Scribd Logo
Upload

Welcome to Scribd!

  • Formulir Pengajuan Klaim: BPJS Kesehatan Cab. KOTA BUMI

    Uploaded by

    Emi Suci
    3 views1 page
    This document is a claim form submitted to BPJS Kesehatan (Indonesia's universal healthcare program) by the provider SERUPA INDAH for promotional healthcare services provided in August 2017. It includes 4 transactions totaling 100,000 in costs for IVA services provided to 4 patients on August 15th, 2017. The claim form is dated September 7th, 2017 and submitted by the party filing the claim.

    Original Description:

    pr

    Original Title

    PrintOut

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    Report this Document
    This document is a claim form submitted to BPJS Kesehatan (Indonesia's universal healthcare program) by the provider SERUPA INDAH for promotional healthcare services provided in August 2017. It includes 4 transactions totaling 100,000 in costs for IVA services provided to 4 patients on August 15th, 2017. The claim form is dated September 7th, 2017 and submitted by the party filing the claim.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    3 views1 page

    Formulir Pengajuan Klaim: BPJS Kesehatan Cab. KOTA BUMI

    Uploaded by

    Emi Suci
    This document is a claim form submitted to BPJS Kesehatan (Indonesia's universal healthcare program) by the provider SERUPA INDAH for promotional healthcare services provided in August 2017. It includes 4 transactions totaling 100,000 in costs for IVA services provided to 4 patients on August 15th, 2017. The claim form is dated September 7th, 2017 and submitted by the party filing the claim.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    BPJS Kesehatan Cab.

    KOTA BUMI
    FORMULIR PENGAJUAN KLAIM

    Nomor FPK : L1708000002041


    Provider : SERUPA INDAH
    Bulan Pelayanan : August, 2017
    Pelayanan : Promotif

    Total Data : 4

    Total Tagihan : 100,000

    NO TRANSAKSI TANGGAL NAMA PESERTA JENIS KLAIM Biaya


    08080204L1708157081 15/08/201 NELIYANA IVA 25,000
    08080204L1708157083 15/08/201 SUGIARTI IVA 25,000
    08080204L1708157088 15/08/201 SURYANI IVA 25,000
    08080204L1708157091 15/08/201 SURYANI IVA 25,000

    Tanggal, 07 September 2017


    Pengaju Klaim,

    07/09/2017 09.03.26

    You might also like