PT.

ASURANSI JIWA INHEALTH INDONESIA

REKAPITULASI PENGAJUAN TAGIHAN

Tanggal Pelayanan : 01 Des 2016 s/d 31 Des 2016

Nama PPK : IF RSIA CICIK
Tingkat Pelayanan : RJTL

No. No. Ref SJP NOKA PISA Nama Kode BU No RSP Tgl Pel Nama Obat R/N Jml Harga Harga Aju
1 0301R0141216X000001 1001426743394 P AULIA RIFKA 01140190 1 03/12/2016 Tramadol kapsul N 10,00 4.060 4.060
2 0301R0141216X000010 1001010563651 P SARI RAHMADANI, S. 00500006 1 07/12/2016 Starfolat 0,4 mg Dexa N 20,00 4.000 4.000
PSI
3 0301R0141216X000006 1011014059228 I SISILIA VIZAYANA 01140215 1 07/12/2016 Sangobion Kapsul - N 5,00 8.200 8.200
HAMID MERC - Kaps
4 0301R0141216X000005 1001011382662 P MAISA YULIA, AMD 00500006 1 08/12/2016 Starfolat 0,4 mg Dexa N 30,00 5.800 5.800
5 0301R0141216X000004 1051446798426 2 YU KING INDRA 01120199 1 10/12/2016 Cefixime kapsul R.1 4,00 6.240 15.501
Prednison tablet R.2 15,00 2.502
Vitamin A tablet R.2 8,00 701
Paracetamol tablet R.3 9,00 1.080
Ctm tablet R.2 8,00 528
Ambroxol tablet R.2 5,00 672
Equal tablet R.2 8,00 1.978
6 0301R0141216X000019 1001424936958 P MUSTIKA EKA PUTRI 01140190 1 14/12/2016 Asam Mefenamat 50mmg N 10,00 2.668 18.668
tablet
Cefixime 100mg kapsul N 10,00 16.000
7 0301R0141216X000016 1001429322052 P IBDAL MAULINI 01140190 1 14/12/2016 Cavit D3 500,003 mg Merc N 30,00 40.000 44.652
Asam Mefenamat tablet N 10,00 2.668
Nifedipin tablet N 10,00 1.984
8 0301R0141216X000017 1041012671668 1 FIRSTA NOVINA 01140157 1 15/12/2016 Alleron tablet R.2 6,00 396 9.676
KURNIA PUTRI Vitamin B komplek R.2 4,00 398
Dumin tablet R.3 4,00 1.752
Cefixime 100,g kapsul R.1 3,00 4.680
Vitamin A tablet R.2 4,00 398
Equal tablet R.2 1,00 252
9 0301R0141216X000015 1001456811235 P AULIA SATRIA 01140196 1 15/12/2016 Starfolat 0,4 mg Dexa N 30,00 5.800 54.200
Flucoral kapsul N 2,00 48.400
10 0301R0141216X000014 1041005192984 1 ATHMAR ZHAFRAN 01140215 1 16/12/2016 Valisanbe 5mg tablet R.2 5,00 1.716 10.424
YOZA Epexol tablet R.3 3,00 3.060
Cefixime 100mg kapsul R.1 2,00 3.120
Alleron tablet R.3 5,00 330
Vitamin A tablet R.3 4,00 398
11 0301R0141216X000013 1011012918502 I SUCI LESTARI, A. MD 00500006 1 16/12/2016 Cavit D3 500,003 mg Merc N 10,00 13.600 26.240
Biosanbe kapsul N 10,00 12.640
12 0301R0141216X000018 1001006334088 P RINI ALVIANI. AMD 00500006 1 17/12/2016 Cavit D3 500,003 mg Merc N 30,00 40.000 45.800
Starfolat 0,4 mg Dexa N 30,00 5.800
13 0301R0141216X000012 1001435644168 P LISTI AFWANAMD 01140217 1 18/12/2016 Nova T 1 unit dengan luas N 1,00 214.300 214.300
permukaan tembaga
sekitar 380 mm2 yang
distabilkan dengan inti
perak Bayr
14 0301R0141216X000011 1001456812956 P SYAFRIYANI 01140196 1 18/12/2016 Starfolat 0,4 mg Dexa N 30,00 5.800 45.800
Cavit D3 500,003 mg Merc N 30,00 40.000
15 0301R0141216X000020 1041446798425 1 YU YIYIE INDRA 01120199 1 19/12/2016 Cefixime 100mg kapsul R.1 6,00 9.360 14.892
Alleron tablet R.3 10,00 660
Vitamin A tablet R.3 8,00 797
Paracetamol tablet R.2 10,00 1.200
Ambroxol tablet R.3 8,00 1.075
16 0301R0141216X000021 1011010563674 I DESI KARLINA SARI 00500006 1 20/12/2016 Starfolat 0,4 mg Dexa N 30,00 5.800 78.200
Anvomer B6 tablet N 30,00 72.400
17 0301R0141216X000022 1041009671226 1 RAFFI HADYAN 02230011 1 22/12/2016 Paracetamol 500mg tablet R.2 11,00 1.320 16.575
RIDHO PRATAMA Ambroxol tablet R.3 9,00 1.210
Cefixime 100mg kapsul R.1 7,00 10.920
Alleron tablet R.3 8,00 528
Vitamin A tablet R.3 8,00 797
18 0301R0141216X000023 1051009671227 2 RAIZEL ALFARIDHO 02230011 1 22/12/2016 Cefixime 100mg kapsul R.1 4,00 6.240 11.117
SYAFIQ Alleron tablet R.3 8,00 528
Vitamin A tablet R.3 8,00 797
Paracetamol 500mg tablet R.2 9,00 1.080
Ambroxol tablet R.3 5,00 672
19 0301R0141216X000024 1061009671228 3 RAEFALLIO 02230011 1 22/12/2016 Paracetamol tablet R.2 4,00 480 10.794
ALFARIDHO Ambroxol tablet R.3 4,00 538
ZHAFRAN
Vitamin A tablet R.3 4,00 398
Cefixime 100mg kapsul R.1 3,00 4.680
Alleron tablet R.3 6,00 396
Prednison tablet R.3 15,00 2.502
20 0301R0141216X000026 1041438854878 1 MUHAMMAD 01140219 1 26/12/2016 Paracetamol 500mg tablet R.1 4,00 480 7.467
SHAQUEL ARKAN Ambroxol tablet R.2 3,00 403
ATTAURI
Alleron tablet R.2 4,00 264
Amoxicilin 500mg tablet R.2 5,00 2.220
Prednison tablet R.2 15,00 2.502

Halaman 1
05-01-2017 11:14:16 | SIMO | PT. Asuransi Jiwa InHealth Indonesia
 PT. ASURANSI JIWA INHEALTH INDONESIA
REKAPITULASI PENGAJUAN TAGIHAN

Vitamin A tablet R.2 4,00 398

21 0301R0141216X000032 1011424930119 I RIKA PUTRI 01140190 1 31/12/2016 Nova T N 1,00 225.800 241.340
SWAYANTI Asam Mefenamat 500mg N 15,00 3.460
tablet
Amoxicilin 500mg tablet N 15,00 6.880
Neurodex tablet N 10,00 5.200
Total Rp. 887.706

Menyetujui,

Halaman 2
05-01-2017 11:14:16 | SIMO | PT. Asuransi Jiwa InHealth Indonesia