FORMULIR PENGAJUAN KLAIM JAMKESDA

RAWAT JALAN
POLINDES LOBUK
No.

Tanggal

No. Kartu/SPM

Nama Pasien

Jenis
Kelamin

Umur
(Thn)

Alamat

Diagnosa
(Code ICD X)

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26

1/11/2016
1/11/2016
1/11/2016
1/11/2016
1/11/2016
1/11/2016
2/11/2016
2/11/2016
2/11/2016
2/11/2016
2/11/2016
3/11/2016
3/11/2016
3/11/2016
3/11/2016
3/11/2016
3/11/2016
4/11/2016
4/11/2016
4/11/2016
4/11/2016
5/11/2016
5/11/2016
5/11/2016
5/11/2016
5/11/2016

3529054107850204
352905540880002
3529055904770001
3529055304910003
3529051106900004
3529051107950002
3529051108720003
3529055006940003
3529055604650004
3529055004780002
3529052007400001
3529056004950001
3529110107821159
3529055306910002
3529055809690004
3529056305970003
3529055004950001
3529055704820004
3529052104820002
3529056203760001
3529056006830004
3529052508800002
3529050202730007
3529051105730002
3529052212820002
3529056006720002

Maswati
Muslihati
Immiyati
Farida Diana
Moh As'adi
Eko Maruddin
Sumarto
Pipin Andayani
Sujani
Patmasari
Muhayyin
Gusini
Junaidi
Maftuhatul Qarimah
Salehami
Riza Handini
Qurratul Aini
Handana
Moh. Syaiful
Muriyati
Rustiyani
Moh. Khumaini
Suhartono
Moh. Hosri
Fathor Rahem
Manisa

P
P
P
P
L
L
L
P
P
P
L
L
L
P
L
P
P
P
L
P
P
L
L
L
L
P

29
26
37
23
24
19
42
20
49
36
40
19
32
23
45
17
19
32
32
38
31
34
41
41
32
42

Aengnyior
Aengnyior
Tarogan
Aengnyior
Aengnyior
Aengnyior
Tarogan
Lobuk
Kopao
Lobuk
Lobuk
Aengnyior
Kopao
Lobuk
Kopao
Aengnyior
Aengnyior
Lobuk
Tarogan
Aengnyior
Tarogan
Tarogan
Lobuk
Tarogan
Lobuk
Aengnyior

27

7/11/2016

3529051401820004

Rahman

32

Aengnyior Demam (R50)

Demam (R.50)
Gastritis (K 29 )
Gastritis (K 29 )
Batuk (R05)
Nyeri Kepala (R51)
Demam (R50)
Gastritis (K 29 )
Nyeri Kepala (R51)
Batuk (R05)
Demam (R50)
Nyeri Kepala (R51)
Demam (R50)
Demam (R50)
Nyeri Kepala (R51)
Demam (R50)
Demam (R50)
Demam (R50)
Demam (R50)
Rhematoid arhtitis (M06)
Nausea dan vomitus(R11)
Gastritis (K 29 )
Nyeri Kepala (R51)
Gastritis (K 29 )
Nyeri Kepala (R51)
Nyeri Kepala (R51)
Demam (R50)

BULAN : NOVEMBER 2016

Karcis
Tindakan
Masuk
Injeksi
Injeksi
Injeksi
Injeksi
Injeksi
Injeksi
Injeksi
Injeksi
Injeksi
Injeksi
Injeksi
Injeksi
Injeksi
Injeksi
Injeksi
Injeksi
Injeksi
Injeksi
Injeksi

7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500

7,500

28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58

7/11/2016
7/11/2016
7/11/2016
7/11/2016
8/11/2016
8/11/2016
8/11/2016
8/11/2016
8/11/2016
8/11/2016
8/11/2016
8/11/2016
9/11/2016
9/11/2016
9/11/2016
9/11/2016
9/11/2016
9/11/2016
10/11/2016
10/11/2016
10/11/2016
10/11/2016
10/11/2016
10/11/2016
11/11/2016
11/11/2016
11/11/2016
11/11/2016
11/11/2016
11/11/2016
11/11/2016

