LAMPIRAN FORMULIR PENGAJUAN KLAIM ( FPK )

UPT PUSKESMAS PENANAE

KOTA BIMA

Jenis Pelayanan : ANC/PNC

Bulan : PEBRUARI 2015

JENIS
NO POLINDES NAMA PENDERITA NO. KARTU NO.HP TGL. MASUK
PELAYANAN
1 PENANAE Nuriman 0001481924823 085333777961 2,5,15 Jan,3 Peb PNC 4 Kali
2 Siti Hawa 0001483012225 085238593040 2,5,15 Jan,6 Peb PNC 4 Kali
3 Haryati 0001443768535 0817567899 27,30 Jan,8,28 Peb PNC 4 Kali
4 KENDO Siti Rahmah 0000848914356 082340528654 7,12,22 Jan,6 Peb PNC 4 Kali
5 Leni Widia 0000849279677 082359480016 20,26 Jan,3,9 Peb PNC 4 Kali
6 NTOBO Siti Hajar 0001476331107 085238237378 3,9,17 Jan,3 Peb PNC 4 Kali
7 RONTU Rukmini 0001795665249 085205477689 6'8'11 Jan,6 Peb PNC 4 Kali
8 PENARAGA Herlinda 0001442822826 085205023377 1'6 Jan,4 Peb PNC 3 Kali
9 Sri Ramadani 0001325240717 085238691799 3,6,11 Jan,8 Peb PNC 4 Kali
10 Jainab 0000148570762 082145196062 15,18,23 Jan,20 Peb PNC 4 Kali
11 Masyitah 0000145530472 081803666149 22,25,30 Jan,25 Peb PNC 4 Kali
12 Nurwahidah 0000849020797 081236427105 21'24'30 Jan,25 Peb PNC 4 Kali
13 RITE Rifki Eka Sulastri 0001787852839 8,12,20 Jan,2 Peb PNC 4 Kali
14 RABANGODU SLTAN Ana Ledu Ona 0001480861451 085253967866 PNC 4 Kali
15 Sri Mulyati 0000145583346 085937035249 17,19,21 Jan,20 Peb PNC 4 Kali
16 Baiq Ismawati 00001475784911 085338602669 9,1,16 Jan,21 Peb PNC 4 Kali
17 RABADOMPU BARAT Kurniati 0000848907922 085337369773 17,19 Jan,17,28 Peb PNC 4 Kali
18 RABADOMPU TIMUR Yusmin 0001449989278 085253537678 3,6,30 Jan,11 Peb PNC 4 Kali
19 Dewi Nur Handayani 0001443184716 081338044216 9,12 Jan,5,17 Peb PNC 4 Kali
20 Siti Suara 0001058568669 085337247489 6,9 Jan,2,14 Peb PNC 4 Kali
21 Misnah 0001058568355 085337026476 4,7,31 Jan 12 Peb PNC 4 Kali
22 Fitri Rahmawati 0001058569031 085238796121 6,9 Jan,2 14 Peb PNC 4 Kali
23 NITU Taasiah 0000848984185 PNC 4 Kali
24 Fitri 0000849548441 PNC 4 Kali
25 Yanti 0000849013672 PNC 4 Kali
 JENIS
NO POLINDES NAMA PENDERITA NO. KARTU NO.HP TGL. MASUK
PELAYANAN
26 Halimah 0001789119808 PNC 4 Kali
27 Reni 0000849566452 27,3 Jan,14,25 Peb PNC 4 Kali
28 Salmah 0000848987842 25,30 Jan,12,25 Peb PNC 4 Kali
29 PUSKESMAS Suci Wulandari 0001795133349 082247165139 5,8,17 Jan,10 Peb PNC 4 Kali
30 Arina 0001791334269 8,12,24 Jan, 13 Peb PNC 4 Kali
31 Endang Kurniati 0001428583893 081339779956 26,29 Jan,14,26 Pen PNC 4 Kali
32 Sumarni 0001381050562 25,28 Jan,16,28 Peb PNC 4 Kali
TOTAL TAGIHAN

Raba-Bima, 09 Maret 2015

Kepala UPT. Puskesmas PenanaE

Hj. Siti Aisyah, A.Md.Kep

NIP 19661231 198703 2 140
BESARAN TARIF JUMLAH TAGIHAN

Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 75,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
 BESARAN TARIF JUMLAH TAGIHAN

Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 3,175,000

Bidan

Rosita
NIP 19730813 199203 2 004
 LAMPIRAN FORMULIR PENGAJUAN KLAIM ( FPK )
UPT PUSKESMAS PENANAE
KOTA BIMA

Jenis Pelayanan : ANC/PNC

Bulan : MARET 2015

JENIS
NO POLINDES NAMA PENDERITA NO. KARTU NO.HP TGL PELAYANAN
PELAYANAN
1 PENANAE Nurlaila 0001786103774 085288038855 3,9,16 Peb,10 Mar PNC 4 Kali
2 Yeni Kurniati 0000848816908 082359655668 5,10,27 Peb,10 Mar PNC 4 Kali
3 Ernawati 0001429784212 082339819901 10,14,21 Peb,16 Mar PNC 4 Kali
4 Sri Santriatin 0001100557181 085205394650 11,16,23 Peb,17 Mar PNC 4 Kali
5 Hasna 0000848515588 12,17,24 Peb,18 Mar PNC 4 Kali
6 Nurmaharaeni 0001424823658 082338249912 17,22 Peb,1,26 Mar PNC 4 Kali
7 Maedihar 0001271402673 085253447528 17,22,Peb,4,26 Mar PNC 4 Kali
8 Titi 0000848320784 082341571159 20,25 Peb,4,26 Mar PNC 4 Kali
9 Ririn Indriani 0001575737403 085338697329 21,26 Peb,5,26 Mar PNC 4 Kali
10 Aprianti 0001481322071 085338381894 28 Peb,4,11,31 Mar PNC 4 Kali
11 Fatimah 0000848311986 085253227807 28 Peb,4,11,31 Mar PNC 4 Kali
12 KENDO Suci Yulianti 0000145876296 082341159219 5,10,18 Peb,6 Mar PNC 4 Kali
13 Evayani 0001575737076 085338806463 7,11,20 Peb,9 Mar PNC 4 Kali
14 Endang 0000848900935 085205763997 11,16,24 Peb,13 Mar PNC 4 Kali
15 Suharni 0000848943246 085253877749 16,20 Peb,2,18 Mar PNC 4 Kali
16 RITE Nuraya 0000848653705 081270025196 13,16,28 Peb,20 Mar PNC 4 Kali
17 PENARAGA Kurniati 0001812677332 085253835050 12,24,28 Peb,18 Mar PNC 4 Kali
18 Sri Zumharis 0000849632916 085338720620 23,25 Peb,6,28 Mar PNC 4 Kali
19 Iin Inayah 0001452159944 085386523059 30 Jan,4,14 Peb,13 Mar PNC 4 Kali
20 Sri Handayani 0001448884168 082359079752 8,11 Peb,2,26 Mar PNC 4 Kali
21 Masita 0000001021509 085333699899 3,6,12 Peb,10 Mar PNC 4 Kali
22 Wahidah 0001804786424 085339767761 5,8,18 Peb,13 Mar PNC 4 Kali
23 Asmaul husnah 0000207239229 085338720550 21,24,28 Peb,27 Mar PNC 4 Kali
24 RONTU Siti Nur 0000848173397 082339031504 2,4,15 Peb,12 Mar PNC 4 Kali
25 Nurbaiturahmah 00008481561657 082359058648 4,6,17 Peb,12 Mar PNC 4 Kali
 JENIS
NO POLINDES NAMA PENDERITA NO. KARTU NO.HP TGL PELAYANAN
PELAYANAN
26 Mirawati 0000848938037 085205761122 8,10,21 Peb,12 Mar PNC 4 Kali
27 Rosalina 0000848772911 082219219742 24,26 Peb,19,30 Mar PNC 4 Kali
28 RABADOMPU BARAT Sri Retno W 0001430052107 081339712082 24,26 Peb,23,31 Mar PNC 4 Kali
29 RABADOMPU TIMUR Yunitasari 0000848622317 082341327156 18,21 Peb,18,30 Mar PNC 4 Kali
30 Masdah 0000849043552 085205477768 22,25 Peb,21,31 Mar PNC 4 Kali
31 Nursyam 0001480781529 082342304345 22,25 Peb,20,31 Mar PNC 4 Kali
32 RABANGODU SELATAN Ferawati 0001799245495 085253576916 4,10 Peb,17,2 Mar PNC 4 Kali
33 Nurmawati 0001425085446 085337070708 7,10,13 Peb,6 Mar PNC 4 Kali
34 Rita 0001058556137 085238650784 13,20,26 Peb,13 Mar PNC 4 Kali
35 Emilia 0001280946183 085338222847 18,24 Peb,2,17 Mar PNC 4 Kali
36 RABANGODU UTARA Ndari Asmawati 0001425723322 085339814743 4,8,17 Peb,14 Mar PNC 4 Kali
37 Sri Rahmawati 0001786147119 085295441585 23,27 Jan,5 Peb,5 Mar PNC 4 Kali
38 PUSKESMAS Sri Wahyuningsih 0001445439003 085934444230 17,20,27 Peb,13 Mar PNC 4 Kali
39 Nurmasita 0001388739339 085238040343 27 Peb,2,10,24 Mar PNC 4 Kali
40 NTOBO Eka Pratama 0001226530271 28,3,9,27 Maret PNC 4 Kali
41 Mahani 0000849325307 26 Peb,2,10,20 Mar PNC 4 Kali
42 Siti Hawa 0000848338323 28 Peb,4,15,20 Mar PNC 4 Kali
TOTAL TAGIHAN

