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  • Formulir Pengajuan Klaim Tingkat Pertama: BPJS Kesehatan Cab. KEBUMEN

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    7 views2 pages

    Formulir Pengajuan Klaim Tingkat Pertama: BPJS Kesehatan Cab. KEBUMEN

    Uploaded by

    Hammet Hammet
    data

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 2

    BPJS Kesehatan Cab.

    KEBUMEN
    FORMULIR PENGAJUAN KLAIM TINGKAT PERTAMA

    Nomor FPK : P1612000007785


    Provider : KALIKAJAR
    Bulan Pelayanan : December, 2016

    Pelayanan : RITP
    Total Data : 17

    Total Tagihan : 10,200,000

    NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG TINDAKAN Biaya


    111407071216Y000001 SAMSIYAH 02/12/201 02/12/2016 Paket persalinan per vaginam normal 600,000
    111407071216Y000002 RUMINAH 02/12/201 02/12/2016 Paket persalinan per vaginam normal 600,000
    111407071216Y000003 IRA LUSIANA 02/12/201 02/12/2016 Paket persalinan per vaginam normal 600,000
    111407071216Y000004 UMAROH 05/12/201 05/12/2016 Paket persalinan per vaginam normal 600,000
    111407071216Y000005 TRIWIS 06/12/201 06/12/2016 Paket persalinan per vaginam normal 600,000
    111407071216Y000006 BANIYAH 12/12/201 12/12/2016 Paket persalinan per vaginam normal 600,000
    111407071216Y000007 ISTIKOMAH 12/12/201 12/12/2016 Paket persalinan per vaginam normal 600,000
    111407071216Y000008 USWATUN 12/12/201 12/12/2016 Paket persalinan per vaginam normal 600,000
    111407071216Y000009 SITI FATONAH 13/12/201 13/12/2016 Paket persalinan per vaginam normal 600,000
    111407071216Y000010 YULI HANDAYANI 15/12/201 15/12/2016 Paket persalinan per vaginam normal 600,000
    111407071216Y000011 JUPIDA NINGSIH 23/12/201 23/12/2016 Paket persalinan per vaginam normal 600,000
    111407071216Y000012 LINA MUSAROFAH 24/12/201 24/12/2016 Paket persalinan per vaginam normal 600,000
    111407071216Y000013 HANIFAH 30/12/201 30/12/2016 Paket persalinan per vaginam normal 600,000
    111407071216Y000014 ENDAH YUNITA 30/12/201 30/12/2016 Paket persalinan per vaginam normal 600,000

    Tanggal terima Tanggal, 01 January 2017


    Verifikator, Pengaju Klaim,

    01/01/2017 21.29.31
    BPJS Kesehatan Cab. KEBUMEN
    FORMULIR PENGAJUAN KLAIM TINGKAT PERTAMA

    Nomor FPK : P1612000007785


    Provider : KALIKAJAR
    Bulan Pelayanan : December, 2016

    Pelayanan : RITP
    Total Data : 17

    Total Tagihan : 10,200,000

    NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG TINDAKAN Biaya


    111407071216Y000015 PONIYAH 30/12/201 30/12/2016 Paket persalinan per vaginam normal 600,000
    111407071216Y000016 HENI WIKANTI 30/12/201 30/12/2016 Paket persalinan per vaginam normal 600,000
    111407071216Y000017 SRI HANDAYANI 31/12/201 31/12/2016 Paket persalinan per vaginam normal 600,000

    Tanggal terima Tanggal, 01 January 2017


    Verifikator, Pengaju Klaim,

    01/01/2017 21.29.31

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