84.85.86.87.88.89.90.91.92.1 (satu) kartu garansi Foto Fundus Camera serial number321022.COO Ophthalmic Instruments.Foto Fundus Camera.Manual book Foto Fundus Camera.1 (satu) kartu garansi Operating Microscope Floor Stand ForOphthalmology.COO Leica M620 F20 Surgical

.= Bahwa sesuai dengan kontrak Nomor : 027/2991/RSUCM/APBN/2012tanggal 23 Juli 2012 barang yang harus diadakan adalah :e 1 (satu) unit CTscan 16 Slices dengan harga Rp. 6.818.000.000,e 1 (satu) unit Denthal Panoramic dengan harga Rp. 1.558.400.000,e 1 (satu) unit Mobile Xray dengan harga Rp. 550.310.000,1 (satu) set High Power Diode Laser System for Surgery denganharga Rp. 2.824.600.000,1 (satu) set Laparoscopy Set dengan harga Rp. 1.655.800.000,1 (satu) unit Elektro Surgical Unit (ESU) dengan hargaRp

. 142.930.000,2 (dua) unit Operating Table dengan harga Rp. 1.275.452.000,1 (satu) set Operating Lamp LED + Camera CCTV dengan hargaRp. 779.200.000,1 (Satu) set Mayor Surgery Set dengan harga Rp. 68.215.000,e 1 (satu) set Orthopedic Set dengan harga Rp. 141.000.000,e 7 (tujuh) unit Brancard dorong dengan harga Rp. 102.270.000.e 1 (satu) unit Operating Microscope dengan harga Rp.740.240.000,e 2 (dua) set peralatan Neonatal dan Maternal dengan hargaRp. 1.654.860.000,1 (satu) set Central Patient Monitor

Mayor Surgery Set:e 1(satu) buah Haberer Reter45x300 mm Merk SHMGermany;e 1(satu) buah Myrtle Leaf Probe 14,5 cm Merk SHMGernay;e 2(dua) buah Bak Instrument Besar Uk 538x32x10 cm MerkMagnate Thailand;90.

Mayor Surgery Set:1(satu) buah Haberer Reter45x300 mm Merk SHMGermany;1(satu) buah Myrtle Leaf Probe 14,5 cm Merk SHMGernay;2(dua) buah Bak Instrument Besar Uk 53x32x10 cm MerkMagnate Thailand;90.

Mayor Surgery Set:e 1(satu) buah Haberer Reter45x300 mm Merk SHMGermany;e 1(satu) buah Myrtle Leaf Probe 14,5 cm Merk SHMGermany;e 2(dua) buah Bak Instrument Besar Uk 53x32x10 cm Merk MagnateThailand;90.

PERALATAN IGD1 Ultrasonic Nebulizer 4 unit2 Minor Sugery Set 4 set3 Lampu Operasi Mobile 2 unit4 Vena Section Set 2 set5 Pulse Oxymeter 2 unit6 Defibrilator 1 unit7 Orthopedic Surgery Set 1 set8 Basic Pediatric Set 1 set9 Amputation Set 1 set10 Basic Urologi Surgery Set 1 set11 Mayor Obgyn Surgery Set 1 set12 Mayor Surgery Set 1 set13 Suction Pump Mobile 2 unit14 Bedside Monitor 2 unit15 Basic Head & Neck Surgery Set 1 set16 Autoclave 1 unit17 Electrocauter 1 unit18 Meja Operasi 1 unit19 Lampu Operasi

Pembelian tersebut kemudian dibayar oleh PTMesarinda Abadi kepada PT Petan Daya Medica sesuai kuitansinomor 165/2012 tanggal 7 Desember 2012.Cataract Set merk Pricisemed tipe Various, Minor Surgery Setuntuk Mata merk Pricisemed tipe Various, dan Trial Lens merkShin Nippon tipe CP30 masingmasing sebanyak 1 (satu) setdipesan oleh PT Petan Daya Medica kepada PT Citra MedicaIndonesia pada tanggal 24 September 2012 dengan nomor PO164/2012DA.