3529056912840005
3529056110880002
3529055203740003
3529055405890004
3529056310930002
3529055402820005
3529052308760001
3529050907840003
3529055404840007
3529056110700001
3529051008690002
3529054801920002
3529065907910004
3529055105730001
3529055105800002
3529052107920001
3529052107890006
3529055707450001
3529056005910003
3529054605930001
3529052008760001
3529053000670016
35290560302720001
3529050402740003
3529050812890002
3529051411750002
3529051908600003
3529051401910002
3529055012920002
3529056907850001
3529056805810004

Sri Sulastri
Atmina
Asmi
Erniati
Titin Hidayati
Tini Lestari
Jubriyanto
Rahamdan
Asriya
Siarma
Madraha
Retini Rasanti
Israini
Maisuna
Su'diyah
Sandi
Samsul Arifin
Rapi'ah
Rasmawati
Yuniarti
Asmawi
Sahlan
Susmiyati
Sumarto
Misnoto
Edi
Abu Kamal
Faisal
Sunadatul
Manisa
Hatipa

P
P
P
P
P
P
L
L
P
P
L
P
L
P
P
L
L
P
P
P
L
L
P
L
L
L
L
L
P
P
P

30
26
40
25
21
32
38
30
30
44
45
22
23
41
34
22
25
40
23
20
38
47
40
40
25
39
28
24
22
29
33

Tarogan
Aengnyior
Aengnyior
Aengnyior
Lobuk
Tarogan
Aengnyior
Lobuk
Lobuk
Tarogan
Lobuk
Tarogan
Kopao
Tarogan
Aengnyior
Aengnyior
Lobuk
Kopao
Aengnyior
Aengnyior
Tarogan
Kopao
Tarogan
Aengnyior
Tarogan
Aengnyior
Kopao
Kopao
Lobuk
Lobuk
Kopao

Gastritis (K 29 )
Gastritis (K 29 )
Nausea dan vomitus(R11)
Demam (R.50)
Hipertensi Sekunder (I 15)
Demam (R.50)
Demam (R50)
Nyeri Kepala (R51)
Batuk (R05)
Demam (R50)
Demam (R50)
Nyeri Kepala (R51)
Demam (R.50)
Demam (R50)
Nyeri Kepala (R51)
Rhematoid arhtitis (M06)
Stomatitis (K12)
Demam (R.50)
Batuk (R.05)
Rhematoid arhtitis (M06)
Gastritis (K 29 )
Demam (R50)
Demam (R50)
Nyeri Kepala (R51)
Rhematoid arhtitis (M06)
Nyeri Kepala (R51)
Nausea dan vomitus(R11)
Rhematoid arhtitis (M06)
Nyeri Kepala (R51)
Gastritis (K 29 )
Batuk (R05)

59
60
61

12/11/2016
12/11/2016
12/11/2016

3529051506860005
3529054802880004
3529054511950001

Jakfar
Istianingsih
Intan Triananda

L
P
P

28
26
19

Lobuk
Nausea dan vomitus(R11)
Aengnyior Gastritis (K 29 )
Aengnyior Demam (R50)

Injeksi
Injeksi
Injeksi
Injeksi
Injeksi
Injeksi
Injeksi
Injeksi
Injeksi
Injeksi
Injeksi
Injeksi
Injeksi
Injeksi
Injeksi
Injeksi
Injeksi
Injeksi
Injeksi
Injeksi
Injeksi
Injeksi

