BP Demangan November 2015

DAFTAR TAGIHAN KLAIM RAWAT JALAN JAMKESMAS DI PELAYANAN DASAR
PROPINSI : JAWA TIMUR BULAN November

KOTA : MADIUN TAHUN :
POLI : BP UMUM …...
PELKES & BESARAN
NO KARTU PESERTA JNS KLM TANGGAL TANDA
UMUR TARIF SESUAI PERDA
NO NAMA PASIEN DIAGNOSA
(RP)
JAMKESMAS L P KUNJUNGAN TANGAN
< 1 TH 1-4 TH 5-14TH 15-44TH 45-64TH 65>TH BP UMUM
1 2 3 4 5 6 7 8 9
1 SUTIANI 0000785238928 1 1 2/11/2015 M36
2 TOTOK SUBIANTO 0000786388296 1 1 2/11/2015 J45
3 ISMAIL 0000786237603 1 1 2/11/2015 J10
4 KATEMI 00011049783916 1 1 2/11/2015 M36
5 PARINUK 0000787714389 1 1 2/11/2015 E11
6 MAIMUN 000078658568 1 1 2/11/2015 I50
7 SUPRIHATIN 0000787203988 1 1 2/11/2015 E11
8 TUTIK 0000787300042 1 1 2/11/2015 E11
9 SRI PURWANINGRUM 0000786477892 1 1 2/11/2015 G43
10 LANDEP 0000786342813 1 1 2/11/2015 E11
11 WAHID 0000786367361 1 1 2/11/2015 E11
12 SUMINI 0001049784783 1 1 2/11/2015 M36
13 KEREN CANTIKA 0001049784129 1 1 2/11/2015 J10
14 SARNO DINSOS 1 1 3/11/2015 V20
15 GIRAH 0000786692283 1 1 3/11/2015 M36
16 TATIK 0000786188654 1 1 3/11/2015 E11
17 SULAMI 0001049784873 1 1 3/11/2015 B35
18 SUPRIYONO 0000786755586 1 1 4/11/2015 G44
19 WIJI 0000786754293 1 1 4/11/2015 K29
20 SINEM 0000786754034 1 1 4/11/2015 J45
21 SRI HARTATIK 0000786772664 1 1 4/11/2015 L23
22 KASMI 0000786771584 1 1 4/11/2015 M36
23 ACHMAD SYAIFUDIN 0000786905831 1 1 4/11/2015 V20
24 NURIK H 00007874444121 1 1 4/11/2015 A18
25 KASIYEM 0000786701182 1 1 5/11/2015 E11
JUMLAH TOTAL 0 0 0 4 17 4 7 18
Mengetahui
Kepala Puskesmas Demangan

PROPINSI : JAWA TIMUR BULAN : NOVEMBER
KOTA : MADIUN TAHUN 2015
PELKES & BESARAN
(RP)
1 2 3 4 5 6 7 8 9
1 ERNA DWI S 0000786769751 1 1 5/11/2015 B05
2 SRI WAHYUTI 0000786351633 1 1 5/11/2015 G44
3 NANDI MAULANA 0000787229818 1 1 5/11/2015 J11
4 DANANG KURNIAWWAN 0000787675689 1 1 6/11/2015 E11
5 WAGIRAH 0000786877367 1 1 6/11/2015 E11
6 MARSI 0000786524264 1 1 6/11/2015 E11
7 WAHYU SRI REJEKI DINSOS 1 1 6/11/2015 J10
8 JUVANO DINSOS 1 1 6/11/2015 R50
9 DENI DWI K 0000786478994 1 1 6/11/2015 B01
10 NINIK K 0000787107508 1 1 6/11/2015 M36
11 KATIYEM 0000785252147 1 1 6/11/2015 H52
12 MARIYANI 0000788745629 1 1 6/11/2015 M36
13 CHURIYATUL 0000786485665 1 1 6/11/2015 J10
14 GUNAWAN 0000786485204 1 1 6/11/2015 Q69
15 TINO PUTRA D A 0000786409345 1 1 6/11/2015 B01
16 KATEMI 0000786389782 1 1 6/11/2015 M36
17 SARNO DINSOS 1 9/11/2015 M36
18 UMMI WINARSEH DINSOS 1 9/11/2015 M36
19 SULAMI 0001049784873 1 9/11/2015 K29
20 PAERAN 0000787048132 1 9/11/2015 M36
21 BAMBANG 0000786351756 1 9/11/2015 J11
22 YENIK 0000787224036 1 9/11/2015 M36
23 NANIK SETYORINI 0000786917035 1 9/11/2015 M36
24 SUKIRAH 0000786102715 1 9/11/2015 M36
25 ANDIN 0000786833291 1 9/11/2015 L23
JUMLAH TOTAL 2 3 4 6 5 8 13
Mengetahui

KOTA : MADIUN TAHUN : 2015
PELKES & BESARAN
(RP)
1 2 3 4 5 6 7 8 9
1 SUKINI 0001082043369 1 1 9/11/2015 M36
2 ANDI SUSANTO 0000080495908 1 1 9/11/2015 J11
3 AGUS SUGIARNO 0000786753213 1 1 9/11/2015 J11
4 HARIYANTO 0001049786673 1 1 9/11/2015 A18
5 REMI 0000786793252 1 1 9/11/2015 J45
6 TYAS BUDIARSEH 0000787024258 1 1 9/11/2015 J11
7 PRIHATEN 0000787023426 1 1 9/11/2015 M36
8 TUKIMAN 0000786422081 1 1 9/11/2015 A01
9 SUMINI 0000786422136 1 1 9/11/2015 M36
10 SEMI 0000787216858 1 1 10/11/2015 J44.9
11 SUPARTI 0000786723052 1 1 10/11/2015 J10
12 MARINEM 0001049783466 1 1 10/11/2015 G44
13 WINIH 0000786234464 1 1 10/11/2015 M36
14 WAHYUNI 0000786949738 1 1 10/11/2015 G11
15 SURYATI 0000786897134 1 1 10/11/2015 J11
16 HANDOYO 0000786905504 1 1 11/10/2015 J11
17 JOVIT F 0000786284998 1 1 11/10/2015 V20 15000
18 KURNIA HARY 0000786483371 1 1 11/10/2015 A09
19 SITIN 0000786787918 1 1 11/10/2015 G44
20 JESI AULIA 0000787049594 1 11/10/2015 B05
21 NUR KHASANAH 0000786367203 1 1 11/10/2015 M36
22 UTUN SABARWATI '0000786402933 1 1 11/10/2015 G44
23 YATIMAN 0000078529331 1 1 11/10/2015 M36
24 SIUKINO 0000786727539 1 1 11/10/2015 K29
25 YULIANTI 0000786814716 1 11/11/2015 M36
JUMLAH TOTAL 0 0 1 6 13 4 8 16
Mengetahui

PELKES & BESARAN
(RP)
1 2 3 4 5 6 7 8 9
1 SITI KASIANI 0000786871899 1 1 11/11/2015 G44
2 HARJO MISKUN 0000787039018 1 1 12/11/2015 E11
3 KEMIS 0000786478408 1 1 12/11/2015 H52
4 SURIP 0000786400209 1 1 12/11/2015 164
5 RIYONO 0000786520754 1 1 12/11/2015 H26
6 ERNI DINSOS 1 1 12/11/2015 G44
7 ERFAN DINSOS 1 1 12/11/2015 J10
8 KASIYEM 0000786701182 1 1 12/11/2015 M36
9 MINARNI 0000786847634 1 1 12/11/2015 M36
10 PURNOMO 0000786483191 1 1 12/11/2015 M36
11 SEMI 0000787216858 1 1 12/11/2015 J44
12 DANI 0001049784445 1 1 13/11/2015 J45
13 DEWIS ,0000786859233 1 1 13/11/2105 J45
14 JOVIT 0000786284998 1 1 13/11/2195 V20
15 SUYATNO 0000786915753 1 1 13/11/2285 M36
16 SRI WAHYUNI 00007861405148 1 1 13/11/2375 M36
17 BAYU A 0000786393573 1 1 13/11/2465 R05
18 NINIK S K 0000787481414 1 1 13/11/2555 I69/I10
19 GIANTO DINSOS 1 1 13/11/2645 A09
20 ANJARWATI 0000786388948 1 1 13/11/2735 K29
21 PIPIT YULI A 0000786858579 1 1 13/11/2825 J11
22 HARI SUNARYO 0001049785334 1 1 13/11/2915 J10
23 TELLY WILIS AY 0000786767343 1 1 13/11/3005 J45
24 PRIHATIN MUJI RAHAYU 0000786222606 1 1 13/11/3095 M36
25 NGADIMO HADI S 0000786221381 1 1 13/11/3185 M36
JUMLAH TOTAL
Mengetahui
PELKES & BESARAN
(RP)
1 2 3 4 5 6 7 8 9
1 SRI WIJAYANTI 0000786156502 0 1 1 13/11/2015 M36
2 BOINEM 0000786757612 1 1 16/11/2015 M36
3 SUMARMI 0000786206711 1 1 16/11/2015 M36
4 SUNARWAN 0000786506499 1 1 16/11/2015 G46
5 DEVI CANTIKA 0000786118555 1 1 16/11/2015 H00
6 JOVIT FIRMANDA 0000786284998 1 1 16/11/2015 V20 15000
7 ERNI DINSOS 1 1 16/11/2015 J10
8 BASURI DINSOS 1 1 16/11/2015 J11
9 RONI DINSOS 1 1 16/11/2015 J45
10 EVIYANTI DINSOS 1 1 16/11/2015 J45
11 CANDRA GUNAWAN DINSOS 1 1 16/11/2015 J11
12 MOH IQBAL DINSOS 1 1 16/11/2015 J11
13 NURIK HANDAYANI 00007874444121 1 1 16/11/2015 M36
14 SUYATMI 0000785253565 1 1 16/11/2015 J11
15 SITI KHAROMAH 0000787116082 1 1 16/11/2015 B02
16 ARIF ABADI 0000786766217 1 1 16/11/2015 B02
17 SAMINEM 0000786324161 1 1 16/11/2015 K29
18 SUMARMI 0000786096314 1 1 16/11/2015 J11
19 YULI T 0001083697031 1 1 16/11/2015 K30
20 WAHYUNI SRI A 0000786949738 1 1 17/11/2015 I95
21 NANDA P 0001049784074 1 1 17/11/2015 J11
22 UMI WINARSIH DINSOS 17/11/2015 B05
23 PONIRAH DINSOS 17/11/2015 B05
24 TRI UTAMI 0000786853574 1 17/11/2015 M36
25 UMI YATUN 0000786825696 0 1 17/11/2015 M36
JUMLAH TOTAL 0 1 2 8 12 0 7 14
Mengetahui

