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

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    Ninditya Sunandar
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    4 views2 pages

    Formulir Pengajuan Klaim Tingkat Pertama: BPJS Kesehatan Cab. KUDUS

    Uploaded by

    Ninditya Sunandar
    null

    Copyright:

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

    BPJS Kesehatan Cab.

    KUDUS
    FORMULIR PENGAJUAN KLAIM TINGKAT PERTAMA

    Nomor FPK : P1807000035163


    Provider : Pulokulon I
    Bulan Pelayanan : July, 2018
    Pelayanan : RJTP

    Total Data : 17

    Total Tagihan : 255,000

    NO TRANSAKSI NAMA PESERTA TANGGAL TINDAKAN TENAGA MEDIS Biaya


    113017010718Y000083 SULASTRI 05/07/201 Pelayanan KB : Suntik dr. Iin Nurhayani 15,000
    113017010718Y000158 07/07/201 Pelayanan KB : Suntik dr. Iin Nurhayani 15,000
    113017010718Y000362 SRI WATINI 17/07/201 Pelayanan KB : Suntik dr. Iin Nurhayani 15,000
    113017010718Y000377 PATRI 19/07/201 Pelayanan KB : Suntik dr. Iin Nurhayani 15,000
    113017010718Y000378 NGADIYEM 19/07/201 Pelayanan KB : Suntik dr. Iin Nurhayani 15,000
    113017010718Y000379 TITIK HANDAYANI 12/07/201 Pelayanan KB : Suntik dr. Iin Nurhayani 15,000
    113017010718Y000380 TUGINEM 04/07/201 Pelayanan KB : Suntik dr. Iin Nurhayani 15,000
    113017010718Y000381 NGASMI 02/07/201 Pelayanan KB : Suntik dr. Iin Nurhayani 15,000
    113017010718Y000794 JAYANTI 05/07/201 Pelayanan KB : Suntik dr. Iin Nurhayani 15,000
    113017010718Y000795 MUNIROH 07/07/201 Pelayanan KB : Suntik dr. Iin Nurhayani 15,000
    113017010718Y000796 SULASTRI 07/07/201 Pelayanan KB : Suntik dr. Iin Nurhayani 15,000
    113017010718Y000797 NUR ZAYANTI 11/07/201 Pelayanan KB : Suntik dr. Iin Nurhayani 15,000
    113017010718Y000798 TUTIK HANDAYANI 13/07/201 Pelayanan KB : Suntik dr. Iin Nurhayani 15,000
    113017010718Y000799 ALIF UMAMI 14/07/201 Pelayanan KB : Suntik dr. Iin Nurhayani 15,000

    Tanggal terima Tanggal, 11 August 2018


    Verifikator, Pengaju Klaim,

    11/08/2018 12.06.48
    BPJS Kesehatan Cab. KUDUS
    FORMULIR PENGAJUAN KLAIM TINGKAT PERTAMA

    Nomor FPK : P1807000035163


    Provider : Pulokulon I
    Bulan Pelayanan : July, 2018
    Pelayanan : RJTP

    Total Data : 17

    Total Tagihan : 255,000

    NO TRANSAKSI NAMA PESERTA TANGGAL TINDAKAN TENAGA MEDIS Biaya


    113017010718Y000800 SUMI 18/07/201 Pelayanan KB : Suntik dr. Iin Nurhayani 15,000
    113017010718Y000801 NGAINUN JARIYAH 20/07/201 Pelayanan KB : Suntik dr. Iin Nurhayani 15,000
    113017010718Y000802 SITI MURSIDAH 26/07/201 Pelayanan KB : Suntik dr. Iin Nurhayani 15,000

    Tanggal terima Tanggal, 11 August 2018


    Verifikator, Pengaju Klaim,

    11/08/2018 12.06.48

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