Injeksi
Injeksi

7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500

7,500
7,500
7,500

62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90

12/11/2016
12/11/2016
12/11/2016
14/11/2016
14/11/2016
14/11/2016
14/11/2016
14/11/2016
14/11/2016
14/11/2016
15/11/2016
15/11/2016
15/11/2016
15/11/2016
15/11/2016
16/11/2016
16/11/2016
16/11/2016
16/11/2016
16/11/2016
16/11/2016
16/11/2016
17/11/2016
17/11/2016
17/11/2016
17/11/2016
17/11/2016
17/11/2016
18/11/2016

3529055104890003
3529056611830002
3529050807770001
3529055011770005
3529054404830001
3529056511820002
3529055107830001
3529054511780001
3529050909720002
3529056612890002
3529052506820004
3529054709810002
3529051810890003
3529051806800002
3529055703930003
3529055007800003
3529055801870002
3529050805910001
3529055207820002
3529055407770002
3529050104770004
3529056111750001
3529052406890006
3529050103800002
3529164506890008
3529055209800003
3529052141290001
3529052307790001
3529050310820005

Herlina
Farihah
Juma'ah
Rahema
Evi Komariyah
Rismiyati
Suhartik
Arnima
Ratif
Endang Sri W
Moh. Ridwan
Trikyani
Imam Mahmudi
Abd Hannan
Nurlailli Sunafayati
Patmina
Hidayati
Muh. Nurhalim
Raniyah
Suhimawati
Sanusi Rahman
Arifi
Didik Santoso
M. Rifa'i
Ida Royani
Asmaniyah
Sa'yani
Suriyanto
Yudik A.

P
P
P
P
P
P
P
P
L
P
L
P
L
L
P
P
P
L
P
P
L
L
L
L
P
P
P
L
L

25
31
37
37
31
32
31
36
42
25
32
34
25
34
21
34
27
23
32
37
37
39
25
34
25
34
14
35
32

Tarogan
Kopao
Aengnyior
Lobuk
Lobuk
Tarogan
Tarogan
Aengnyior
Kopao
Lobuk
Lobuk
Lobuk
Tarogan
Tarogan
Lobuk
Aengnyior
Tarogan
Aengnyior
Tarogan
Aengnyior
Lobuk
Tarogan
Tarogan
Aengnyior
Tarogan
Lobuk
Lobuk
Lobuk
Tarogan

Demam (R50)
Nyeri Kepala (R51)
Gastritis (K 29 )
Demam (R50)
Demam (R50)
Karies gigi (K02)
Nyeri Kepala (R51)
Batuk (R05)
Nyeri Kepala (R51)
Demam (R50)
Gastritis (K 29 )
Nyeri Kepala (R51)
Demam (R50)
Karies gigi (K02)
Nyeri Kepala (R51)
Gastritis (K 29 )
Demam (R50)
Demam (R50)
Demam (R50)
Demam (R.50)
Demam (R50)
Demam (R50)
Karies gigi (K02)
Demam (R50)
Demam (R50)
Batuk (R05)
Gastritis (K 29 )
Demam (R50)
Demam (R50)

91
92
93
94
95

18/11/2016
18/11/2016
18/11/2016
18/11/2016
18/11/2016

3529054706720006
3529055701950001
3529052311940006
3529051712770001
3529055107890002

Fariya Yuli
Evi Nurjannah
Ahmad Wafi
Moh. Hajar
Rahmawati

P
P
L
L
P

42
19
30
36
25

Tarogan
Kopao
Kopao
Kopao
Aengnyior

Alergi (L 23)
Gastritis (K 29 )
Demam (R50)
Demam (R50)
Nyeri Kepala (R51)

Injeksi
Injeksi
Injeksi
Injeksi
Injeksi
Injeksi
Injeksi
Injeksi
Injeksi
Injeksi
Injeksi
Injeksi
Injeksi
Injeksi
Injeksi
Injeksi
Injeksi
Injeksi
Injeksi
Injeksi

