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BPJS Kesehatan Cab.

PAMEKASAN
FORMULIR PENGAJUAN KLAIM TINGKAT PERTAMA

Nomor FPK : P1801000034722


Provider : BULANGAN HAJI
Bulan Pelayanan : January, 2018

Pelayanan : RITP
Total Data : 7

Total Tagihan : 4,900,000

NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG TINDAKAN TENAGA MEDIS Biaya
133707020118Y000820 HANIYAH 18/01/201 18/01/2018 Paket Persalinan per Vaginam normal (oleh Bidan) DR TRI SUSANDHI JULIARTO 700,000
133707020118Y000821 ANIS FITRIYAH 06/01/201 06/01/2018 Paket Persalinan per Vaginam normal (oleh Bidan) DR TRI SUSANDHI JULIARTO 700,000
133707020118Y000822 MUTI'AH 03/01/201 03/01/2018 Paket Persalinan per Vaginam normal (oleh Bidan) DR TRI SUSANDHI JULIARTO 700,000
133707020118Y000823 NORHALIMAH 22/01/201 22/01/2018 Paket Persalinan per Vaginam normal (oleh Bidan) DR TRI SUSANDHI JULIARTO 700,000
133707020118Y000824 SUDILAH 05/01/201 05/01/2018 Paket Persalinan per Vaginam normal (oleh Bidan) DR TRI SUSANDHI JULIARTO 700,000
133707020118Y000825 RAHMAWATI 10/01/201 10/01/2018 Paket Persalinan per Vaginam normal (oleh Bidan) DR TRI SUSANDHI JULIARTO 700,000
133707020118Y000826 Lailatul Musyarrofah 12/01/201 12/01/2018 Paket Persalinan per Vaginam normal (oleh Bidan) DR TRI SUSANDHI JULIARTO 700,000

Tanggal terima Tanggal, 12 February 2018


Verifikator, Pengaju Klaim,

12/02/2018 08.09.04