POLI : BP UMUM INDUK
PELKES & BESARAN
(RP)
1 2 3 4 5 6 7 8 9
1 GUNAWAN 0000786846126 0 1 1 ;17/11/2015 M36 5000
2 KATEMI 0000786853765 1 1 17/11/2015 M36 5000
3 BONADI 0000787106496 1 1 17/11/2015 v20 5000
4 ANIK PRIHATIN 0000787056221 1 1 17/11/2015 J10 5000
5 BONADI 0000787106496 1 1 18/11/2015 v20 5000
6 PARINUK 0000787714389 1 1 18/11/2015 I10 5000
7 MARTO SEMAN 0000787189037 1 1 18/11/2015 K29 5000
8 JOVIT FIRMANDA 0000786284998 1 1 18/11/2015 V20 5000
9 RIYAN '0000785837621 1 1 18/11/2015 J11 5000
10 DARMIATI 0000787123034 1 1 18/11/2015 B35 5000
11 SUKIYEM ,0000786161182 1 1 18/11/2015 M36 5000
12 WIJI 0000786159404 1 1 18/11/2015 M36 5000
13 DANI 0001049784445 1 1 19/11/2015 I50 5000
14 SINEM 0000786901307 1 1 19/11/2015 J44 5000
15 ILHAM DINSOS 1 1 19/11/2015 V20 5000
16 KAMIAR 0001049784096 1 1 19/11/2015 M36 5000
17 KEREN CANTIKA 0001049784129 1 1 19/11/2015 L30 5000
18 RUMINATI 0000787121616 1 1 19/11/2015 I10 5000
19 MARIATUN 0001049782250 1 1 19/11/2015 J11 5000
20 MUSINAH 0000787198476 1 1 19/11/2015 E11 5000
21 ANDI MARWAN 0000786475833 1 1 19/11/2015 H66 5000
22 SALUSI 0000786488793 1 1 19/11/2015 M36 5000
23 SAROKI 0000786489658 1 1 19/11/2015 J11 5000
24 ANTI R 0000787093648 1 1 19/11/2015 M36 5000
25 INTAN P 0000786759524 0 1 1 19/11/2015 J11 5000
JUMLAH TOTAL 0 0 2 8 11 4 10 15 125000
Mengetahui

PELKES & BESARAN
(RP)
1 2 3 4 5 6 7 8 9
1 BOINEM 0000786757612 1 1 19/11/2015 M36 5000
2 SUNARTI 0000786195426 1 1 19/11/2015 K29 5000
3 SRI ERI K 0000786508626 1 1 20/11/2015 I10 5000
4 KATIYEM 0000786502089 1 1 20/11/2015 A09 5000
5 THEO SAPUTRA 0000786900431 1 1 20/11/2015 D17 5000
6 KUNTO B 0000706323114 1 1 20/11/2015 N20 5000
7 RULIYAH 0000786882611 1 1 20/11/2015 H81 5000
8 IRA A 0000786125733 1 20/11/2015 H81 5000
9 JOVIT FIRMANDA 0000786284998 1 1 20/11/2015 V20 5000
10 ELIAWATI 0000786873543 1 1 20/11/2015 B02 5000
11 ENDANG S 0000786872586 1 1 20/11/2015 M36 5000
12 ANANDA WAHYU A DINSOS 1 1 20/11/2015 B35 5000
13 NURIK H 0000787444121 1 1 20/11/2015 M36 5000
14 KATEMI 0000786389782 1 1 20/11/2015 M36 5000
15 UMIYATI 0000786510156 1 1 20/11/2015 I95 5000
16 HARIYADI DINSOS 1 1 20/11/2015 M36 5000
17 LILIK DINSOS 1 1 20/11/2015 L23 5000
18 ZAINAL DINSOS 1 1 20/11/2015 J10 5000
19 MULYANTO DINSOS 1 1 20/11/2015 J10 5000
20 KADIRAN DINSOS 1 1 20/11/2015 M36 5000
21 WIWIK DINSOS 1 1 20/11/2015 M36 5000
22 ANANDA WAHYU A DINSOS 1 1 20/11/2015 L23 5000
23 BASUKI DINSOS 1 1 20/11/2015 J10 5000
24 KHANAYA TABITHA 000786747093 1 23/11/2015 J10 5000
25 SULASMI NINGSIH 00786365504 1 23/11/2015 M36 5000
JUMLAH TOTAL 0 2 3 9 10 1 9 13 125000
Mengetahui

PELKES & BESARAN
(RP)
1 2 3 4 5 6 7 8 9
1 TUKIRAN 0000786873576 1 23/11/201 I50
2 KLARISA 0000786820746 1 23/11/2015 B35
3 SAMINAH 000786700574 1 23/11/2015 J45
4 TIKIYEM 0001049785299 1 23/11/2015 G44
5 NIRMALA 0000787100793 1 23/11/2015 J10
6 SAMINAH 0000786700574 1 23/11/2015 J45
7 PARIANI 0000786889438 1 23/11/2015 J10
8 MARIYANI 0000786745629 1 23/11/2015 M36
9 SULASTRI 0000787123642 1 23/11/2015 J10
10 RISKI 0000787125791 1 23/11/2015 J10
11 ELY ERNAWATI 0000786229334 1 23/11/2015 M36
12 NOVUTA TRI 0000786227916 1 23/11/2015 M35
13 WIJI 0000786159404 1 23/11/2015 M36
14 RENDI GILANG 0000786265997 1 23/11/2015 J11
15 SUGIMIN 0000786265299 1 1 23/11/2015 M36
16 GENDON 0000786119848 1 23/11/2015 I10
17 BONARI 0000787449824 1 23/11/2015 G46
18 TUMI 0000787450252 1 23/11/2015 I10
19 JUMIRAN 0000786757026 1 23/11/2015 I10
20 WIJI LESTARI 0000786514353 1 1 23/11/2015 M36
21 RAMADANI PRADA 0001049782634 1 1 23/11/2015 D
22 WIDYANINGSIH 0000786499661 1 23/11/2015 M36
23 MOCH SATRIA 0000787266426 1 24/11/2015 V20
24 SUMIATI 0000786604475 1 24/11/2015 K29
25 SUGENG 0000786609573 1 1 24/11/2015 F28
JUMLAH TOTAL 0 0 5 10 8 2 3 1 0
Mengetahui

PELKES & BESARAN
(RP)
1 2 3 4 5 6 7 8 9
1 ISMAIL 0000786237603 1 1 24/11/2015 J11 5000
2 SUMINI 0000786865713 1 1 24/11/2015 M81 5000
3 LUGIYATI 0000786803229 1 1 24/11/2015 K29 5000
4 EGIS WIYANLING 000078677229 1 1 24/11/2015 J11 5000
5 PUJI HARIYANTO 0000786766364 1 1 24/11/2015 K12 5000
6 ERVINA AURA 0001049784917 1 1 24/11/2015 D17 5000
7 DJOHARIANTO 000104978149 1 1 24/11/2015 M36 5000
8 SAMSINI 0000786469353 1 1 25/11/2015 M36 5000
9 MIRIN 0000786343263 1 1 25/11/2015 E11 5000
10 SARIYEM 0000786135723 1 1 25/11/2015 M36 5000
11 ZENUK 0000787118859 1 25/11/2015 G44 5000
12 AYUNINGRUM 0000786907451 1 25/11/2015 A09 5000
13 SUKILAH 0000786916686 1 1 25/11/2015 D17 5000
14 SUKINEM 0000786085266 1 1 25/11/2015 A09 5000
15 AKBAR BAGUS 0000787103706 1 25/11/2015 A09 5000
16 ANGGUN KIRANA 0000786185403 1 25/11/2015 J11 5000
17 HARIADI 0000786896987 1 1 25/11/2015 F28 5000
18 SUGENG PRAMUDAWARDANI 0000786185032 1 25/11/2015 K29 5000
19 DIKA HENDRA 0000786065242 1 1 25/11/2015 V20 5000
20 SAHARA 0000786540317 1 25/11/2015 N39 5000
21 ISWARI 0000786772056 1 1 25/11/2015 E11 5000
22 PURWATI 0000786815684 1 25/11/2015 J10 5000
23 EKO ADI 0000787034979 1 25/11/2015 J10 5000
24 SUPRAPTO 0000787104347 1 25/11/2015 V20 5000
25 PARTINI 0000787229155 1 25/11/2015 R05 5000
125000
Mengetahui
PELKES & BESARAN
(RP)
1 2 3 4 5 6 7 8 9
1 MAULIDATU 0000787230213 1 1 25/11/2015 J11 5000
2 SUPRAPTO 0000787104347 1 1 25/11/2015 V20 5000
3 PANEN 0000786829972 1 1 26/11/2015 I50 5000
4 PARINUK 0000787714389 1 1 26/11/2015 M36 5000
5 FEBRIANDA SENJA 0000786925708 1 1 26/11/2015 C81 5000
6 NATANAEL 0000787107036 1 1 26/11/2015 E11 5000
7 TUMIRAN 0001049789136 1 1 27/11/2015 R05 5000
8 ENDANG LESTARI DINSOS 1 27/11/2015 M36 5000
9 NABELLA YESI Y 0000786273412 1 1 27/11/2015 J11 5000
10 SOEJONO 0000106423738 1 27/11/2015 M36 5000
11 SUTILAH 0000786844596 1 27/11/2015 M36 5000
12 RIZMA MAULANA 0000795595689 1 27/11/2015 G40 5000
13 PRIHATIN 0000787023426 1 27/11/2015 M36 5000
14 MIHAT 0000786469847 1 27/11/2015 I10 5000
15 PEREI OUAN 0000786389782 1 27/11/2015 M36 5000
16 KASMIYATUN 0000787414814 1 1 30/11/2015 M36 5000
17 ARIN 0001623268405 1 1 30/11/2015 H11 5000
18 ADIVA A 0001623268416 1 1 30/11/2015 L23 5000
19 IRVAN DANI F 0000786860436 1 1 30/11/2015 J10 5000
20 SUMIATI 0000786504475 1 1 30/11/2015 K29 5000
21 SUNARNI 0000786144903 1 1 30/11/2015 J11 5000
22 ATIK 0000787275696 1 1 30/11/2015 M36 5000
23 KADIMEN 0000787237446 1 1 30/11/2015 I10 5000
24 GIANTO DINSOS 1 1 30/11/2015 L23 5000
25 KURNIAWAN DINSOS 1 1 30/11/2015 L23 5000
JUMLAH TOTAL 0 1 2 7 13 2 6 12 125000
Mengetahui