Raba-Bima, 09 April 2015

Kepala UPT. Puskesmas PenanaE

Hj. Siti Aisyah, A.Md.Kep

NIP 19661231 198703 2 140
BESARAN TARIF JUMLAH TAGIHAN

Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
 BESARAN TARIF JUMLAH TAGIHAN

Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 25,000 Rp 100,000
Rp 4,200,000

Bidan Koordinator

Supartinah Mahjam,SST
NIP 19760328 200501 2 013
 LAMPIRAN FORMULIR PENGAJUAN KLAIM ( FPK )
UPT PUSKESMAS PENANAE
KOTA BIMA

Jenis Pelayanan : PNC

Bulan : APRIL 2015

JENIS
NO POLINDES NAMA PENDERITA NO. KARTU NO.HP TGL PELAYANAN
PELAYANAN
1 PENANAE Dewi Anggriani 0000146812702 081353320172 2 Maret KN & KF 1,2
14 Maret KN 3
6 April KF 3
2 Nurhayati 0001299214383 085338104746 2 Maret KN & KF 1,2
14 Maret KN 3
6 April KF 3
3 Suharti 0000848564559 085338445753 27 Maret KN & KF 1,2
31 Maret KN 3
30 April KF 3
4 RITE Najmah 0000848671817 085337777206 5 Maret KN & KF 1,2
19 Maret KN 3
14 April KF 3
5 Rohana 0000847389969 0.0852372665 14 Maret KN & KF 1,2
28 Maret KN 3
23 April KF 3
6 Imas Saibunisah 0001575737798 085333293614 17 Maret KN & KF 1,2
31 Maret KN 3
27 April KF 3
7 KENDO Sinta Susanti 0000145615004 082359597360 28 Maret KN & KF 1,2
14 April KN 3
1 April KF 3
8 Nuraini 0001833052656 085237614734 18 Maret KN 3
8 April KF 3
9 Erni 0001575737087 085238863190 9 Maret KN & KF 1,2
23 Maret KN 3
 JENIS
NO POLINDES NAMA PENDERITA NO. KARTU NO.HP TGL PELAYANAN
PELAYANAN
10 April KF 3
10 Jumratih 0001430734162 085337150552 17 Maret KN & KF 1,2
1 April KN 3
20 April KF 3
11 Yani Cahyanti 0000849103108 30 Maret KN & KF 1,2
11 April KN 3
29 April KF 3
12 Haminah 0000849185613 085238967894 1 Maret KN & KF 1,2
15 Maret KN 3
30 April KF 3
13 PENARAGA Ratih Purwasih 0000848964745 085338500495 5 Maret KN & KF 1,2
19 Maret KN 3
8 April KF 3
14 Lisnawati 0001444832774 082340690830 12 Maret KN & KF 1,2
25 Maret KN 3
16 April KF 3
15 Sri Inayah 0001798551202 081370404059 15 Maret KN & KF 1,2
26 Maret KN 3
20 April KF 3
16 Sri Mariati 0001804790169 085205449691 23 Maret KN & KF 1,2
30 Maret KN 3
15 April KF 3
17 Sahidah 0000849029106 085237266880 23 Maret KN & KF 1,2
30 Maret KN 3
3 April KF 3
18 Agustinah 000157537098 08537454330 23 Maret KN & KF 1,2
30 Maret KN 3
28 April KF 3
19 Sri Wahyuningsih 0000848998899 08234056464 28 Maret KN & KF 1,2
5 April KN 3
30 April KF 3
 JENIS
NO POLINDES NAMA PENDERITA NO. KARTU NO.HP TGL PELAYANAN
PELAYANAN
20 RABANGODU SELATAN Nurkomala 0001391903032 082359288929 6 Maret KN & KF 1,2
19 Maret KN 3
6 April KF 3
21 Raodah 0000849205743 081239756666 20 Maret KN & KF 1,2
2 April KN 3
16 April KF 3
22 Kamelia 0001819924424 082339579730 21 Maret KN & KF 1,2
2 April KN 3
17 April KF 3
23 RABANGODU UTARA Mukmin 000786269767 087766625302 12 Maret KN & KF 1,2
30 Maret KN 3
17 April KF 3
24 Azhar 0001575737122 085338380970 13 Maret KN & KF 1,2
25 Maret KN 3
23 April KF 3
25 Emy Sukriani 0001796866053 081339877997 17 Maret KN & KF 1,2
2 April KN 3
24 April KF 3