Table Unit 754.170.000,0 754.170.000,2 Operating Lamp Unit 635.505.000,0 635.505.000,Ceiling System 0 003 ICU Bed Hospital Unit 46.516.500,00 279.099.000,004 Patient Monitor 5 Unit 171.390.000,0 1.028.340.00Parameter 0 0,005 Ventilator for Adult & Unit 610.568.000,0 1.831.704.00Pediatric 0 0,006 Syringe Pump Unit 39.948.200,00 39.948.200,007 Infusion Pump Unit 51.958.700,00 51.958.700,008 Cataract Set Set 77.027.800,00 77.027.800,009 Operating Unit 18.609.300,00 18.609.300,0Microscope 010 Minor Surgery

Satuan (Rp) (Rp)n, dan KB 1 Syringe Medima/ 1 Unit 15.590.909,0 15.590.909,09Pump $1 9 2 Infusion Medima/S 1 Unit 20.268.181,8 20.268.181,82Pump 1 2 Total 35.859.090,91 Diskon Total Harga Setelah Diskon 35.859.090,91 PPN 3.585.909,09 Harga Pembelian (Pembulatan) 39.445.000,00 (6) Pembelian Alat Kesehatan/Kedokteran/KB berupa 1 (satu) setCataract Set, 1 (satu) set Minor Surgery Set untuk Mata, 1 (satu)set Trial Lens, dan 1 (satu) set Automatic Chart Projector sesuaiFaktur Penjualan Nomor 24/CMI/XII

Djoelham Binjai6. 1 (satu) Unit Operating Table7. 1 (satu) Unit Lampu Operasi8. 6 (enam) Unit ICU Bed Hospital9. 6 (enam) Unit Patient Monitor 5 parameter10. 3 (tiga) Unit Ventilator for adult& pediatric11. 1 (satu) Unit Siringe PumpHalaman 66 dari 111 Halaman Putusan Nomor 26/Pid.SusTPK/2018/PT MDN12.13.14.15.16.17.18.19,20.21.22.23.24.25.26.27.28.29.30.31.32.33.34.35.36.37.38.39.40.1 (satu) Unit Infusion Pump1 (satu) Set Catarac set1 (satu) Unit Operating Microscope1 (satu) Set Minor surgery set

Elektro Surgery. Meja Operasi. Alat Operasi Bedah Mulut567. Lampu Operasi89.

Bor Orthopedi / electric Power System ForOrthopaedic Large Bone Surgery;193k. Anasthesi Machine 2 Flowmeter with 1 Vaporizer,Mounting and Integrated Ventilator the future ofAnasthesia Machine;.

DINAR RAYA MEGAH pernah terdapat kerusakan terhadapbarang atau item suction pump bagian dari suction surgery tetapi pada saat initelah mendapatkan perbaikan dari PT.

Suction surgery kepada PT.CIMEKAR14. Operating Table Electric kepada PT.SANI15.

Suction Surgery.9. Set alat Orthopedi.10.USG 3 D.11.Operating Lamp Multicolor C.12.Bor Orthopedi / electric Power System For Orthopaedic LargeBone Surgery.13.lmunology Analysis.43814.

harus diadakan oleh penyedia adalah :e 1 (satu) unit CT scan 16 Slices Rp6.818.000.000,00e 1 (satu) unit denthal panoramic Rp1.558.400.000,00e 1 (satu) unit mobile Xray Rp550.310.000,00e 1 (satu) set High power diode laser system forsurgery Rp2.824.600.000,00e 1 (satu) set Laparoscopy set Rp1.655.800.000,00e 1 (satu) unit Elektro Surgical Unit (ESU) Rp142.930.000,00e 2 (dua) unit Operating Table Rp1.275.452.000,00e 1 (satu) set Operating Lamp LED + camera CCTV Rp779.200.000,00e 1 (satu) set Mayor Surgery

BETA MEDICALyaitu:e 1 (satu) unit CT scan 16 Slicese 1 (satu) unit denthal panoramice 1 (satu) unit mobile Xraye 1 (satu) set High Power Diode Laser System For Surgerye 1 (satu) unit Elektro Surgical Unit (ESU)e 2 (dua) unit Operating Tablee 1 (satu) set Operating Lamp LED + camera CCTVe 1 (satu) set Mayor Surgery sete 1 (satu) set Orthopedic sete 7 (tujuh) unit Brancard doronge 1 (satu) unit Operating Microscopee 2 (dua) set peralatan Neonatal dan maternale 1 (Satu) set Central Patient Monitor with

Set.Peralatan Neonatal yaitu:= 2 unit incubator baby merek Olidef type SCTI Line 4 V1,= 2 unit CPAP With Compresor merek MedinGermany typeEASY Blinder.Peralatan Maternal yaitu := 2 unit Vacuum listrik 20It (2 Jar Lt.2) merek AlsaItaly typeCortex 200/20Lt (2 Jar. 2 Lt),= 2 set Sectio Causarean Instrumen Set merek SHMGermanytype Various,e 1 set Accessories Dental Panoramic : Film Kodak Lasermerek Kodak.Pada saat diperiksa oleh panitia penerima hasil pekerjaan, ada beberapa item barangberupa item Mayor Surgery