PELKES & BESARAN
(RP)
1 2 3 4 5 6 7 8 9
1 SRI ERY K 0000786508626 1 1 30/11/2015 I10 5000
2 KATIRAH 0000786914381 1 1 30/11/2015 E11 5000
3 MARIYANI 0000786843099 1 1 30/11/2015 E11 5000
4 NURIK HANDAYANI 0000787444121 1 1 30/11/2015 M36 5000
5 5000
6 5000
7 5000
8 5000
9 5000
10 5000
11 5000
12 5000
13 5000
14 5000
15 5000
16 5000
17 5000
18 5000
19 5000
20 5000
21 5000
22 5000
23 5000
24 5000
25 5000
JUMLAH TOTAL 0 0 0 1 1 2 0 4 125000
Mengetahui
DAFTAR TAGIHAN KLAIM RAWAT JALAN
PROGRAM JAMKESMASTA DI PELAYANAN DASAR
KOTA : MADIUN PUSKESMAS :
BULAN : TAHUN :
POLI :BP UMUM……
PELKES & BESARAN
NO KARTU KELUARGA UMUR TANGGAL TARIF SESUAI PERDA
NO NAMA PASIEN DIAGNOSA (RP)
BHBS JASPEL TOTAL
< 1 TH 1-4 TH 5-14TH 15-44TH 45-64TH 65>TH POLI UMUM
1 2 3 L P L P L P L P L P L P 5 6 7 8 9 10
1 BUDI HARIYONO 3577032204072236 1 2/11/2015 COR 3000 2000 5000
2 ROHADI 3577032801100004 1 2/11/2015 E11 3000 2000 5000
3 MOHAMAT FEBRI E S 3577032204071585 1 2/11/2015 J10 3000 2000 5000
4 SOEDIRO 3577022104079797 1 2/11/2015 M36 3000 2000 5000
5 SUWARNO 3577032204070111 1 2/11/2015 I10 3000 2000 5000
6 MISWAN 3577032204070077 1 2/11/2015 M36 3000 2000 5000
7 PAVITA AYU S 3577031007120006 1 2/11/2015 J11 3000 2000 5000
8 TRI LESTARI 3577032204071101 1 2/11/2015 M36 3000 2000 5000
9 AYUNDA ARDINI P 3577032204071101 1 2/11/2015 J10 3000 2000 5000
10 SRI YULIANTI 3577032905090001 1 2/11/2015 I10 3000 2000 5000
11 CARIM 3577032905090001 1 2/11/2015 H10 3000 2000 5000
12 CHELSEA KIRANA M 3577032004077260 1 2/11/2015 J10 3000 2000 5000
13 DWI SULASTRI 3577032204070111 1 2/11/2015 M36 3000 2000 5000
14 DWI PURWATI 1250029800343 1 2/11/2015 M36 3000 2000 5000
15 LIKLIS S 35770322041500013 1 2/11/2015 G43 3000 2000 5000
16 DEFICHA Z Z 3577031611090011 1 2/11/2015 J45 3000 2000 5000
17 YAYUK 3577022104079310 1 2/11/2015 E11 3000 2000 5000
18 ISAFA Y S 357703200611001 1 2/11/2015 J11 3000 2000 5000
19 SUMINEM 3577031409090004 1 2/11/2015 M36 3000 2000 5000
20 FRISCA AMALIA P P 3577032004076057 1 2/11/2015 J10 3000 2000 5000
21 IWANG ANDRO 3577030401110033 1 2/11/2015 V20 3000 2000 5000
22 HARMONO 3577032204073202 1 2/11/2015 M36 3000 2000 5000
23 RIZA YOSAP A 3577031007120007 1 2/11/2015 G44 3000 2000 5000
24 WIJI S 3577032204072568 1 2/11/2015 G44 3000 2000 5000
25 SUDJARWO 3577032004075650 1 2/11/2015 M36 3000 2000 5000
JUMLAH TOTAL 1 1 3 3 8 4 5 75000 50000 125000
Mengetahui
Kepala Puskesmas Demangan Pelaksana Pelayanan

BULAN : TAHUN :
POLI :BP UMUM……
PELKES & BESARAN
NO KARTU KELUARGA UMUR TANGGAL
TARIF SESUAI PERDA
NO NAMA PASIEN DIAGNOSA BHBS JASPEL TOTAL
(RP)
1 2 3 L P L P L P L P L P L P 5 6 7 8 9 10
1 SUYAHMI 3577032004075650 1 2/11/2015 J10 3000 2000 5000
2 WAGI RAHAYU 3577032204070350 1 2/11/2015 I84 3000 2000 5000
3 KYNARA AZ ZAHRA P A 3577031302130002 1 2/11/2015 J10 3000 2000 5000
4 SADREMI 3577032204077667 1 2/11/2015 J11 3000 2000 5000
5 MUNAFATIN 3577032004075006 1 2/11/2015 L23 3000 2000 5000
6 SRI SUPATMI 357703214079882 1 2/11/2015 M36 3000 2000 5000
7 ROBERTHA PRIN C 3577032204073071 1 2/11/2015 I10 3000 2000 5000
8 BAYTU SANJOYO 3577032004074991 1 2/11/2015 E11 3000 2000 5000
9 SUPRAPTI 3577031007040001 1 2/11/2015 L23 3000 2000 5000
10 NANIK 35777032204074949 1 2/11/2015 M36 3000 2000 5000
11 SETIYONO 3577032204074949 1 2/11/2015 M36 3000 2000 5000
12 KAYLARAFA 35770326091320002 1 2/11/2015 L23 3000 2000 5000
13 TRI YUWONO 3577032204076329 1 2/11/2015 F23 3000 2000 5000
14 YOHANA 3577032104076160 1 2/11/2015 M36 3000 2000 5000
15 SUSI CANDRA 3577032406100003 1 2/11/2015 M36 3000 2000 5000
16 SUPARMI 3570032204071766 1 3/11/2015 I10 3000 2000 5000
17 IKE NOVITASARI 3577032407120002 1 3/11/2015 J10 3000 2000 5000
18 YUDA ASMARA 3577031705840003 1 3/11/2015 J10 3000 2000 5000
19 SUWARNO 3577032204072819 1 3/11/2015 M36 3000 2000 5000
20 DEBPI 3577032004075454 1 3/11/2015 M36 3000 2000 5000
21 DIDIK 3577032605090010 1 3/11/2015 V20 3000 2000 5000
22 ALYANTI 3577032605090010 1 3/11/2015 J45 3000 2000 5000
23 YENI 3577032503100006 1 3/11/2015 A09 3000 2000 5000
24 KASINEM 125002/98/02051 1 3/11/2015 E11 3000 2000 5000
25 KUSTIYEM 3577022204071123 1 3/11/2015 I10 3000 2000 5000
JUMLAH TOTAL 3 1 2 8 2 6 1 2
Mengetahui

BULAN : TAHUN :
POLI :BP UMUM……
PELKES & BESARAN
TARIF SESUAI PERDA
(RP)
1 2 3 L P L P L P L P L P L P 5 6 7 8 9 10
1 NANA SUPRANI 3577020307130001 1 3/11/2015 M36 3000 2000 5000
2 SLAMET 3577032104070397 1 3/11/2015 J11 3000 2000 5000
3 ZAULKARNAEN 3577032907110001 1 3/11/2015 J11 3000 2000 5000
4 SUGIHARTI 3577032907110001 1 3/11/2015 M36 3000 2000 5000
5 SITI RAHAYU 3577032104079103 1 3/11/2015 E11 3000 2000 5000
6 LILIK KASMIATI 3577032304090011 1 3/11/2015 J11 3000 2000 5000
7 SUKIRAH 3577030302120007 1 3/11/2015 M36 3000 2000 5000
8 WISNU 3577032104077961 1 3/11/2015 J11 3000 2000 5000
9 WIWIK SUPRIYATI 3577032104077961 1 3/11/2015 G44 3000 2000 5000
10 RININGSEH 3577032204070958 1 3/11/2015 M36 3000 2000 5000
11 DALIL 3577032204070972 1 3/11/2015 M36 3000 2000 5000
12 SEMI 3577030503090005 1 3/11/2015 M36 3000 2000 5000
13 MUHAMMAD REHAN 3577032301140007 1 3/11/2015 A09 3000 2000 5000
14 SUNARYADI 3577022204070035 1 3/11/2015 J11 3000 2000 5000
15 ZULFADHLI 3577021404100001 1 3/11/2015 J11 3000 2000 5000
16 DIANDRA ADINDA 355032004077080 1 3/11/2015 J10 3000 2000 5000
17 SOEMARMI 3577031809140006 1 3/11/2015 M36 3000 2000 5000
18 ALVARO 3577020402140001 1 3/11/2015 J11 3000 2000 5000
19 KHALIFAH 3577032204074330 1 3/11/2015 J11 3000 2000 5000
20 SUMARYANI 3577032204074337 1 3/11/2015 J11 3000 2000 5000
21 SRI HANDAYANI 3577031005120006 1 3/11/2015 G44 3000 2000 5000
22 ANDR KARISTIAWAN 3577032204073247 1 3/11/2015 B35 3000 2000 5000
23 DEA 1250020200948 1 3/11/2015 J11 3000 2000 5000
24 NINIT KUNCORO 3577032204076163 1 3/11/2015 F23 3000 2000 5000
25 SHOFAN RIZAL 3577032204073185 1 3/11/2015 J10 3000 2000 5000
JUMLAH TOTAL 2 3 3 1 1 2 10 2 1
Mengetahui

