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  • FPK Manual Prolanis

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    endah retno
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    This form is a claim application (FPK) submitted to BPJS Kesehatan, the Indonesian national health insurance program. It is from Puskesmas Pulokulon II health center located in Sembungharjo, Pulokulon. The claim is for the month of December 2017 and includes a 100,000 Rupiah fee for an instructor's honorarium for a senior exercise club program called Klub Prolanis Mulia Sehat held at the health center in December. The total claimed amount is 100,000 Rupiah. The bottom section is for BPJS Kesehatan to approve the claim.

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    This form is a claim application (FPK) submitted to BPJS Kesehatan, the Indonesian national health insurance program. It is from Puskesmas Pulokulon II health center located in Sembungharjo, Pulokulon. The claim is for the month of December 2017 and includes a 100,000 Rupiah fee for an instructor's honorarium for a senior exercise club program called Klub Prolanis Mulia Sehat held at the health center in December. The total claimed amount is 100,000 Rupiah. The bottom section is for BPJS Kesehatan to approve the claim.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
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    5 views4 pages

    FPK Manual Prolanis

    Uploaded by

    endah retno
    This form is a claim application (FPK) submitted to BPJS Kesehatan, the Indonesian national health insurance program. It is from Puskesmas Pulokulon II health center located in Sembungharjo, Pulokulon. The claim is for the month of December 2017 and includes a 100,000 Rupiah fee for an instructor's honorarium for a senior exercise club program called Klub Prolanis Mulia Sehat held at the health center in December. The total claimed amount is 100,000 Rupiah. The bottom section is for BPJS Kesehatan to approve the claim.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
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    of 4

    FORMULIR PENGAJUAN KLAIM (FPK)

    BPJS KESEHATAN
    KCU SEMARANG
    RAWAT JALAN v
    RAWAT INAP

    Tgl. Diajukan 5 Desember 2017 Diterima tgl. :


    Klaim Bulan Desember 2017 FPK Reg. No :

    NAMA PPK : Puskesmas Pulokulon II


    ALAMAT : Jln Raya Danyang-Kuwu KM 12 Kolekti RSU A B C RS Khusus
    Sembungharjo Pulokulon
    RS Swasta RS ABRI RS POLRI
    TELEPON : Apotik Optik Faskes Tk. 1

    DIAJUKAN (diisi PPK) DISETUJUI (diisi oleh BPJS Kesehatan)


    NO KODE AKUN JENIS BIAYA HARI RAWAT HARI RAWAT
    KASUS JUMLAH BIAYA KASUS
    KALI TINDAKAN KALI TINDAKAN

    Biaya Kegiatan Kelompok


    1 Klub Prolanis Mulia Sehat
    Puskesmas Pulokulon 2

    - Honor Instruktur Senam


    Prolanis Bulan Desember Rp 100,000
    2017

    JUMLAH Rp 100,000

    Sembungharjo, 5 Desember 2017 Semarang, Tgl……………………………………


    Nama PPK : Puskesmas Pulokulon II (Tgl Disetujui BPJS Kesehatan)

    dr.Rina Kartini (……………………………………………)


    NIP.19810421 200907 2 001
    )

    DISETUJUI (diisi oleh BPJS Kesehatan)

    JUMLAH BIAYA

    Semarang, Tgl……………………………………

    (……………………………………………)

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