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  • Cash Disbursment Voucher: Cirebon

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    Sundari Mahendra
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    This document is a cash disbursement voucher from a hospital to an insurance company for a medical claim. It details a payment of 3,522,101 Indonesian Rupiah to PT. Mensa Binasures for an inpatient claim for a patient named Riasih. The claim number is C/03/11008009 from March 17, 2011. The payment includes costs for a specialist doctor visit, room and board per day, daily doctor visits, and various hospital treatment expenses. The total submitted amount of 3,522,101 Rupiah was approved with no amounts rejected or in excess.

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    This document is a cash disbursement voucher from a hospital to an insurance company for a medical claim. It details a payment of 3,522,101 Indonesian Rupiah to PT. Mensa Binasures for an inpatient claim for a patient named Riasih. The claim number is C/03/11008009 from March 17, 2011. The payment includes costs for a specialist doctor visit, room and board per day, daily doctor visits, and various hospital treatment expenses. The total submitted amount of 3,522,101 Rupiah was approved with no amounts rejected or in excess.

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    7 views2 pages

    Cash Disbursment Voucher: Cirebon

    Uploaded by

    Sundari Mahendra
    This document is a cash disbursement voucher from a hospital to an insurance company for a medical claim. It details a payment of 3,522,101 Indonesian Rupiah to PT. Mensa Binasures for an inpatient claim for a patient named Riasih. The claim number is C/03/11008009 from March 17, 2011. The payment includes costs for a specialist doctor visit, room and board per day, daily doctor visits, and various hospital treatment expenses. The total submitted amount of 3,522,101 Rupiah was approved with no amounts rejected or in excess.

    Copyright:

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    of 2

    CASH DISBURSMENT VOUCHER

    User CDV Number Cash / Bank Bank Account Chart of Account Bank Account Process Date Payment By Bank Code Cash Cheque BG TO 10207/CDV/KLM/JAHE/3/2011/CDV/K Paid Transfer to Bank Branch PT. SUMBER BAHAGIA SENTOSA Mandiri
    Cirebon

    Voucher Number Accounting Period

    City Currency IDR

    1340004264288

    Acc. Number

    T1

    T2

    T3

    T4

    T5

    Account Name

    Category CLM

    Description Pembayaran klaim MENSA_RINAP atas nama RIASIH dari PT. MENSA BINASUKSES Nomor Claim C/03/11008009 tanggal 03/17/2011

    Org Amount 3,522,101.00

    Total in Words Prepared by Checked by

    # Tiga Juta Lima Ratus Dua Puluh Dua Ribu Seratus Satu Rupiah # 03/27/2011 sinta Ir. M. khoirun, MM, AA Approved by
    Ka. Div Non KBM

    3,522,101.00

    Rate Accepted Excess Eq. IDR


    3,522,101.00 0.00 3,522,101.00

    Perusahaan / Group Masa Kontrak

    : :

    RS Putera Bahagia 01/07/2010 s/d 01/06/2011

    PT. MENSA BINASUKSES -Telp. -- Fax.


    No.
    1

    Nomor Peserta
    421.0.004.O0433B

    Nama Peserta
    RIASIH

    Nomor Klaim
    C/03/11008009

    Nilai Klaim

    Ditolak

    Disetujui
    0.00 0.00 0.00 0.00 100,000.00 280,000.00 255,000.00 2,887,101.00

    Ex Gratia

    Excess
    0.00 0.00 0.00 0.00

    - Kunjungan Dokter Ahli - Kamar dan makan per hari - Kunjungan Dokter per hari - Biaya Aneka Perawatan Rumah Sakit

    100,000.00 280,000.00 255,000.00 2,887,101.00

    3,522,101.00

    0.00

    3,522,101.00

    0.00

    Jumlah diajukan Biaya Materai Pembulatan Jumlah disetujui Jumlah ditolak Jumlah excess

    Rp. Rp. Rp. Rp. Rp. Rp.

    3,522,101.00

    3,522,101.00 0.00 0.00

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