BULAN : TAHUN :
POLI :BP UMUM……
PELKES & BESARAN
TARIF SESUAI PERDA
(RP)
1 2 3 L P L P L P L P L P L P 5 6 7 8 9 10
1 ANISA FEBRIANTI 3577032004076589 1 3/11/2015 J10 3000 2000 5000
2 RINI ASTUTI 3577032104079139 1 3/11/2015 M36 3000 2000 5000
3 BUDI HARIYONO 3577032204072236 1 3/11/2015 V20 3000 2000 5000
4 Y.HARIYADI 3577032104072883 1 3/11/2015 M36 3000 2000 5000
5 MUASIH 3577032204072827 1 3/11/2015 E11 3000 2000 5000
6 MUTIMAH 3577032004074590 1 3/11/2015 M36 3000 2000 5000
7 MUTIMAH 3577032004074590 1 3/11/2015 M36 3000 2000 5000
8 SUPRIYADI 1250039903870 1 3/11/2015 M36 3000 2000 5000
9 REHAN 3577012104072597 1 3/11/2015 J11 3000 2000 5000
10 TAZKIYA AULIYA 3577032104070163 1 3/11/2015 J11 3000 2000 5000
11 NURHAYATI 3577032104072273 1 3/11/2015 A18.8 3000 2000 5000
12 TRIMO TRIONO 3577032204073780 1 3/11/2015 M36 3000 2000 5000
13 SUSI 3577032406100003 1 4/11/2015 D17 3000 2000 5000
14 CHAYAT 35770322610110002 1 4/11/2015 E11 3000 2000 5000
15 SITI RIFAIANI 3577032204071661 1 4/11/2015 M36 3000 2000 5000
16 SUGIARTI 3577032204071667 1 4/11/2015 M36 3000 2000 5000
17 SUPARYATI 3577032004076619 1 4/11/2015 M36 3000 2000 5000
18 ROHMAWATI 3577032104079637 1 4/11/2015 M36 3000 2000 5000
19 RATNA DEWANI 3577032909100006 1 4/11/2015 J11 3000 2000 5000
20 SATRIA 3577032204071969 1 4/11/2015 J11 3000 2000 5000
21 LILIK WINARNI 3577032204071969 1 4/11/2015 J11 3000 2000 5000
22 SOEDJIATI 3577032004075441 1 4/11/2015 M36 3000 2000 5000
23 DANISTA 3577030611080010 1 4/11/2015 M36 3000 2000 5000
24 SUSANA DYAH 3577032204075190 1 4/11/2015 M36 3000 2000 5000
25 ANTON HARI 3577030908120005 1 4/11/2015 J11 3000 2000 5000
JUMLAH TOTAL 1 3 1 1 3 4 10 2
Mengetahui

BULAN NOVEMBER TAHUN : 2015

POLI :BP UMUM……
PELKES & BESARAN
TARIF SESUAI PERDA
(RP)
1 2 3 L P L P L P L P L P L P 5 6 7 8 9 10
1 SUGIARTI 3577032204070194 1 1 4/11/2015 L23 3000 2000 5000
2 SUMADI 3577032204076552 1 1 4/11/2015 E11 3000 2000 5000
3 DENIS 3577032104079613 1 1 4/11/2015 M36 3000 2000 5000
4 ERWAN ADI PANGESTU 3577032204070586 1 1 4/11/2015 H60 3000 2000 5000
5 DIMAS KURNIAWAN 3577031712090002 1 1 4/11/2015 J11 3000 2000 5000
6 KAMIYAH 3577032104077478 1 1 4/11/2015 M36 3000 2000 5000
7 GUNAWAN 3577032310120011 1 1 4/11/2015 M17 3000 2000 5000
8 DJUMADI 3577032204072729 1 1 4/11/2015 M36 3000 2000 5000
9 ALISYA 3577032204070061 1 1 4/11/2015 J10 3000 2000 5000
10 SULIMAH 3577032104070410 1 1 4/11/2015 M36 3000 2000 5000
11 YAYUK 3577031903120003152 1 1 4/11/2015 M36 3000 2000 5000
12 ANISA 12500/05/00625 1 1 4/11/2015 J45 3000 2000 5000
13 LATIF 3577032204071875 1 1 4/11/2015 J10 3000 2000 5000
14 BUDI MARTONO 125002/01/00869 1 1 4/11/2015 M36 3000 2000 5000
15 SUPRIATIN 357703011010000 1 1 4/11/2015 I10 3000 2000 5000
16 NANIK PUSPAWATI 357703210409821 1 1 4/11/2015 H25 3000 2000 5000
17 KAMSIAH 3577032104079915 1 1 4/11/2015 K39 3000 2000 5000
18 MARTINA INDAH P S 3577031812120022 4/11/2015 M36 3000 2000 5000
19 GATOT H 3577031812120022 1 1 4/11/2015 K29 3000 2000 5000
20 KAHNO 3577032204076341 1 1 4/11/2015 E11 3000 2000 5000
21 AURELLYA B DP 3577030701090025 1 1 4/11/2015 J10 3000 2000 5000
22 NABILA 3577030701090025 1 1 4/11/2015 J10 3000 2000 5000
23 AHMAD KHAIRUDIN 3577032104079929 1 1 5/11/2015 J11 3000 2000 5000
24 TUGIMIN 3577032204070112 1 1 5/11/2015 I10 3000 2000 5000
25 MUHAMMAD G H S 3577032204072234 1 1 5/11/2015 J10 3000 2000 5000
JUMLAH TOTAL 1 1 1 2 3 2 6 7 1 24 75000 50000 125000
Mengetahui

POLI :BP UMUM……
PELKES & BESARAN
TARIF SESUAI PERDA
(RP)
1 2 3 L P L P L P L P L P L P 5 6 7 8 9 10
1 RANDY NUR F 3577031501130006 1 5/11/2015 J11 3000 2000 5000
2 ALFRIEL SHANDY S 3577032308110009 1 5/11/2015 V20 3000 2000 5000
3 KUSRAHAYU 3577032204077927 1 5/11/2015 E11 3000 2000 5000
4 HERMANTO 3577032204073824 1 5/11/2015 I69 3000 2000 5000
5 SARIMIN 3577032204075215 1 5/11/2015 I84 3000 2000 5000
6 SISWATI 3577032204070134 1 5/11/2015 M36 3000 2000 5000
7 DUTA 3577031702150006 1 5/11/2015 J11 3000 2000 5000
8 SADIYEM 3577032104079894 1 5/11/2015 G44 3000 2000 5000
9 WINARSIH 3577022104079048 1 5/11/2015 J45 3000 2000 5000
10 ADI SAPUTRA 3577031306120002 1 5/11/2015 V20 3000 2000 5000
11 SYAVAZAHRA I 3577032604120001 1 5/11/2015 J11 3000 2000 5000
12 DJUMIRIN 3577032204072255 1 5/11/2015 M36 3000 2000 5000
13 SALSABILA 3577030412140012 1 5/11/2015 J11 3000 2000 5000
14 ZHEFARA MAURA A 3577032204071512 1 5/11/2015 J10 3000 2000 5000
15 RANDIM S 3577032104070399 1 5/11/2015 I10 3000 2000 5000
16 TJUJU SUPARTI 3577032104070399 1 5/11/2015 M36 3000 2000 5000
17 BINTANG TIAR P 357703204076109 1 5/11/2015 V20 3000 2000 5000
18 MAILI S 1250029801944 1 5/11/2015 G44 3000 2000 5000
19 SEPTIA DCS' 1250029801944 1 5/11/2015 K12 3000 2000 5000
20 CHOIRUL 3577012004076130 1 5/11/2015 L23 3000 2000 5000
21 PUJI S 3577012004076130 1 5/11/2015 M36 3000 2000 5000
22 ALVARO NIZAM F 3577020402140001 1 5/11/2015 A09 3000 2000 5000
23 AGUSTIN ERINA D 1250039903870 1 5/11/2015 L23 3000 2000 5000
24 REFAN HADRIAN A 3577032204073423 1 5/11/2015 J10 3000 2000 5000
25 SUHARI 3577032201073075 1 M36 3000 2000 5000
JUMLAH TOTAL 1 4 3 2 2 3 3 6 1 75000 50000 125000
Mengetahui

POLI :BP UMUM……
PELKES & BESARAN
TARIF SESUAI PERDA
(RP)
1 2 3 L P L P L P L P L P L P 5 6 7 8 9 10
1
2 A NAJWA SALSA B 3577032001110001 1 5/11/2015 J11 3000 2000 5000
3 SUWARNO 1250029802049 1 5/11/2015 M36 3000 2000 5000
4 TRI A 3577032104079278 1 5/11/2015 E11 3000 2000 5000
5 WINDA M 3577032204072457 1 6/11/2015 F23 3000 2000 5000
6 AQILA KHANZANIA 3577032003140003 1 6/11/2015 I84 3000 2000 5000
7 PONIYEM 3577032204072487 1 6/11/2015 M36 3000 2000 5000
8 KASRI M 3577032204072629 1 6/11/2015 R05 3000 2000 5000
9 RATNADEWANI J N E 3577032909100006 6/11/2015 J10 3000 2000 5000
10 M ALZICO F 35770315001130003 1 6/11/2015 R50 3000 2000 5000
11 APRILIA FITRI S 3577031707140001 1 6/11/2015 J10 3000 2000 5000
12 FIO ANANTA P 3577032204072617 1 6/11/2015 J10 3000 2000 5000
13 MUHAMMAD ROHID N 3577020106150007 1 6/11/2015 J10 3000 2000 5000
14 MUDJIYO 3577032104079589 1 6/11/2015 M36 3000 2000 5000
15 ARI SETYAWAN 3577032204071153 1 6/11/2015 J10 3000 2000 5000
16 PURWATI 3577032204072795 1 6/11/2015 E11 3000 2000 5000
17 KARTINI W 3577032204073812 1 6/11/2015 R05 3000 2000 5000
18 SRI KAHYUNIEK 3577032204077079 1 6/11/2015 M36 3000 2000 5000
19 ENY INDARWATI 3577031811080013 1 6/11/2015 G44/I10 3000 2000 5000
20 SRI SUWARNI 3577032104070340 1 6/11/2015 M36 3000 2000 5000
21 NARIASIH 3577032104070339 1 6/11/2015 M36 3000 2000 5000
22 SURATMAN 3577032104070324 1 6/11/2015 I10 3000 2000 5000
23 SUDARWATI 3577302204073444 1 6/11/2015 E11 3000 2000 5000
24 SRI SUPATMI 3577032104079882 1 6/11/2015 B02 3000 2000 5000
25 MUJIANTO 3577032104079075 1 6/11/2015 B01 3000 2000 5000
JUMLAH TOTAL 2 1 1 2 1 2 4 10 72000 48000 120000
Mengetahui