26 Fitri 0000194127884 085239425466 21 Maret KN & KF 1,2
6 April KN 3
28 April KF 3
27 Yati 0000146819777 085237110135 25 Maret KN & KF 1,2
8 April KN 3
30 April KF 3
28 RABADOMPU BARAT Saodah 0001835398337 25 Maret KN & KF 1,2
21 April KN 3
30 April KF 3
29 Rabiah 0000849106181 085338759674 29 Maret KN & KF 1,2
25 April KN 3
30 April KF 3
30 Suryani 0000848595948 082359481413 23 Maret KN & KF 1,2
 JENIS
NO POLINDES NAMA PENDERITA NO. KARTU NO.HP TGL PELAYANAN
PELAYANAN
19 April KN 3
30 April KF 3
31 Haryati 0000145751433 085205995453 23 Maret KN & KF 1,2
19 April KN 3
30 April KF 3
32 RABADOMPU TIMUR Misbah 0001793778953 081239899808 2 Maret KN & KF 1,2
29 Maret KN 3
10 April KF 3
33 Faturahmah 0001184163985 081237933319 8 Maret KN & KF 1,2
4 April KN 3
16 April KF 3
34 Maani 0000848952099 085337027492 8 Maret KN & KF 1,2
4 April KN 3
16 April KF 3
35 Umrah 0001479529394 085338574101 1 Maret KN & KF 1,2
28 Maret KN 3
9 April KF 3
36 Erni 0001452784702 082339296872 23 Maret KN & KF 1,2
19 April KN 3
30 April KF 3
37 Rohani 0000848954812 082339502157 25 Maret KN & KF 1,2
21 April KN 3
30 April KF 3
38 Wilyuhan 0001786755554 082145005168 20 Maret KN & KF 1,2
16 April KN 3
30 April KF 3
39 Eka D 0001818276118 082339855399 17 Maret KN & KF 1,2
14 April KN 3
26 April KF 3
40 NITU Misbah 0000848152618 6 Maret KN & KF 1,2
28 Maret KN 3
 JENIS
NO POLINDES NAMA PENDERITA NO. KARTU NO.HP TGL PELAYANAN
PELAYANAN
30 April KF 3
41 Meri Mariam 0000849028432 6 Maret KN & KF 1,2
28 Maret KN 3
30 April KF 3
42 Mariati 0000849564044 14 Maret KN & KF 1,2
31 Maret KN 3
22 April KF 3
43 NTOBO Rohani 0001833038289 085237231654 21 Maret KN 3
28 Maret KF 3
44 Aprila 0001274703581 082240916764 14 Maret KN & KF 1,2
28 Maret KN 3
20 April KF 3
45 Kurniawati 0000848333169 085239619957 28 Maret KN & KF 1,2
9 April KN 3
30 April KF 3
46 Saidah 0000848289622 082250051204 31 Maret KN & KF 1,2
9 April KN 3
30 April KF 3
47 Madiha 0001058578255 085337586563 4 Maret KN & KF 1,2
15 April KN 3
05 April KF 3
48 PUSKESMAS Yeti Krisnawati 0000205710761 085338235183 6 Maret KN & KF 1,2
18 Maret KN 3
30 April KF 3
49 Fitri Ramdhani 0001261210397 4 Maret KN & KF 1,2
14 Maret KN 3
6 April KF 3
50 RONTU Masita 0001810177918 085337402902 28 Pebruari KN & KF 1,2
13 Maret KN 3
06 April KF 3
51 Nuraini 0001440925211 28 Maret KN & KF 1,2
 JENIS
NO POLINDES NAMA PENDERITA NO. KARTU NO.HP TGL PELAYANAN
PELAYANAN
13 Maret KN 3
06 April KF 3
52 Sri Sukmawati 0001058554427 085338950191 10 Maret KN & KF 1,2
23 Maret KN 3
20 April KF 3
53 Sarfiah 0001575737289 085339766503 17 Maret KN & KF 1,2
2 April KN 3
27 April KF 3
TOTAL TAGIHAN

Raba-Bima, 11 Mei 2015

Kepala UPT. Puskesmas PenanaE

Hj. Siti Aisyah, A.Md.Kep

NIP 19661231 198703 2 140
BESARAN TARIF JUMLAH TAGIHAN

Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 50,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
BESARAN TARIF JUMLAH TAGIHAN
Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
BESARAN TARIF JUMLAH TAGIHAN

Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 75,000
BESARAN TARIF JUMLAH TAGIHAN

Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
BESARAN TARIF JUMLAH TAGIHAN
Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 50,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 75,000
 BESARAN TARIF JUMLAH TAGIHAN

Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 3,925,000

Bidan Koordinator

Supartinah Mahjam,SST
NIP 19760328 200501 2 013
 LAMPIRAN FORMULIR PENGAJUAN KLAIM ( FPK )
UPT PUSKESMAS PENANAE
KOTA BIMA
Jenis Pelayanan : PNC
Bulan : MEI 2015
JENIS
NO POLINDES NAMA PENDERITA NO. KARTU NO.HP TGL PELAYANAN
PELAYANAN
1 PENANAE Nurhaidah 0001800093778 11 April KN & KF 1,2
22 April KN 3
15 Mei KF 3
2 Sumiati 0001575209867 12 April KN & KF 1,2
24 April KN 3
18 Mei KF 3
3 Masyita 0001058571652 082342044775 17 April KN & KF 1,2
29 April KN 3
21 Mei KF 3
4 Suhudiah 0000145616804 085239010182 24 April KN & KF 1,2
2 Mei KN 3
22 Mei KF 3
5 Siti Nur 0001575737436 085205099301 29 April KN & KF 1,2
9 Mei KN 3
25 Mei KF 3
6 Fatimah 0000849261216 085339232028 30 April KN & KF 1,2
11 Mei KN 3
30 Mei KF 3
7 RITE Mita Yuli Erawati 0001575737616 0853371221137 7 April KN & KF 1,2
20 April KN 3
1 Mei KF 3
8 Nuraini 0000847410535 082339600578 8 April KN 3
22 April KN 3
15 Mei KF 3
9 Yuliana 0000848041839 085238701731 9 April KN & KF 1,2
21 April KN 3
18 Mei KF 3
 JENIS
NO POLINDES NAMA PENDERITA NO. KARTU NO.HP TGL PELAYANAN
PELAYANAN
10 Nurhasanah 0001575737785 082341989789 17 April KN & KF 1,2
30 April KN 3
25 Mei KF 3
11 Fajar Aisah 0001797200651 085239528928 20 April KN & KF 1,2
4 mei KN 3
30 Mei KF 3
12 Anggriani 0000844768034 082359413696 20 April KN & KF 1,2
4 mei KN 3
30 Mei KF 3
13 KENDO Damrah 0001107200103 085339094445 9 April KN & KF 1,2
21 April KN 3
8 Mei KF 3
14 Saodah 0000849312819 085237427329 14 April KN & KF 1,2
27 April KN 3
13 Mei KF 3
15 RONTU Hadijah 0001478467765 081353138693 4 April KN & KF 1,2
23 April KN 3
19 Mei KF 3
16 Kasmiatun 0001058554552 082340145897 18 April KN & KF 1,2
28 April KN 3
28 Mei KF 3
17 Yulianti 0001576545682 085205345165 23 April KN & KF 1,2
6 Mei KN 3
30 Mei KF 3
18 PENARAGA Ati Kurniati 0001800620572 087766310898 5 April KN & KF 1,2
21 April KN 3
4 Mei KF 3
19 Siti Masita 0001452163476 082235908288 1 April KN & KF 1,2
23 April KN 3
10 Mei KF 3
20 Yuni Susanti 0001446902717 082144256039 10 April KN & KF 1,2
24 April KN 3
11 Mei KF 3
 JENIS
NO POLINDES NAMA PENDERITA NO. KARTU NO.HP TGL PELAYANAN
PELAYANAN
21 Nunung Suryani 0001839877119 085337033001 20 April KN & KF 1,2
28 April KN 3
29 Mei KF 3
22 Nurhaidah 0001299210107 082339934128 21 April KN & KF 1,2
29 April KN 3
26 Mei KF 3
23 Ida Faridah 0000848407127 085338697063 23 April KN & KF 1,2
8 Mei KN 3
29 Mei KF 3
24 Harnah 0001058558589 082144454454 24 April KN & KF 1,2
15 Mei KN 3
28 Mei KF 3
25 Yusmiati 0001810994815 082342320207 5 April KN & KF 1,2
14 April KN 3
9 Mei KF 3
26 RABANGODU SELATAN Syukriyati 0001444172613 082359469499 16 April KN & KF 1,2
27 April KN 3
11 Mei KF 3
27 RABANGODU UTARA Katrina Lende 0001787146277 085327693022 1 April KN & KF 1,2
12 April KN 3
5 Mei KF 3
28 Nurlailah 0001799262639 082236883902 2 April KN & KF 1,2
16 April KN 3
8 Mei KF 3
29 hayatunufus 0001834258757 085237988763 18 April KN & KF 1,2
28 April KN 3
16 mei KF 3
30 Samsiah 0001057641445 085237988763 16 April KN & KF 1,2
25 April KN 3
20 Mei KF 3
31 Siti Rohani 0000145816841 085239777330 16 April KN & KF 1,2
27 April KN 3
18 mei KF 3
 JENIS
NO POLINDES NAMA PENDERITA NO. KARTU NO.HP TGL PELAYANAN
PELAYANAN
32 RABADOMPU BARAT Dian Ningsih 0001787166494 085205371166 3 April KN & KF 1,2
30 April KN 3
13 mei KF 3
33 RABADOMPU TIMUR Rini A 0001440707894 085205618599 2 April KN & KF 1,2
29 April KN 3
11 Mei KF 3
34 Sri Rahmiatun 0000150560302 085338698838 20 April KN & KF 1,2
17 Mei KN 3
29 Mei KF 3
35 Nursafillah 0001058568221 085337222189 15 April KN & KF 1,2
12 mei KN 3
24 mei KF 3
36 Nunung 0000848653334 082359272595 20 April KN & KF 1,2
17 mei KN 3
29 mei KF 3
37 Arman 0001576545478 085205260404 11 April KN & KF 1,2
8 mei KN 3
25 Mei KF 3
38 NITU Ratnah 0000849046397 082339035971 4 April KN & KF 1,2
17 April KN 3
4 Mei KF 3
39 St Mariam 0000848224269 7 April KN & KF 1,2
28 April KN 3
9 Mei KF 3
TOTAL TAGIHAN
Raba-Bima, 10 Juni 2015
Kepala UPT. Puskesmas PenanaE