Injeksi
Injeksi

7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500

7,500
7,500
7,500
7,500
7,500

96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131

18/11/2016
19/11/2016
19/11/2016
19/11/2016
19/11/2016
19/11/2016
21/11/2016
21/11/2016
21/11/2016
21/11/2016
21/11/2016
21/11/2016
22/11/2016
22/11/2016
22/11/2016
22/11/2016
22/11/2016
22/11/2016
22/11/2016
23/11/2016
23/11/2016
23/11/2016
23/11/2016
23/11/2016
23/11/2016
23/11/2016
23/11/2016
24/11/2016
24/11/2016
24/11/2016
24/11/2016
25/11/2016
25/11/2016
26/11/2016
26/11/2016
26/11/2016

3529051204900003
3529051708920005
3529051308850005
3529056007950006
3529054706750001
3529050605710004
3529050604780006
3529054608890006
3529052506930001
3529051803930004
3529056603890002
3529055609940002
3529056807680001
3529050705620002
3529052606700002
3529050608860004
3529055512760003
3529054509710001
3529054605850003
3529050211671154
3529050406840001
3529055609820005
3529051107810003
3529050604710002
3529055805940003
3529050506790002
3529055002870003
3529052403770002
3529054205770002
3529051201740008
3529055506890014
3529051306830004
3529055611930001
3529051212700012
3529051204850007
3529051510700010

Sudarmono
Bayuda W. Al-Fautsi
Adi Ashadi
Lissofi Laili
Tola'ena
Baisono
Andi Haryadi
Ama Dawiyati
Pridani
Sayuti
Suhartatik
Sulfatul Aini
Juhariyah
Mathari
Harto
Marham
Suhatina
Saniyati
Maimuna
Musa
Jamal
Ribut Warni
Hasan Basri
M. Saleh
Jamilatus Zuhriya
Saleh
Susantin
Abd. Halim
Umamah
Moh. Jumal
Rinawati
Supriyadi
Yuliyana
Taufik Nawasi
Adnanto
Naim Erfandi

L
L
L
P
P
L
L
P
P
L
P
P
P
L
L
L
P
P
P
L
L
P
L
L
P
L
P
L
P
L
P
L
P
L
L
L

24
22
29
19
39
43
36
25
21
21
25
20
46
52
44
28
38
43
29
47
30
32
33
43
20
35
27
37
37
40
45
31
21
44
29
44

Aengnyior
Tarogan
Lobuk
Aengnyior
Lobuk
Lobuk
Kopao
Tarogan
Aengnyior
Aengnyior
Aengnyior
Tarogan
Lobuk
Lobuk
Tarogan
Lobuk
Tarogan
Aengnyior
Tarogan
Kopao
Lobuk
Kopao
Aengnyior
Aengnyior
Aengnyior
Lobuk
Tarogan
Lobuk
Lobuk
Aengnyior
Tarogan
Aengnyior
Lobuk
Aengnyior
Aengnyior
Aengnyior

Alergi (L 23)
Hipertensi Sekunder (I 15)
Demam (R50)
Gastritis (K 29 )
Nyeri Kepala (R51)
Nyeri Kepala (R51)
Demam (R50)
Demam (R50)
Demam (R.50)
Gastritis (K 29 )
Nyeri Kepala (R51)
Nyeri epigastrium
Demam (R50)
Batuk (R.05)
Karies gigi (K02)
Demam (R50)
Batuk (R05)
Nyeri Kepala (R51)
Demam (R50)
Gastritis (K 29 )
Demam (R50)
Demam (R50)
Nausea dan vomitus(R11)
Demam (R50)
Demam (R50)
Demam (R50)
Nausea dan vomitus(R11)
Demam (R50)
Batuk (R05)
Demam (R.50)
Alergi (L 23)
Demam (R50)
Demam (R.50)
Demam (R50)
Nausea dan vomitus(R11)
Karies gigi (K02)

Injeksi
Injeksi
Injeksi
Injeksi
Injeksi
Injeksi
Injeksi
Injeksi
Injeksi
Injeksi
Injeksi
Injeksi
Injeksi

