FORM PENGAJUAN KLAIM BIDAN JEJARING

BULAN : MEI 2017

KLAIM TAGIHAN : RJTP ( ANC, PNC) NAMA BIDAN JEJARING :Iis Hanipah, Amd. Keb

NAMA FKTP :Klinik Afifah NAMA BANK :BRI

PIMPINAN FKTP : Sri Mujiwati, Amd. Keb., SKM., MM NOMOR REKENING : 0895-01-031428-53-7

TOTAL TAGIHAN :Rp. 1,850,000 NOMOR NPWP BIDAN : 80.724.034.6-445.000

NO NAMA PASIEN NO. BPJS ALAMAT TANGGAL GPA JENIS BESARAN PAKET TOTAL BIAYA
PELAYANAN TAGIHAN DISETUJI

1 Ai Aryanti 0000416664123 Kp. Pasir Tengah rt 03/ rw 15 01-05-2017 G1P0A0 ANC Rp. 200.000 Rp. 275,000

06-05-2017,
11-05-2017,
PNC Rp. 75.000
26-05-2017

2 Rp. 200,000 Rp. 275,000

Astuti 0000415903882 Kp. Cihamerang rt 03/ rw 05 01-05-2017 G1P0A0 ANC

07-05-2017, Rp .75.000
10-05-2017, PNC
18-05-2017

3 Rp.200,000 Rp. 275,000

Rina Karlina 0002209566262 Kp.Cidodol rt 01/ rw 11 10-05-2017 G2P1A0 ANC

12-05-2017 Rp. 75,000

17-05-2017, PNC
24-05-2017

4 Kp. Lembang rt 02 / rw 11 Rp. 200,000 Rp. 275,000

Fitriani 0000415444689 15-05-2017 G2P1A0 ANC

17-05-2017, Rp. 75,000

20-05-2017, PNC
30-05-2017
5 Iis Sumarni 0001250565333 Kp. Cireuma rt 01 / rw 10 20-05-2017 G2P1A0 ANC Rp.200,000 Rp. 250,000

24-05-2017, Rp. 50.000

PNC
28-05-2017

6. Tati 0000416543139 Kp.Patrol Sari rt 01/ rw 01 12-05-2017 G2P1A0 ANC Rp.200,000 Rp. 250.000

26-05-2017, Rp. 50.000

PNC
30-05-2017

7. Nyai Rohaeti 0000416782765 Kp.Rancaselang rt 01/ rw 09 15-05-2017 G2P1A0 ANC Rp.200,000 Rp. 250.000

27-05-2017, Rp. 50.000

PNC
31-05-2017

TOTAL Rp. 1.850,000 Rp. 1.850,000

Verifikator BPJS Kesehatan Klinik Afifah Bidan Jejaring

( ............................................) {Sri Mujiwati, Amd. Keb., SKM., MM) ( Iis Hanipah, Amd. Keb)