BETA MEDICALyaitu:e 1 (Satu) unit CT scan 16 Slicese 1 (satu) unit denthal panoramice 1 (satu) unit mobile Xraye 1 (satu) set High power diode laser system for surgerye 1 (satu) unit Elektro Surgical Unit (ESU)e 2 (dua) unit Operating Tablee 1 (satu) set Operating Lamp LED + Camera CCTV 1 (satu) set Mayor Surgery sete 1 (satu) set Orthopedic sete 7 (tujuh) unit Brancard doronge 1 (satu) unit Operating Microscopee 2 (dua) set peralatan Neonatal dan maternale 1 (Satu) set Central Patient Monitor with

BETA MEDICALyaitu:1 (satu) unit CT scan 16 Slices1 (satu) unit denthal panoramice 1 (satu) unit mobile Xraye 1 (satu) set High power diode laser system for surgerye 1 (satu) unit Elektro Surgical Unit (ESU)e 2 (dua) unit Operating Tablee 1 (satu) set Operating Lamp LED + camera CCTVe 1 (satu) set Mayor Surgery sete 1 (satu) set Orthopedic sete 7 (tujuh) unit Brancard doronge 1 (satu) unit Operating Microscopee 2 (dua) set peralatan Neonatal dan maternale 1 (Satu) set Central Patient Monitor with

NAMA ALAT VOLUME HARGA SATUAN TOTAL HARGAPeralatan KamarOperasi1 Operating table 3 Unit 1.651.500.000, 4.954.500.000,00002 Operating lamp 1 Unit 399.920.000,00 399.920.000,00ceiling3 Mesin Anasthesi +1 5 Unit 1.204.100.000, 6.020.500.000,00Ventilator 004 Electrocauter 4 Unit 279.360.000,00 1.117.440.000,005 Minor Surgery Set 7 Set 56.581.000,00 396.067.000,00Peralatan Mata1 Foto Fundus Carrera 1 Unit 1,560.000.000, 1,560.000.000,00002 Operating 1 Unit 3.555.980.000, 3.555.980.000,00Microscope Floor

L 253319.Surat tanda pengiriman barang Minor Surgery Set dari PT.Sindang Muda Serasan ke RSUD Raden Mattaher.Packing List Minor Surgery Set.1 (satu) kartu garansi Foto Fundus Camera serial number321022.COO Ophthalmic Instruments.Foto Fundus Camera.Manual book Foto Fundus Camera.1 (satu) Kartu garansi Operating Microscope Floor Stand ForOphthalmology.COO Leica M620 F20 Surgical Microscope And Accessories SO13510314 2 Sets.Foto Operating Microscope Floor Stand For Ophthalmology.Manual Book Operating

Nomor 16 dan 20 Satu COO 11Diagnostic Radiographic &Floroscope TVXRay SystemMerk: HyundayModel: HD 5125AD PERALATAN THT 12THT SET ( Ent Surgery Set)Merk: LawtonModel: LO120014Negara: Germany PERALATAN ICUICCU 13Ventilator With CompressorMerk: NewportModel: E 360 w/CompressorNegara: USA 14 ICUICCU Bed Elektric Type PlasticPanel + MattresMerk: SKNModel: SKN 00114ce24 Halaman 88Putusan No.5/Pid.SusTPK/2016/PT.

L 253319.Surat tanda pengiriman barang Minor Surgery Set dari PT.Sindang Muda Serasan ke RSUD Raden Mattaher.Packing List Minor Surgery Set.1 (satu) kartu garansi Foto Fundus Camera serial number321022.COO Ophthalmic Instruments.Foto Fundus Camera.Manual book Foto Fundus Camera.1 (satu) kartu garansi Operating Microscope Floor Stand ForOphthalmology.COO Leica M620 F20 Surgical Microscope And Accessories SO13510314 2 Sets.Foto Operating Microscope Floor Stand For Ophthalmology.Manual Book Operating

THT Set (Ent Surgery Set) 1 set 193.881.600 193.881.6005. Cataract Set 1 set 184.965.800 184.965.8006. Tonsillectomy Set 1 set 100.599.700 100.599.700Ts Basic Orthopaedic Set 1 set 508.720.100 508.720.1008. UV Room Sterillizer 4 unit 30.396.500 121.586.0009. Dental Unit 1 unit 221.608.400 221.608.40010. Meja Operasi 2 unit 977.534.700 1.955.069.40011. Pap Smear Test 1 set 18.271.700 18.271.70012. Meatotomy Set 1 set 314.014.000 314.014.00013.