POLI :BP UMUM……
PELKES & BESARAN
TARIF SESUAI PERDA
(RP)
1 2 3 L P L P L P L P L P L P 5 6 7 8 9 10
1 SUDARSIH 3577032112110010 1 6/11/2015 J10 3000 2000 5000
2 ADZAR Zaidan AR 3577032112110010 1 6/11/2015 J10 3000 2000 5000
3 SITI UTIKAH 3577032204071772 1 6/11/2015 R05 3000 2000 5000
4 JINAH E M 3577030905120002 1 6/11/2015 J10 3000 2000 5000
5 IRIAN C 3520040311100003 1 6/11/2015 F23 3000 2000 5000
6 SALWA IKHA N P 35770322601110005 1 6/11/2015 J10 3000 2000 5000
7 NABILA D N A 3577032004075536 6/11/2015 J10 3000 2000 5000
8 ABDULLAH K A 3577032004075536 6/11/2015 B01 3000 2000 5000
9 SITI M 3577032104079478 1 6/11/2015 M36 3000 2000 5000
10 MUHAMMAD K F 3577032104079478 1 6/11/2015 R50 3000 2000 5000
11 NGATENO 3577022104079345 1 9/11/2015 M36 3000 2000 5000
12 SLAMET 125002/99/07814 1 9/11/2015 M36 3000 2000 5000
13 YASIR 3577032204070478 1 9/11/2015 E11 3000 2000 5000
14 AHMAD 3577032812100040 1 9/11/2015 J11 3000 2000 5000
15 SRIYATUN 3577022104075727 1 9/11/2015 E11 3000 2000 5000
16 GIRI WIDODO 3577030912100009 1 9/11/2015 H10 3000 2000 5000
17 SUHARMANI 3577032204070241 1 9/11/2015 M36 3000 2000 5000
18 SUHARMANI 3577032204070241 1 9/11/2015 K29 3000 2000 5000
19 SUPINI 3577032104079603 1 9/11/2015 K29 3000 2000 5000
20 SEMI 3577030503090005 1 9/11/2015 M36 3000 2000 5000
21 FITAMAL 3577033108090008 1 9/11/2015 A09 3000 2000 5000
22 SUPRIHATIN 3577032204072331 1 9/11/2015 M36 3000 2000 5000
23 SUYONO 3577032204072331 1 9/11/2015 M36 3000 2000 5000
24 JEVAN 3577032806130003 1 9/11/2015 J11 3000 2000 5000
25 HERY 3577032204071957 1 9/11/2015 K29 3000 2000 5000
JUMLAH TOTAL 0 2 1 2 1 3 3 5 3 3 75000 50000 125000
Mengetahui

POLI :BP UMUM……
PELKES & BESARAN
TARIF SESUAI PERDA
(RP)
1 2 3 L P L P L P L P L P L P 5 6 7 8 9 10
1 ANING SUSANTI 3577032204071586 1 9/11/2015 J11 3000 2000 5000
2 KASPINI 3577032204072120 1 9/11/2015 E11 3000 2000 5000
3 JUMADI 3577032104076371 1 9/11/2015 E11 3000 2000 5000
4 GALUH SUKMA 3577032506090003 1 9/11/2015 J11 3000 2000 5000
5 EDY MULYONO 3577032204072946 1 9/11/2015 M36 3000 2000 5000
6 ADI SUKIRNO 3577031801080009 1 9/11/2015 A98 3000 2000 5000
7 UMIYATI 3577032004075601 1 9/11/2015 J10 3000 2000 5000
8 WIJIARSEH '3577030204120002 1 9/11/2015 M36 3000 2000 5000
9 VERANDA 3577032204071602 1 9/11/2015 J11 3000 2000 5000
10 REVANDYTO 3577031311090008 1 9/11/2015 J11 3000 2000 5000
11 SUGIHARNI 3577032907110001 1 9/11/2015 M36 3000 2000 5000
12 SHOFIYYA HUSNA 3577030401110074 1 9/11/2015 J11 3000 2000 5000
13 GALUR ARYA 3577032004076151 1 9/11/2015 L23 3000 2000 5000
14 DEWI HERMIN 3577032004076151 1 9/11/2015 M36 3000 2000 5000
15 SITI MARYAM 3577032204070982 1 9/11/2015 M36 3000 2000 5000
16 MUHAMAD RADITYA 3577031909110001 1 9/11/2015 J11 3000 2000 5000
17 DJOEANG FIRMAN 3577032104079266 1 9/11/2015 J11 3000 2000 5000
18 RIZKY 3577032701100002 1 9/11/2015 BO1 3000 2000 5000
19 EGA SELFIANA 3577032104079651 1 9/11/2015 V20 3000 2000 5000
20 DEBBY 3577033112140007 1 9/11/2015 F28 3000 2000 5000
21 NINIK SRIWAHYUNI 3577033112140007 1 9/11/2015 G44 3000 2000 5000
22 MOCHAMMAD YONGKI 3577032204070628 1 9/11/2015 J11 3000 2000 5000
23 APRIANI 3577032204070628 1 9/11/2015 M36 3000 2000 5000
24 SHITI SETYO 3577032204072063 1 9/11/2015 B01 3000 2000 5000
25 SEPTIANO 3577031412110003 1 9/11/2015 J11 3000 2000 5000
JUMLAH TOTAL 5 2 2 2 5 2 7 75000 50000 125000
Mengetahui