Hj. Siti Aisyah, A.Md.Kep

NIP 19661231 198703 2 140
BESARAN TARIF JUMLAH TAGIHAN

Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
BESARAN TARIF JUMLAH TAGIHAN

Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
BESARAN TARIF JUMLAH TAGIHAN

Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
 BESARAN TARIF JUMLAH TAGIHAN

Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 2,925,000

Bidan Koordinator

Supartinah Mahjam,SST
NIP 19760328 200501 2 013
 LAMPIRAN FORMULIR PENGAJUAN KLAIM ( FPK )
UPT PUSKESMAS PENANAE
KOTA BIMA
Jenis Pelayanan : PNC
Bulan : JUNI 2015
JENIS
NO POLINDES NAMA PENDERITA NO. KARTU NO.HP TGL PELAYANAN
PELAYANAN
1 PENANAE Safiah 0000848315092 4 Mei KN & KF 1,2
18 Mei KN 3
9 Juni KF 3
2 Sri Ardiningsih 0001575737414 085239527160 11 Mei KN & KF 1,2
25 Mei KN 3
16 Juni KF 3
3 Nuryati 0000848801439 11 Mei KN & KF 1,2
25 Mei KN 3
16 Juni KF 3
4 Dini Andriani 0001576954844 24 Mei KN & KF 1,2
13 Juni KN 3
30 Juni KF 3
5 Fatimah 0000848431978 30 Mei KN & KF 1,2
13 jun i KN 3
30 Juni KF 3
6 RITE Nurmi 0001058573608 085253383840 15 Mei KN & KF 1,2
28 Mei KN 3
24 juni KF 3
7 Nurdiana 0000198644499 082341524112 21 Mei KN & KF 1,2
4 Juni KN 3
21 Juni KF 3
8 PENARAGA Nurwati 0000849699729 082340935110 5 Mei KN 3
17 Mei KN 3
10 Juni KF 3
9 Neni Anggriani 0001475760791 085338561169 16 Mei KN & KF 1,2
28 Mei KN 3
23 Juni KF 3
10 Nurillah 0001804795312 082340485760 20 mei KN & KF 1,2
 JENIS
NO POLINDES NAMA PENDERITA NO. KARTU NO.HP TGL PELAYANAN
PELAYANAN
28 Mei KN 3
13 Juni KF 3
11 Sri Nurul Ningsih 0011576337591 085238596859 2 Mei KN & KF 1,2
28 Mei KN 3
25 Juni KF 3
 JENIS
NO POLINDES NAMA PENDERITA NO. KARTU NO.HP TGL PELAYANAN
PELAYANAN
12 Nurnaningsih 0001804727121 085338342964 29 Mei KN & KF 1,2
12 Juni KN 3
24 Juni KF 3
13 Nia Kurniasari 0000848459597 085205824779 10 Mei KN & KF 1,2
20 Mei KN 3
15 Juni KF 3
14 Evi Maulida 0001576955035 085253331401 13 Mei KN & KF 1,2
25 Mei KN 3
18 Juni KF 3
15 Indriati 0000145671221 085253596990 23 Mei KN & KF 1,2
3 Juni KN 3
27 Juni KF 3
16 Faujiatun 0001058559478 085237566860 30 Mei KN & KF 1,2
13 Juni KN 3
30 Juni KF 3
17 KENDO Fitriani 0001576954855 15 Mei KN & KF 1,2
28 Mei KN 3
15 Juni KF 3
18 Astuti 0000849038826 18 Mei KN & KF 1,2
30 Mei KN 3
16 Juni KF 3
19 Mardiana 0000848480692 082340444820 18 mei KN & KF 1,2
1 Juni KN 3
17 Juni KF 3
20 Aisah 0000848908045 085253323796 19 mei KN & KF 1,2
1 Juni KN 3
18 juni KF 3
21 RONTU Nahra 0001478337074 085238972113 1 Mei KN & KF 1,2
15 mei KN 3
10 Juni KF 3
22 Fadlun 0000848184412 085205028097 6 mei KN & KF 1,2
19 mei KN 3
15 Juni KF 3
 JENIS
NO POLINDES NAMA PENDERITA NO. KARTU NO.HP TGL PELAYANAN
PELAYANAN
23 Junari 0000849099745 085337078812 14 Mei KN & KF 1,2
28 Mei KN 3
23 Juni KF 3
24 Nurhasanah 0000146811926 085337402902 25 mei KN & KF 1,2
8 Juni KN 3
30 juni KF 3
25 Salmah 0000848204313 082341517741 28 Mei KN & KF 1,2
10 Juni KN 3
30 Juni KF 3
26 RABANGODU UTARA Sri Ramdahan 0001575737144 085205404804 15 Mei KN & KF 1,2
18 Mei KN 3
5 Juni KF 3
27 Ratnah 0001804340553 7 Mei KN & KF 1,2
20 Mei KN 3