Basic Eye Surgery Set 1 unit 176.410.500 176.410.500Total 9.595.000.000 Bahwa tender/pelelangan Pengadaan AlatAlat KesehatanRumah Sakit tersebut diikuti oleh 12 (dua belas)perusahaan yang memasukkan dokumen penawaran, yakniPT. Raiti Brothers, PT. Javera Tobias, PT. Dimas IntiMedilab, CV. Surya Indah Perkasa, PT. Bintang Hoe, PT.Pusaka Amsal Farma, CV. Tunas Agung, PT. PanteBidadari, CV. Fahyusma Sakti, PT. Kesuka Farma, PT.Medical Bandar Dua, dan PT.

QTY DESCRIPTION UNIT PRICE AMOUNT1. 2 Unit LAMPU OPERASI Rp.167.072.345, Rp.Merk : SKYLUXJAPAN 4+ 334.144.690,MINDRAYCHINA Model: 14 + 600 Ds 1 Set THT SET (ENT SURGERY SET) Rp.82.657.315, Rp.Merk : LAWTONGERMANY 82.657.315,Model : LO1C20014 Hal 49 dari 223 Hal. Put. No. 15/Pid.Sus/2012/P.TipikorBNA50 3, 1 Set CATARACT SET Rp. Rp.Merk : LAWTONGERMANY 78.856.243, 78.856.243,Model : LO1CR01024. 1 Set TONSILLECTOMY SET Rp.

THT Set (Ent Surgery Set) 1 set 193.881.600 193.881.6005. Cataract Set 1 set 184.965.800 184.965.8006. Tonsillectomy Set 1 set 100.599.700 100.599.7007. Basic Orthopaedic Set 1 set 508.720.100 508.720.1008. UV Room Sterillizer 4 unit 30.396.500 121.586.0009. Dental Unit 1 unit 221.608.400 221.608.40010. Meja Operasi 2 unit 977.534.700 1.955.069.40011. Pap Smear Test 1 set 18.271.700 18.271.70012; Meatotomy Set 1 set 314.014.000 314.014.00013.

Mayor Surgery Instrument Set AS: Mediziniechnile 1 Set/ Germany16. Minor Surgery Instrument Set PSs Mescizinitescriiks 2 Set/ Germany17. Operating Lamp CombinationCeilling Surgical Camera & Uzumcu Turkey 1 unitMonitoring System18. Operating Table Electric Uzumcu Turkey 1 unit19. Resucitation Bag For Adult Uzumcu Turkey 2 Set20. Resucitation Bag For Child Uzumcu Turkey 1 Set21. Resucitation Bag For Infant Uzumcu Turkey 1 Set22. Surgical Sunction Pump Uzumcu Turkey 2 Unit23.

Mayor Surgery Instrument Set AS Medizinwsetinits 1 Set/ Germany16. Minor Surgery Instrument Set AS Maaizinteeials 2 Set/ Germany17. Operating Lamp CombinationCeilling Surgical Camera & Uzumcu Turkey 1 unitMonitoring System18. Operating Table Electric Uzumcu Turkey 1 unit19. Resucitation Bag For Adult Uzumcu Turkey 2 Set20. Resucitation Bag For Child Uzumcu Turkey 1 Set21. Resucitation Bag For Infant Uzumcu Turkey 1 Set22. Surgical Sunction Pump Uzumcu Turkey 2 Unit23.

Basic Surgery Set AS Mecizinieetinils 1 Set/ Germany7. Circumcisation Instrument Set AS Mecizinieehniks 1 Set/ GermanyPT. MEGAH 8. Drainage Section Pump Uzumcu Turkey 2 UnitPERKASA 9. Elektro Surgical Ubit for OR Uzumcu Turkey 1 UnitAS Medizintechnik10. Haemorroid Instrument Set / Germany 1 Set11. Intubation Kit AS! Medlizintechnik 1 Set/ Germany12.Laparotomy Instrument Set AS Medizineehnils 1 Set/ Germany13. Large Suture Set AS Mecizinieetinils 1 Set/ Germany14.

Mayor Surgery Instrument Set AS Mecizinieetinils 1 Set/ Germany16. Minor Surgery Instrument Set AS Mecizinieetinils 2 Set/ Germany17. Operating Lamp Combination Uzumcu Turkey 1 unit Putusan Perkara No. 06/Pid.SusTPK/2015/PN.Pgp Hal. 67 dari hal 176Ceilling Surgical Camera &Monitoring System 18. Operating Table Electric Uzumcu Turkey 1 unit19. Resucitation Bag For Adult Uzumcu Turkey 2 Set20. Resucitation Bag For Child Uzumcu Turkey 1 Set21. Resucitation Bag For Infant Uzumcu Turkey 1 Set22.

