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    5 views2 pages

    BPJS Inc PDF

    Uploaded by

    Destya devi

    Copyright:

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

    BPJS Kesehatan Cab.

    SINGKAWANG
    FORMULIR PENGAJUAN KLAIM TINGKAT PERTAMA

    Nomor FPK : P1603000017135


    Provider : PALOH
    Bulan Pelayanan : March, 2016

    Pelayanan : RITP
    Total Data : 15

    Total Tagihan : 9,150,000

    NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG TINDAKAN Biaya


    150306010316Y000374 titin sumantik 06/03/201 06/03/2016 Paket persalinan per vaginam normal 600,000
    150306010316Y000375 vina 13/03/201 13/03/2016 Paket persalinan per vaginam normal 600,000
    150306010316Y000376 nursida 16/03/201 16/03/2016 Paket persalinan per vaginam normal 600,000
    150306010316Y000377 KENI SRIWAHYUNI 09/03/201 09/03/2016 Paket persalinan per vaginam normal 600,000
    150306010316Y000378 RAHMAWATI 20/03/201 20/03/2016 Paket persalinan per vaginam normal 600,000
    150306010316Y000379 sakila 15/03/201 15/03/2016 Paket persalinan per vaginam normal 600,000
    150306010316Y000380 SRI MONILA 12/03/201 12/03/2016 Paket persalinan per vaginam normal 600,000
    150306010316Y000381 NATASYA AURELYA 12/03/201 12/03/2016 Paket persalinan per vaginam normal 600,000
    150306010316Y000382 nita h 10/03/201 10/03/2016 Paket persalinan per vaginam normal 600,000
    150306010316Y000383 foti martin 10/03/201 10/03/2016 Paket persalinan per vaginam normal 600,000
    150306010316Y000384 SANTI 19/03/201 19/03/2016 Paket persalinan per vaginam normal 600,000
    150306010316Y000385 RENI 31/03/201 31/03/2016 Paket persalinan per vaginam normal 600,000
    150306010316Y000386 EMA 19/03/201 19/03/2016 Paket persalinan per vaginam normal 600,000
    150306010316Y000387 SUMI HARSIH 01/03/201 01/03/2016 Paket persalinan per vaginam normal 600,000

    Tanggal terima Tanggal, 07 April 2016


    Verifikator, Pengaju Klaim,

    07/04/2016 11.19.38
    BPJS Kesehatan Cab. SINGKAWANG
    FORMULIR PENGAJUAN KLAIM TINGKAT PERTAMA

    Nomor FPK : P1603000017135


    Provider : PALOH
    Bulan Pelayanan : March, 2016

    Pelayanan : RITP
    Total Data : 15

    Total Tagihan : 9,150,000

    NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG TINDAKAN Biaya


    150306010316Y000391 LENI 19/03/201 19/03/2016 Paket Persalinan per Vaginam dengan tindakan 750,000

    Tanggal terima Tanggal, 07 April 2016


    Verifikator, Pengaju Klaim,

    07/04/2016 11.19.38

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