POLI :BP UMUM……
PELKES & BESARAN
TARIF SESUAI PERDA
(RP)
1 2 3 L P L P L P L P L P L P 5 6 7 8 9 10
1 SULAIMAN 1250029910309 1 10/11/2015 I10 3000 2000 5000
2 AHMAD YUSUF R 3577032204070215 1 10/11/2015 J10 3000 2000 5000
3 TUGIMIN 3577032204070112 1 10/11/2015 I50 3000 2000 5000
4 RASIMAN 3577032004075918 1 10/11/2015 B35 3000 2000 5000
5 SAMIYONO 3577032910080011 1 10/11/2015 J44 3000 2000 5000
6 YANTO 3577032004077290 1 10/11/2015 J10 3000 2000 5000
7 TUMINAH 3577032204072763 1 10/11/2015 E11 3000 2000 5000
8 SUMARMI 3577032204075821 1 10/11/2015 E11 3000 2000 5000
9 FAUZAH AGUSTINA 3577032003140003 1 10/11/2015 J10 3000 2000 5000
10 AQILA K B 3577032003140003 1 10/11/2015 I84 3000 2000 5000
11 SUTINI 3577022104076136 1 10/11/2015 M36 3000 2000 5000
12 SRI WAHJOENING 3577032204074910 1 10/11/2015 M36 3000 2000 5000
13 VINA Y 3577032204072312 1 10/11/2015 J11 3000 2000 5000
14 TRI DEMES M 3577032204072312 1 10/11/2015 M36 3000 2000 5000
15 RR INDRIA S 3577030302090008 1 10/11/2015 N39 3000 2000 5000
16 DJUMADI 3577032204072661 1 10/11/2015 F23 3000 2000 5000
17 HARTATIK 3577022204070793 1 10/11/2015 M36 3000 2000 5000
18 KAMIRAH 3577032004076626 1 10/11/2015 J11 3000 2000 5000
19 TITIN S 3577032204071703 1 10/11/2015 M36 3000 2000 5000
20 HARMONO 3577032204073202 1 10/11/2015 I10 3000 2000 5000
21 NYAMI 3577032204072361 1 10/11/2015 M36 3000 2000 5000
22 RISKI APRILIA 3577022204070056 1 10/11/2015 J11 3000 2000 5000
23 SURYANI 3577032204071925 1 10/11/2015 M36 3000 2000 5000
24 KUSRAHAYU 3577032204077927 1 10/11/2015 J10/E11 3000 2000 5000
25 BINTANG TIAR P 3577032004076109 1 10/11/2015 V20 3000 2000 5000
JUMLAH TOTAL 0 1 2 3 4 1 11 3 75000 50000 125000
Mengetahui
POLI :BP UMUM……
PELKES & BESARAN
TARIF SESUAI PERDA
(RP)
1 2 3 L P L P L P L P L P L P 5 6 7 8 9 10
1 SRI HANDAYANI 3577031005120006 1 10/11/2015 K29 3000 2000 5000
2 ALTHAF NAFIS J 3577032510120001 1 10/11/2015 J10 3000 2000 5000
3 NAKULA AZKA N J 3577032510120001 1 10/11/2015 J10 3000 2000 5000
4 ETTY INDAH K 3577031909120003 1 10/11/2015 E11 3000 2000 5000
5 ADI SWAPUTRA 3577031306120002 1 10/11/2015 V20 3000 2000 5000
6 FIRDA A 3577032004077080 1 10/11/2015 R05 3000 2000 5000
7 SRININGSIH 3577030502610006 1 10/11/2015 J11 3000 2000 5000
8 TOHARI 3577032004076439 1 10/11/2015 E11 3000 2000 5000
9 PRABU YUWA 3577031801130001 1 10/11/2015 J11 3000 2000 5000
10 SAMUEL 3577032204072317 1 10/11/2015 L23 3000 2000 5000
11 SUWANDI 3577032204072317 1 10/11/2015 J11 3000 2000 5000
12 HENDRO DWI SUSENO 3577032802110001 1 10/11/2015 J11 3000 2000 5000
13 MASYHADI 3577030309140002 1 10/11/2015 K29 3000 2000 5000
14 WINARTI 3577032204072515 1 11/10/2015 G44 3000 2000 5000
15 WIWIK S 3577032004075369 1 11/10/2015 M36 3000 2000 5000
16 DJUMINEM 3577030805140002 1 11/10/2015 J45 3000 2000 5000
17 SARBINAH 3577032204071935 1 11/10/2015 M36 3000 2000 5000
18 MISIRAH 3577032204073558 1 11/10/2015 M36 3000 2000 5000
19 MARSINI 3577032104079266 1 11/10/2015 M36 3000 2000 5000
20 DJOEANG FIRMAN C 3577032104079266 1 11/10/2015 J10 3000 2000 5000
21 TUTIK DWI L 3577032204071812 1 11/10/2015 G44 3000 2000 5000
22 MARWATI 3577032512100051 1 11/10/2015 J11 3000 2000 5000
23 SISKAWATI 3577030912100028 1 11/10/2015 K29 3000 2000 5000
24 PRIHATI 3577032104070343 1 11/10/2015 E11 3000 2000 5000
25 RANGGA 3577012004077625 1 11/10/2015 K29 3000 2000 5000
JUMLAH TOTAL 1 0 3 2 0 2 7 1 6 2 1 75000 50000 125000
Mengetahui
POLI :BP UMUM……
PELKES & BESARAN
TARIF SESUAI PERDA
(RP)
1 2 3 L P L P L P L P L P L P 5 6 7 8 9 10
1 CALVIN 357703220407637 1 11/11/2015 H60 3000 2000 5000
2 VALERINA K R 3577032104070140 1 11/11/2015 J10 3000 2000 5000
3 PUJIATI RAHAYU 3577032104070140 1 11/11/2015 E11 3000 2000 5000
4 RIZKY 35770322041500013 1 11/11/2015 J11 3000 2000 5000
5 SUJARIANTO 3577032801090003 1 11/11/2015 K29/M36 3000 2000 5000
6 BUDI CAHYONO 3577010802110010 1 11/11/2015 J11 3000 2000 5000
7 PUDJIATI R 3577032204070494 1 11/11/2015 E11/I10 3000 2000 5000
8 WIJI 3577032204077094 1 11/11/2015 L23 3000 2000 5000
9 YUSUF 3577034206530003 1 11/11/2015 L23 3000 2000 5000
10 MUHAMMAD HAFIZH 3577032409120005 1 11/11/2015 J11 3000 2000 5000
11 SRI ENDANG WATI 3577032104079372 1 11/11/2015 J11 3000 2000 5000
12 BERLIANO 3577032204071262 1 11/11/2015 L23 3000 2000 5000
13 SUTRISNO 3577032104070025 1 11/11/2015 A18 3000 2000 5000
14 MUSTIKA DWIYANTO 3577032104077247 1 11/11/2015 M36 3000 2000 5000
15 DWI IRFAN 3577032004076151 1 11/11/2015 G44 3000 2000 5000
16 GALUR 3577032004076150 1 11/11/2015 J11 3000 2000 5000
17 LARASATI 3577032204070582 1 12/11/2015 M36 3000 2000 5000
18 SABINA VISKA D P 3577032905090001 1 12/11/2015 J10 3000 2000 5000
19 ZALFA PUTRI W 3577032204071544 1 12/11/2015 R11 3000 2000 5000
20 MISWAN 3577032204070077 1 12/11/2015 I69 3000 2000 5000
21 RIRIS S 3577032903840003 1 12/11/2015 K29 3000 2000 5000
22 JUMADI 3577032004076852 1 12/11/2015 H52 3000 2000 5000
23 JIHAN AYU M F 3577030611120009 1 12/11/2015 A09 3000 2000 5000
24 SULASTRI 3577032806110014 1 12/11/2015 M36 3000 2000 5000
25 MINTEN 3577032104079562 1 12/11/2015 E11 3000 2000 5000
JUMLAH TOTAL 0 3 3 3 5
Mengetahui
POLI :BP UMUM……
PELKES & BESARAN
TARIF SESUAI PERDA
(RP)
1 2 3 L P L P L P L P L P L P 5 6 7 8 9 10
1 WIJI SUWARNI 3577032204072568 1 12/11/2015 M36 3000 2000 5000
2 NOVENDA S H 3577032204072568 1 12/11/2015 H52 3000 2000 5000
3 R NESTHA SCANIA M 3577031603150001 1 12/11/2015 V20 9000 6000 15000
4 SUDJIMIN 3577032204072139 1 12/11/2015 A18 3000 2000 5000
5 KAR5SIATI 3577032204072139 1 12/11/2015 M36 3000 2000 5000
6 SUGENG 3577032004077156 1 12/11/2015 R05 3000 2000 5000
7 USMAN 3577032204076926 1 12/11/2015 G44 3000 2000 5000
8 HARIYANTO 3577032104070150 1 12/11/2015 E11 3000 2000 5000
9 SUYATI 3577032204072289 1 12/11/2015 I25 3000 2000 5000
10 SUPARTI 3577032204070290 1 12/11/2015 M36 3000 2000 5000
11 SETYOWATI 3577032004075112 1 12/11/2015 R05 3000 2000 5000
12 FILZA Q 3577032204071172 1 12/11/2015 J10 3000 2000 5000
13 ROBERTHA PRIN C 3577032204073071 1 12/11/2015 I10 3000 2000 5000
14 DJUMIRATUN 3577032204076082 1 12/11/2015 L23 3000 2000 5000
15 MUTIMAH 1250020100891 1 12/11/2015 M36 3000 2000 5000
16 MAISZAH 3577032004074590 1 12/11/2015 M36 3000 2000 5000
17 RACHEL I M 3577032204072301 1 12/11/2015 J11 3000 2000 5000
18 NANIK K 3577032204072301 1 12/11/2015 M36 3000 2000 5000
19 SUSILO 3577032204075250 1 12/11/2015 M36 3000 2000 5000
20 ANDIK JOKO N 3577031801120014 1 12/11/2015 K35 3000 2000 5000
21 SUPRAPTO 3577031801080047 1 12/11/2015 D 3000 2000 5000
22 ARINTO 3577032006110008 1 12/11/2015 E11 3000 2000 5000
23 WINARSIH 1250029805958 1 12/11/2015 M79 3000 2000 5000
24 YEYEN MEI L 3577032007120005 1 12/11/2015 R05 3000 2000 5000
25 BUDI MARTONO 1250020100893 1 12/11/2015 M36 3000 2000 5000
JUMLAH TOTAL 0 1 3 4 4 2 9 2
Mengetahui
POLI :BP UMUM……
PELKES & BESARAN
TARIF SESUAI PERDA
(RP)
1 2 3 L P L P L P L P L P L P 5 6 7 8 9 10
1 ABDULLAH K A 3577032004075536 1 12/11/2015 M36 3000 2000 5000
2 SOEMARSIH 3577032204072167 1 13/11/2015 H52 3000 2000 5000
3 SOEPARMI 3570032204071766 1 13/11/2015 M36 3000 2000 5000
4 PONIYEM 3577032204072487 1 13/11/2015 M36 3000 2000 5000
5 SUGENG 3577032004077156 1 13/11/2015 J10 3000 2000 5000
6 ERNIK P 357703220477151 1 13/11/2015 I10 3000 2000 5000
7 WAHYU SUPRAPTI 3577032204072357 1 13/11/2015 J45 3000 2000 5000
8 SUHARMAN 3577032204070241 1 13/11/2015 M36 3000 2000 5000
9 YULIATIN 3577030810100005 1 13/11/2015 H10 3000 2000 5000
10 SUTRIANTO 1250020300204 1 13/11/2015 J10 3000 2000 5000
11 HADI WIYONO 3577032204070230 1 13/11/2015 G44 3000 2000 5000
12 ESTIKAH 3577032206072895 1 13/11/2015 E11 3000 2000 5000
13 DENIS A 3577032104079613 1 13/11/2015 J45 3000 2000 5000
14 PURWOTO 3577032204070552 1 13/11/2015 M36 3000 2000 5000
15 MARPUNGAH 3577032204070552 1 13/11/2015 M36 3000 2000 5000
16 KRISDIANTO 3577032404140001 1 13/11/2015 J45 3000 2000 5000
17 FIRSA RSHMATUL J 3577031711090001 1 13/11/2015 J11 3000 2000 5000
18 RONALD J P 3577032907100002 1 13/11/2015 J10 3000 2000 5000
19 RETNO P 3577032812100063 1 13/11/2015 A09 3000 2000 5000
20 SUMILAH 3577034206530003 1 13/11/2015 E11/I10 3000 2000 5000
21 EKO WAHYUDI S 3577030909770004 1 13/11/2015 M36 3000 2000 5000
22 HARSONO 3577032004075665 1 13/11/2015 G46 3000 2000 5000
23 JUMIATI 3577032004075665 1 13/11/2015 N40 3000 2000 5000
24 KUSMIATI 3577032906120002 1 13/11/2015 H26 3000 2000 5000
25 ROELI F 3577030501150008 1 13/11/2015 H52 3000 2000 5000
JUMLAH TOTAL 0 1 1 1 4 6 3 8 1
Mengetahui
POLI :BP UMUM……
PELKES & BESARAN
TARIF SESUAI PERDA
(RP)
< 1 TH1-4 TH 5-14TH 15-44TH 45-64TH 65>TH POLI UMUM
1 2 3 L P L P L P L P L P L P 5 6 7 8 9 10
1 TANI 3577032204076170 1 13/11/2015 K12 3000 2000 5000
2 SAYEKTI 1250020001368 1 16/11/2015 G544 3000 2000 5000
3 KENZIE FAWWAS A 357032402090013 1 16/11/2015 J10 3000 2000 5000
4 EDI T 3577032004076381 1 16/11/2015 G43 3000 2000 5000
5 DINAH 3577030610100004 1 16/11/2015 L23 3000 2000 5000
6 ADI SUKIRNO 3577031801080009 1 16/11/2015 I10 3000 2000 5000
7 MARSIYAH 3577032004070747 1 16/11/2015 J11 3000 2000 5000
8 SRI WATIK 3577032204070369 1 16/11/2015 E11 3000 2000 5000
9 RIYAN DIKI S 3577030403140002 1 16/11/2015 V20 3000 2000 5000
10 NITA RAHMAWATI 3577030610110001 1 16/11/2015 A18.2 3000 2000 5000
11 YUNI S 3577032104079900 1 16/11/2015 E11 3000 2000 5000
12 JUMINEM 3577030805140002 1 16/11/2015 M36 3000 2000 5000
13 ARIYADI 1250029904234 1 16/11/2015 M36 3000 2000 5000
14 SUYATNO 3577032204072842 1 16/11/2015 M36 3000 2000 5000
15 ENDANG 3577032204074020 1 16/11/2015 K29 3000 2000 5000
16 SITI FATIMAH 3577032104076204 1 16/11/2015 J10 3000 2000 5000
17 RAMADHANY ARFA B 3577032104076204 1 16/11/2015 H10 3000 2000 5000
18 HASNA K 3577020307130001 1 16/11/2015 L23 3000 2000 5000
19 DARMINING 3577032004077396 1 16/11/2015 M36 3000 2000 5000
20 GANDUNG S 3577032204075400 1 16/11/2015 G44 3000 2000 5000
21 WIWIN SRI W 3577032001100003 1 16/11/2015 E11 3000 2000 5000
22 M FARREL 3577032104079266 1 16/11/2015 J11 3000 2000 5000
23 ANING SUSANTI 3577032204071586 1 16/11/2015 I10 3000 2000 5000
24 OKTAVIA K 3577022004070807 1 16/11/2015 J11 3000 2000 5000
25 ARYASA PUTRA A 3577030106140016 1 16/11/2015 J11 3000 2000 5000
JUMLAH TOTAL 0 1 1 3 1 1 9 3 5 2
Mengetahui
POLI :BP UMUM……
PELKES & BESARAN
TARIF SESUAI PERDA
(RP)
1 2 3 L P L P L P L P L P L P 5 6 7 8 9 10
1 HARMONO 3577032204073202 1 16/11/2015 M36 3000 2000 5000
2 SLAMET 1250029907814 1 16/11/2015 K35 3000 2000 5000
3 ANDI RISKY R 3577032104071811 1 16/11/2015 G44 3000 2000 5000
4 YUSA ADI P 3577032204071290 1 16/11/2015 J11 3000 2000 5000
5 SITI UTIKAH 3577032204071772 1 16/11/2015 J11 3000 2000 5000
6 SRI REJEKI 3577022509130002 1 16/11/2015 I84 3000 2000 5000
7 VEBRIAN TRI S K Y 3577032204072208 1 16/11/2015 B02 3000 2000 5000
8 GUMONO 3577032204072111 1 16/11/2015 G44 3000 2000 5000
9 INIT WAHYUNI 3577032204072111 1 16/11/2015 I69 3000 2000 5000
10 SRI NURINDA 3577032004077500 1 16/11/2015 I10 3000 2000 5000
11 KANTININGSIH 3577032204072251 1 16/11/2015 E11 3000 2000 5000
12 TATIK KASIYAH 3577032101110013 1 16/11/2015 M36 3000 2000 5000
13 SILVIA BELA S 3577032204071222 1 16/11/2015 B02 3000 2000 5000
14 PUDJIATI R 3577032204070494 1 16/11/2015 M36 3000 2000 5000
15 IWANG ANDRO 3577030401110033 1 16/11/2015 V20 3000 2000 5000
16 SEWI A K 3577032204072705 1 16/11/2015 M36 3000 2000 5000
17 MUHAMMAD SETIAWAN 3577032205140004 1 16/11/2015 J10 3000 2000 5000
18 NANIK SUGIARTI 3577032205140004 1 16/11/2015 E11 3000 2000 5000
19 SUPUNI 3577032204070895 1 16/11/2015 E11 3000 2000 5000
20 EKO HARI 3577032204071066 1 16/11/2015 B99 3000 2000 5000
21 MARIYAH 3577032204070161 1 17/11/2015 M36 3000 2000 5000
22 ISMIATUN 1250029805944 1 17/11/2015 M36 3000 2000 5000
23 SAMI 125002/98/06782 17/11/2015 J10 3000 2000 5000
24 SUPARDI 3577032204070161 1 17/11/2015 H25 3000 2000 5000
25 DIJAH 3577032204072898 1 17/11/2015 J11 3000 2000 5000
0 1 1 3 1 1 6 2 7 2
Mengetahui
POLI :BP UMUM……
PELKES & BESARAN
TARIF SESUAI PERDA
(RP)
1 2 3 L P L P L P L P L P L P 5 6 7 8 9 10
1 PAINI 35772032004076552 1 17/011/2015 M36 3000 2000 5000
2 YULI K 03577030401110043 1 17/11/2015 E11 3000 2000 5000
3 ADIN SULISTIONO 3577032204071637 1 17/11/2015 M36 3000 2000 5000
4 RINAWATI 3577032204071587 1 17/11/2015 M36 3000 2000 5000
5 KARTINI 3577032204070456 1 17/11/2015 M79 3000 2000 5000
6 MINTARSIH 3577032204073212 1 17/11/2015 E11 3000 2000 5000
7 SUHARMI 3577032203110001 1 17/11/2015 M36 3000 2000 5000
8 SUMILAH M KUSNI 3577032204071203 1 17/11/2015 I10 3000 2000 5000
9 HABSYAH AS S 3577032802130003 1 17/11/2015 J11 3000 2000 5000
10 SUPRIHATIN 3577032204072331 1 17/11/2015 M36 3000 2000 5000
11 FITRI SUTINAH 3577032204073214 1 17/11/2015 M36 3000 2000 5000
12 SRI KUSTANTI 3577032204076783 1 17/11/2015 A16 3000 2000 5000
13 BIBIT 35770032204072154 1 17/11/2015 L23 3000 2000 5000
14 NAZWA PUTRI 3577021307120001 1 17/11/2015 J10 3000 2000 5000
15 ENDANGPRIHATIN 3577022204071573 1 17/11/2015 J10 3000 2000 5000
16 ALVEA EKA 3577031506990008 1 17/11/2015 J10 3000 2000 5000
17 NUR HAYATI 125002/02/01095 1 17/11/2015 M36 3000 2000 5000
18 NAHROWI 3577032004075610 1 17/11/2015 M36 3000 2000 5000
19 TRI BUDI JANTO 3577031004078759 1 17/11/2015 M37 3000 2000 5000
20 CHERLY 3577032812100010 1 17/11/2015 J10 3000 2000 5000
21 LASMINAH '3577032204071520 1 17/11/2015 M36 3000 2000 5000
22 NINING PARMINI 1250020500776 1 17/11/2015 M36 3000 2000 5000
23 ROBERTA PRIN 3577032204073071 1 17/11/2015 M79 3000 2000 5000
24 ARYANTI 3577032204075146 1 17/11/2015 M79 3000 2000 5000
25 AN SRI MURNI 35770221040769 1 17/11/2015 M36 3000 2000 5000
JUMLAH TOTAL 1 0 0 1 0 1 1 10 2 7 1 1
Mengetahui