Mayor Surgery Instrument Set AS: Medizintedhinite 1 Set/ Germany16. Minor Surgery Instrument Set Ass Medizintescnnik 2 Set/ Germany17. Operating Lamp CombinationCeilling Surgical Camera & Uzumcu Turkey 1 unitMonitoring System18. Operating Table Electric Uzumcu Turkey 1 unit19. Resucitation Bag For Adult Uzumcu Turkey 2 Set20. Resucitation Bag For Child Uzumcu Turkey 1 Set21. Resucitation Bag For Infant Uzumcu Turkey 1 Set22. Surgical Sunction Pump Uzumcu Turkey 2 UnitAS Medizintechnik23.

Akibat luka tersebut maka dilakukan operasi eksplorasi rongga perut dan hasilOperasi ditemukan cairan merah segar dan stolsel (bekuan darah) bercampur feses(kotoran) dan terlihnat beberapa usus halus bocor (multiple ileum perforasi) pada 150sentimeter, 160 sentimeter, 170 sentimeter dan 190 sentimeter dari LigamentumTreitz, berdiameter sekitar 23 cm, AAST (American Association for The Surgery ofTrauma) derajat IllIV ; yaitu Kebocoran usus halus sedangberat, dimana usus sampaiterbelah.

Poliklinik Mata Minor Surgery Instrument Set 1 Unit 2 UnitInstrumentTrolleyk. Poliklinik Jiwa Examination Lamp 1 Unit Suction 1 UnitPump 1 UnitDiagnostic SetIl. EMERGENCY (UGD)a. Resusitasi Suction Pump 1 Unit 1 UnitDiagnosticSetHal 7 dari 109 halaman putusan perkara No.01/PID.SUS.TPK/2018/PT.MKS., ECG 1 Unit 3 UnitEmergency Trolley Bedside 3 UnitMonitor 1 UnitDefibrilator Ventilator 1 Unitb.

Poliklinik Mata Minor Surgery Instrument Set 1 Unit 2 UnitInstrumentTrolleyk. Poliklinik Jiwa Examination Lamp 1 Unit Suction 1 UnitPump 1 UnitDiagnostic SetEMERGENCY (UGD)a. Resusitasi Suction Pump 1 Unit 1 UnitDiagnosticSetECG 1 Unit 3 UnitEmergencyTrolley 3 UnitBedsideMonitor 1 UnitDefibrilator 1 UnitVentilatorHal 36 dari 109 halaman putusan perkara No.01/PID.SUS.TPK/2018/PT.MKS.,b.

Poliklinik Mata Minor Surgery Instrument Set 1 Unit 2 UnitInstrumentTrolleyHal 62 dari 109 halaman putusan perkara No.01/PID.SUS.TPK/2018/PT.MKS.,k. Poliklinik Jiwa Examination Lamp 1 Unit 1 UnitSuctionPump 1 UnitDiagnostic SetEMERGENCY (UGD)a. Resusitasi Suction Pump 1 Unit 1 UnitDiagnosticSetECG 1 Unit 3 UnitEmergency Trolley Bedside 3 UnitMonitor 1 UnitDefibrilato' Ventilator 1 Unitb.

Poliklinik Bedah / Surgical Policlinic Diagnostic Set 2 Unit Minor Surgery Instrument Set 3 UnitHal 84 dari 109 halaman putusan perkara No.01/PID.SUS.TPK/2018/PT.MKS.,Instrument Trolley 1 Unit Infusion Pump 1 Unit Electro Cauter Treatment 300 watt 2 Unit UV Room Sterilizator 2 Unitb. Poliklinik Penyakit DalamECG 2 Unit Examination Lamp 1 Unit Instrument Trolley 2 Unit Nebulyzer 1 Unit Suction Pump 1 Unit Diagnostic Set 1 Unitc.

Poliklinik Mata Minor Surgery Instrument Set 1 Unit 2 UnitInstrumentTrolleyk. Poliklinik Jiwa Examination Lamp 1 Unit 1 UnitSuctionHal 85 dari 109 halaman putusan perkara No.01/PID.SUS.TPK/2018/PT.MKS.,Pump 1 UnitDiagnostic SetIl. EMERGENCY (UGD)a. Resusitasi Suction Pump 1 Unit 1 UnitDiagnosticSet ECG 1 Unit 3 UnitEmergency Trolley Bedside 3 UnitMonitor 1 UnitDefibrilato' 1 UnitVentilatorb.