8 juni KF 3
28 Roslinda 0000163959827 085333255121 15 Mei KN & KF 1,2
25 Mei KN 3
17 Juni KF 3
29 Sumiyati 0001575595686 0812374008500 15 Mei KN & KF 1,2
25 Mei KN 3
17 Juni KF 3
30 Mutmainah 0000145814984 085237888812 16 Mei KN & KF 1,2
25 Mei KN 3
16 Juni KF 3
31 Fariati 0000145870784 085239105640 16 Mei KN & KF 1,2
26 Mei KN 3
15 Juni KF 3
32 Nurbaya 0001575737111 085253721572 24 Mei KN & KF 1,2
4 Juni KN 3
23 Juni KF 3
33 Fauziati 0001575737133 082339862339 24 Mei KN & KF 1,2
5 Juni KN 3
26 Juni KF 3
 JENIS
NO POLINDES NAMA PENDERITA NO. KARTU NO.HP TGL PELAYANAN
PELAYANAN
34 Dian Natalia 0000146812735 085205703442 27 Mei KN & KF 1,2
6 Juni KN 3
25 Juni KF 3
35 NITU Fani Fitrianingsih 0001576338456 4 Mei KN & KF 1,2
24 Mei KN 3
12 Juni KF 3
 JENIS
NO POLINDES NAMA PENDERITA NO. KARTU NO.HP TGL PELAYANAN
PELAYANAN
36 Wahyu 0000848156411 2 Mei KN & KF 1,2
23 Mei KN 3
1 Juni KF 3
37 Putri Namira 28 Mei KN & KF 1,2
11 Juni KN 3
22 Juni KF 3
38 Uswatun Hasanah 0000848789368 31 Mei KN & KF 1,2
16 Juni KN 3
22 Juni KF 3
39 RABADOMPU TIMUR Rini Angriani 0000145593887 081339816842 7 Mei KN & KF 1,2
3 Juni KN 3
15 Juni KF 3
40 Nuningsih 0000848448371 085237595242 1 Mei KN & KF 1,2
28 Mei KN 3
9 Juni KF 3
41 Tuti Kurniawati 0000848974814 085333288154 15 Mei KN & KF 1,2
11 Juni KN 3
23 Juni KF 3
42 RABADOMPU BARAT Rukayah 0000849528112 082341054714 1 Mei KN & KF 1,2
26 Mei KN 3
9 Juni KF 3
43 Nurjanah 0000847913769 085205170373 2 Mei KN & KF 1,2
27 Mei KN 3
10 Juni KF 3
44 Nurmalasari 0001058565521 08776710095 3 Mei KN & KF 1,2
29 Mei KN 3
11 Juni KF 3
45 Rita Diansyah 0000848591752 085333344915 2 Mei KN & KF 1,2
29 Mei KN 3
12 Juni KF 3
46 Endang S Taurina 0000848568407 085205027926 3 Mei KN & KF 1,2
30 Mei KN 3
13 juni KF 3
 JENIS
NO POLINDES NAMA PENDERITA NO. KARTU NO.HP TGL PELAYANAN
PELAYANAN
47 Sarafiah 0000849582988 085338984066 7 Mei KN & KF 1,2
3 Juni KN 3
15 Juni KF 3
 JENIS
NO POLINDES NAMA PENDERITA NO. KARTU NO.HP TGL PELAYANAN
PELAYANAN
48 Fatmi 0000848409603 085338806533 5 Mei KN & KF 1,2
1 Juni KN 3
15 Juni KF 3
49 Sri Endang 0000173502876 085338961765 9 Mei KN & KF 1,2
6 Juni KN 3
20 Juni KF 3
50 Raodah 0000848899563 082251743266 12 Mei KN & KF 1,2
8 Juni KN 3
22 Juni KF 3
51 Miratunisah 0001852855817 082340521255 20 Mei KN & KF 1,2
16 Juni KN 3
30 Juni KF 3
52 Anisah 0001852076373 082340529350 21 Mei KN & KF 1,2
17 Juni KN 3
30 Juni KF 3
53 NTOBO Darafiah 0001784941885 18 Mei KN & KF 1,2
25 Mei KN 3
23 Juni KF 3
54 Yusrina 0000849282388 30 Mei KN & KF 1,2
8 Juni KN 3
30 Juni KF 3
55 Nufti 0000849234227 1 Mei KN & KF 1,2
8 Mei KN 3
30 Juni KF 3
56 Ninignsih 0000848411987 2 Mei KN & KF 1,2
15 Mei KN 3
8 Juni KF 3
57 PUSKESMAS Mindaratun 0000848618234 0819070783335 4 Mei KN & KF 1,2
18 Mei KN 3
8 Juni KF 3
58 Yulin Boludawa 0001391903662 085240105519 4 Mei KN & KF 1,2
18 Mei KN 3
8 Juni KF 3
 JENIS
NO POLINDES NAMA PENDERITA NO. KARTU NO.HP TGL PELAYANAN
PELAYANAN
59 Sri Susanti 0001079849744 082339066060 5 Mei KN & KF 1,2
18 Mei KN 3
8 Juni KF 3
TOTAL TAGIHAN
Raba-Bima, 9 Juli 2015
Kepala UPT. Puskesmas PenanaE