POLI :BP UMUM……
PELKES & BESARAN
TARIF SESUAI PERDA
(RP)
1 2 3 L P L P L P L P L P L P 5 6 7 8 9 10
1 CHAESAR 3577022270100006 1 17/11/2015 M36 3000 2000 5000
2 SUGINO 3577031405130007 1 17/11/2015 M36 3000 2000 5000
3 SURATI 3577032204076829 1 17/11/2015 I10 3000 2000 5000
4 AGUS SUHARIYANTO 3577032204071246 1 18/11/2015 K40 3000 2000 5000
5 CHAYAT PUJI 35770322610110002 1 18/11/2015 M36 3000 2000 5000
6 SUKARTI 3577032204072688 1 18/11/2015 I84 3000 2000 5000
7 SULAMI 3577030209140001 1 18/11/2015 L23 3000 2000 5000
8 SURJADI 3577032004077247 1 18/11/2015 J11 3000 2000 5000
9 SUJARIYANTO 3577032801090003 1 J45 3000 2000 5000
10 NADIA RANI 3577032104079553 1 R50 3000 2000 5000
11 CLEARESTA MARVA 3577032204071240 1 J11 3000 2000 5000
12 RUM ANGRRAENI 3577031011080001 1 M36 3000 2000 5000
13 TRY YUWONO 3577031011080001 1 J45 3000 2000 5000
14 SAMSUDIN 357703074150001 1 R50 3000 2000 5000
15 MUGI UTAMA 1250039901325 1 E11 3000 2000 5000
16 JOKO WAHYUDI 3577032204073082 1 I95 3000 2000 5000
17 KADARWATI 3577021202090005 1 J45 3000 2000 5000
18 SULASTRI 3577032204140004 1 M36 3000 2000 5000
19 WENI SITI 1250030700941 1 H60 3000 2000 5000
20 FRENZISKO 1250030700941 1 K12 3000 2000 5000
21 KHALIFAH DWI 3577032204074337 1 M36 3000 2000 5000
22 RUDI WURYANTOKO 3577032204070153 1 J11 3000 2000 5000
23 DWI WAHYUNI 3577032204072154 1 M36 3000 2000 5000
24 MISINAKUN 3577032104070253 1 J11 3000 2000 5000
25 TITIK S 3577032204071557 0 1 I10 3000 2000 5000
JUMLAH TOTAL 0 0 0 0 3 2 2 4 7 5 1 1
Mengetahui
KOTA : MADIUN PUSKESMAS : DEMANGAN
POLI :BP UMUM……
PELKES & BESARAN
TARIF SESUAI PERDA
(RP)
1 2 3 L P L P L P L P L P L P 5 6 7 8 9 10
1 SUKATMI 3577030408110000 1 18/11/2015 M36 3000 2000 5000
2 SURATMAN 3577032104070324 1 18/11/2015 K29 3000 2000 5000
3 SRI SUWARNI 3577032104070340 1 18/11/2015 M36 3000 2000 5000
4 WARSITO 35770322040070571 1 18/11/2015 I10 3000 2000 5000
5 MUTIMAH 1250020100891 1 18/11/2015 J10 3000 2000 5000
6 MAIZAH 3577032004074590 1 18/11/2015 J10 3000 2000 5000
7 NURFADILLAH PUTRI C 3577032004074590 1 18/11/2015 L23 3000 2000 5000
8 RANTI 3577032204072269 1 18/11/2015 I10 3000 2000 5000
9 NUR RETNO 3577022214070889 1 18/11/2015 J10 3000 2000 5000
10 SUGIANTO 3577032204074559 1 18/11/2015 M36 3000 2000 5000
11 SONNY 3577032204071667 1 19/11/2015 M36 3000 2000 5000
12 RAMELAN 3577032204072682 1 19/11/2015 M36 3000 2000 5000
13 MUJI LESTARI 3577032204072682 1 19/11/2015 A09 3000 2000 5000
14 TUMIRIN 3577032004076183 1 19/11/2015 E11 3000 2000 5000
15 SUNDARI 3577032204072206 1 19/11/2015 J11 3000 2000 5000
16 GIARTI 3577032104070333 1 19/11/2015 M36 3000 2000 5000
17 SUPRIYONO 3577032104070333 1 19/11/2015 M36 3000 2000 5000
18 MAILI S 1250029801944 1 19/11/2015 M36 3000 2000 5000
19 CALVIN D B 3577032204071637 1 19/11/2015 J11 3000 2000 5000
20 LASMI 3577032004076663 1 19/11/2015 M36 3000 2000 5000
21 SAYUTI 3577032001076159 1 19/11/2015 I10 3000 2000 5000
22 WINDA M 3577032204072457 1 19/11/2015 F28 3000 2000 5000
23 MIATIN 3577032204070558 1 19/11/2015 G44 3000 2000 5000
24 SARI SRI WAHYU E N 3577032204073360 1 19/11/2015 K35 3000 2000 5000
25 SILVIA R 3577030811130003 1 19/11/2015 M36 3000 2000 5000
JUMLAH TOTAL 3 1 10 2 6 1 2 75000 50000 125000
Mengetahui
POLI :BP UMUM……
PELKES & BESARAN
TARIF SESUAI PERDA
(RP)
1 2 3 L P L P L P L P L P L P 5 6 7 8 9 10
1 MOHAMMAD R 3577032204071551 1 1 19/11/2015 L23 3000 2000 5000
2 PANIKEM 3577032204072913 1 19/11/2015 E11 3000 2000 5000
3 JUMAATI 3577032204072356 1 19/11/2015 L23 3000 2000 5000
4 SETYAWATI 3577032207130001 1 19/11/2015 M36 3000 2000 5000
5 BIBIT R 3577032104079669 1 19/11/2015 M36 3000 2000 5000
6 SITI N P 3577032407140001 1 19/11/2015 K59 3000 2000 5000
7 ENDANG S 3577032204075250 1 19/11/2015 R05 3000 2000 5000
8 MILA NUR R 357703210407113 1 19/11/2015 R50 3000 2000 5000
9 SUHARTINI 3577032105120006 1 19/11/2015 B17 3000 2000 5000
10 AGUSCATURW 3577030901080001 1 19/11/2015 J11 3000 2000 5000
11 WIJIARSIH 357703020412002 1 19/11/2015 E11 3000 2000 5000
12 QAULAN TSAQILA 3577032204076309 1 19/11/2015 J10 3000 2000 5000
13 IDA SULISTIYANA 3577032204076309 1 19/11/2015 J10 3000 2000 5000
14 SHALAHUDIN AL AYUBI 3577032204076309 1 19/11/2015 J10 3000 2000 5000
15 OKTAVIA R P T 3577022204071584 1 19/11/2015 L30 3000 2000 5000
16 PONIYEM 3577032204072487 1 20/11/2015 I10 3000 2000 5000
17 TASMIATI 3577032204072442 1 20/11/2015 M36 3000 2000 5000
18 RIZKI DWI S 3577032204072212 1 20/11/2015 J11 3000 2000 5000
19 SOEPARMI 3570032204071766 1 20/11/2015 I10 3000 2000 5000
20 RUDDY W 3577032204070153 1 20/11/2015 K30 3000 2000 5000
21 RUBILAWATI 3577032312100037 1 20/11/2015 M36 3000 2000 5000
22 YASIR 3577032204070478 1 20/11/2015 M36 3000 2000 5000
23 TRI BUDIJIANTO 3577032104078759 1 20/11/2015 V20 9000 6000 15000
24 SUDJANI 3577032509090001 1 20/11/2015 M36 3000 2000 5000
25 PURWANIASIH P 3577032509090001 1 20/11/2015 M36 3000 2000 5000
JUMLAH TOTAL 1 1 1 1 1 4 2 11 1 3 81000 54000 135000
Mengetahui