Injeksi
Injeksi
Injeksi
Injeksi
Injeksi

Injeksi
Injeksi
Injeksi
Injeksi

7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500

7,500
7,500
7,500
7,500
7,500
7,500
7,500

132
133
134
135
136
137
138
139

26/11/2016
26/11/2016
28/11/2016
28/11/2016
28/11/2016
28/11/2016
29/11/2016
29/11/2016

3529051510760003
3529056002820003
3529051111760002
3529055507820001
3529050302600007
3529052903820002
3529056305740001
3529056105770003

Surahwi
Juhairiyatul
Sunanto
Mudriyani
Rahmad
Iskandar
Sunarwati
Hawati

L
P
L
P
L
L
P
P

38
32
38
36
54
32
40
37

Tarogan
Tarogan
Kopao
Tarogan
Kopao
Lobuk
Aengnyior
Lobuk

Demam (R50)
Demam (R50)
Demam (R50)
Batuk (R05)
Nyeri Kepala (R51)
Nyeri Kepala (R51)
Luka Lecet (T00)
Demam (R50)

Injeksi
Injeksi
Injeksi
Injeksi
Injeksi
Injeksi
Injeksi

7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
1,027,500

Mengetahui
Kepala UPT Puskesmas Bluto

Lobuk,
November 2016
Bidan Desa Lobuk

dr.Hj. Sulaiha Riningsih, M.Si

Endang Sulastri, Amd.Keb

Nip :19750110 200501 2 011

AN : NOVEMBER 2016
Biaya
Total
Tindakan
Biaya
1,000
1,000
1,000
1,000
1,000
1,000
1,000
1,000
1,000
1,000
1,000
1,000
1,000
1,000
1,000
1,000
1,000
1,000
1,000

8,500
8,500
8,500
7,500
8,500
8,500
8,500
7,500
8,500
8,500
8,500
7,500
8,500
7,500
8,500
8,500
8,500
7,500
8,500
8,500
8,500
7,500
8,500
8,500
7,500
8,500

7,500

1,000
1,000
1,000
1,000
1,000
1,000
1,000
1,000
1,000
1,000
1,000
1,000
1,000
1,000
1,000
1,000
1,000
1,000
1,000
1,000
1,000
1,000

1,000
1,000

8,500
7,500
8,500
8,500
7,500
8,500
8,500
8,500
8,500
7,500
8,500
8,500
7,500
8,500
7,500
8,500
8,500
8,500
7,500
8,500
8,500
8,500
8,500
7,500
8,500
8,500
7,500
8,500
8,500
7,500
8,500

8,500
7,500
8,500

1,000
1,000
1,000
1,000
1,000
1,000
1,000
1,000
1,000
1,000
1,000
1,000
1,000
1,000
1,000
1,000
1,000
1,000
1,000
1,000

1,000
1,000

7,500
8,500
7,500
8,500
8,500
8,500
7,500
8,500
8,500
8,500
7,500
8,500
8,500
8,500
7,500
8,500
8,500
7,500
8,500
8,500
7,500
8,500
7,500
8,500
8,500
8,500
7,500
8,500
8,500

7,500
8,500
8,500
7,500
7,500

1,000
1,000
1,000
1,000
1,000
1,000
1,000
1,000
1,000
1,000
1,000
1,000
1,000
1,000
1,000
1,000
1,000
1,000
1,000
1,000

1,000
1,000
1,000
1,000

8,500
8,500
8,500
7,500
8,500
8,500
7,500
8,500
8,500
7,500
8,500
8,500
8,500
8,500
7,500
8,500
8,500
8,500
7,500
8,500
8,500
7,500
8,500
8,500
8,500
7,500
8,500

8,500
7,500
8,500
8,500
8,500
7,500
7,500

1,000
1,000
1,000
1,000
1,000
1,000
1,000
96,000

vember 2016

, Amd.Keb
200501 2 011

8,500
8,500
8,500
7,500
8,500
8,500
8,500
8,500
1,123,500