Hj. Siti Aisyah, A.Md.Kep

NIP 19661231 198703 2 140
BESARAN TARIF JUMLAH TAGIHAN

Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 75,000
BESARAN TARIF JUMLAH TAGIHAN

Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
BESARAN TARIF JUMLAH TAGIHAN

Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
BESARAN TARIF JUMLAH TAGIHAN

Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
BESARAN TARIF JUMLAH TAGIHAN

Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
BESARAN TARIF JUMLAH TAGIHAN

Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
BESARAN TARIF JUMLAH TAGIHAN

Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
BESARAN TARIF JUMLAH TAGIHAN

Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
 BESARAN TARIF JUMLAH TAGIHAN

Rp 25,000
Rp 25,000 Rp 75,000
Rp 25,000
Rp 4,425,000

Bidan Koordinator

Supartinah Mahjam,SST
NIP 19760328 200501 2 013
 LAMPIRAN FORMULIR PENGAJUAN KLAIM ( FPK )
UPT PUSKESMAS PENANAE
KOTA BIMA

Jenis Pelayanan : ANC

Bulan : JULI 2015
JENIS
NO POLINDES NAMA PENDERITA NO. KARTU NO.HP TGL PELAYANAN
PELAYANAN
1 PENARAGA Ramlah 0000848376731 085205094723 5 Januari 2015 K1
4 Maret 2015 K2
4 Mei K3
6 Juli 2015 K4
2 RABADOMPU BARAT Fitrianingsih 0000848586172 085205027928 15 Januari 2015 K1
15 Maret 2015 K2
13 Mei 2015 K3
15 Juli 2015 K4
TOTAL TAGIHAN

Raba-Bima, 10 Agustus 2015

Kepala UPT. Puskesmas PenanaE

Hj. Siti Aisyah, A.Md.Kep

NIP 19661231 198703 2 140
 BESARAN TARIF JUMLAH TAGIHAN

Rp 50,000
Rp 50,000
Rp 200,000
Rp 50,000
Rp 50,000
Rp 50,000
Rp 50,000
Rp 200,000
Rp 50,000
Rp 50,000
Rp 400,000

Bidan Koordinator

Supartinah Mahjam,SST
NIP 19760328 200501 2 013