POLI :BP UMUM……
PELKES & BESARAN
TARIF SESUAI PERDA
(RP)
1 2 3 L P L P L P L P L P L P 5 6 7 8 9 10
1 RUBILAWATI 3577032312100037 1 20/11/2015 M36 3000 2000 5000
2 ISWOROWATI 3577032204071010 1 20/11/2015 K29 3000 2000 5000
3 DEVIA N 3577031811090005 1 20/11/2015 R50 3000 2000 5000
4 SUNARTI 3577032204075509 1 20/11/2015 M36 3000 2000 5000
5 MARWATI 3577032512100051 1 20/11/2015 M36 3000 2000 5000
6 SITI R 3577032104077475 1 20/11/2015 M36 3000 2000 5000
7 SUMIATUN 3577032204071812 1 20/11/2015 I10 3000 2000 5000
8 NINA M 3577032204071812 1 20/11/2015 G44 3000 2000 5000
9 RAFFAA K Z 3577030305130003 1 20/11/2015 J11 3000 2000 5000
10 PUTRI I M 3577032605090010 1 20/11/2015 J11 3000 2000 5000
11 REYHAN S N 3577030208130004 20/11/2015 J10 3000 2000 5000
12 SUYONO 3577032204071333 1 20/11/2015 E11 3000 2000 5000
13 SUKATMI 3577030408110000 1 20/11/2015 M36 3000 2000 5000
14 SETIYONO 3577032204074949 1 20/11/2015 N20 3000 2000 5000
15 NANIK M 3577032204074949 1 20/11/2015 M36 3000 2000 5000
16 CINTYA DIAH P 3577032204071553 1 20/11/2015 J11 3000 2000 5000
17 BRAMI W 3577032504078723 1 20/11/2015 D 3000 2000 5000
18 MUHAMMAD R P 3577032301140007 1 20/11/2015 A09 3000 2000 5000
19 SURINGAH 1250029806622 1 20/11/2015 H81 3000 2000 5000
20 MUASIH 3577032204072827 1 20/11/2015 M36 3000 2000 5000
21 SRI ENDANG W 3577032104079372 1 20/11/2015 M36 3000 2000 5000
22 SUSILO BUDHI W 3577032411080018 1 20/11/2015 F28 3000 2000 5000
23 NYAMI 3577032204072361 1 20/11/2015 M36 3000 2000 5000
24 ANDIK 3577032204071661 1 23/11/2015 V20 3000 2000 5000
25 siti rifai 3577032230307140002 23/11/2015 3000 2000 5000
JUMLAH TOTAL 2 1 2 4 2 9 2 75000 50000 125000
Mengetahui

POLI :BP UMUM……
PELKES & BESARAN
TARIF SESUAI PERDA
(RP)
1 2 3 L P L P L P L P L P L P 5 6 7 8 9 10
1 ARGA 3577032230307140002 1 23/11/2015 J10 3000 2000 5000
2 BERNIKA IVALDO 3577032204076047 1 23/11/2015 ANEMIA 3000 2000 5000
3 AJENG HERDRAS 3577031801710001 1 23/11/2015 B35 3000 2000 5000
4 DYAH 3577031212120007 1 23/11/2015 F33 3000 2000 5000
5 MURSIYEM 3577032204072835 1 23/11/2015 M36 3000 2000 5000
6 AGATHA 3577032104079515 1 23/11/2015 J10 3000 2000 5000
7 ANDI RISKI 3577032104071811 1 23/11/2015 G44 3000 2000 5000
8 RASIM 3577032204075178 1 23/11/2015 M35 3000 2000 5000
9 FIRDA 3577032204070215 1 23/11/2015 J10 3000 2000 5000
10 TUTIK DJARMIHARI 3577032204076480 1 23/11/2015 E11 3000 2000 5000
11 APRILIA 3577022204071719 1 23/11/2015 J10 3000 2000 5000
12 RIAN FEBRI 3577022104078657 1 23/11/2015 D00 3000 2000 5000
13 KAMIRAH 3577010801140005 1 23/11/2015 M36 3000 2000 5000
14 FITRI SUTINAH 3577032204073214 1 23/11/2015 M36 3000 2000 5000
15 SIWARNI 3577032004079982 1 23/11/2015 M36 3000 2000 5000
16 SUNYOTO 3577032004079982 1 23/11/2015 L23 3000 2000 5000
17 NINDYA 3577030302090008 1 23/11/2015 F323 3000 2000 5000
18 PUTRI 3577.032204071033 1 23/11/2015 J10 3000 2000 5000
19 SITI UTIKAH 3577032204071772 1 23/11/2015 H81 3000 2000 5000
20 SAYEKTI 1250020001368 1 23/11/2015 M36 3000 2000 5000
21 NESTHA SCANIA 357703160350001 1 23/11/2015 M36 3000 2000 5000
22 MUJIONO 3577032204070007 1 23/11/2015 R05 3000 2000 5000
23 FERNAANDO 357703024120007 1 23/11/2015 V20 3000 2000 5000
24 WINDA MARDIANA 3577032204072457 1 23/11/2015 F23 3000 2000 5000
25 SUWARTI 3577032507120003 1 23/11/2015 HEPATITIS 3000 2000 5000
JUMLAH TOTAL 75000 50000 125000
Mengetahui

POLI :BP UMUM……
PELKES & BESARAN
TARIF SESUAI PERDA
(RP)
1 2 3 L P L P L P L P L P L P 5 6 7 8 9 10
1 RENAL WARDANA 3577032204073132 1 1 23/11/2015 J11 3000 2000 5000
2 SUGIANTO 3577032204070850 1 1 23/11/2015 L23 3000 2000 5000
3 TUKIRAH 3577032104070338 1 1 23/11/2015 M36 3000 2000 5000
4 RIZKI Q 35770322041500013 1 1 23/11/2015 J11 3000 2000 5000
5 RAHMAT F Z 3577031112080021 1 1 23/11/2015 A09 3000 2000 5000
6 HILMY TANSA J 3577031112080021 1 1 23/11/2015 H10 3000 2000 5000
7 PUTRI OKTA DWI 3577020507110004 1 1 23/11/2015 J10 3000 2000 5000
8 LUSIANI HARTINI 3577032204075600 1 1 23/11/2015 G44 3000 2000 5000
9 SITI YUNI W 3577032204073097 1 1 23/11/2015 A18 3000 2000 5000
10 AGLAI CAESAR W 3577032204071467 1 1 23/11/2015 K59 3000 2000 5000
11 DUWIK DARWATI 3577032204071467 1 1 23/11/2015 G44 3000 2000 5000
12 AHLAN CANDRA 3577032609130004 1 1 23/11/2015 J11 3000 2000 5000
13 TOFA GALIH R 1250020300508 1 1 23/11/2015 J11 3000 2000 5000
14 DEWI K 3577032204071549 1 1 23/11/2015 M36 3000 2000 5000
15 AAN S 3577032004074476 1 1 23/11/2015 M36 3000 2000 5000
16 AZIZAH Q 3577032104079259 1 1 23/11/2015 J11 3000 2000 5000
17 BAMBANG S 3577032605090004 1 1 23/11/2015 M36 3000 2000 5000
18 KEYSA A H 3577020402140004 1 1 23/11/2015 L23 3000 2000 5000
19 KABUL 3577032204076424 1 24/11/2015 M36 3000 2000 5000
20 WINARTI 3577032204072515 1 24/11/2015 M36 3000 2000 5000
21 MUJI LESTARI 3577032204072652 1 24/11/2015 M36 3000 2000 5000
22 ARDIAN SYAH 3577032104079334 1 24/11/2015 L30 3000 2000 5000
23 saidi 3577032004076571 1 24/11/2015 l23 3000 2000 5000
24 SITI FADLAH A 3577032004076571 1 24/11/2015 J11 3000 2000 5000
25 3000 2000 5000
JUMLAH TOTAL 4 5 3 3 5 3 1 24 75000 50000 125000
Mengetahui

POLI :BP UMUM……
PELKES & BESARAN
TARIF SESUAI PERDA
(RP)
1 2 3 L P L P L P L P L P L P 5 6 7 8 9 10
1 TRIASNAH 3577032004076571 1 24/11/2015 M36 3000 2000 5000
2 SIYAM 3577032204072820 1 24/11/2015 K29 3000 2000 5000
3 SUHARMI 3577032203110001 1 24/11/2015 M36 3000 2000 5000
4 NABILA F 3577032812100063 1 24/11/2014 J11 3000 2000 5000
5 AZKA JULIAN R 3577030608090002 1 24/11/2015 J11 3000 2000 5000
6 RENTIKA A.E.P 3577030608090002 1 24/11/2015 J31 3000 2000 5000
7 NURWATI 357703103110004 1 24/11/2015 J11 3000 2000 5000
8 SUKAR 3577032204070293 1 24/11/2015 J11 3000 2000 5000
9 WIWIK SUPRIATI 3577032104077961 1 24/11/2015 I10 3000 2000 5000
10 POERNAMI 3577032204076066 1 24/11/2015 H81 3000 2000 5000
11 TINI 3577032004076689 1 24/11/2015 M36 3000 2000 5000
12 PIYONO 3577032204070342 1 24/11/2015 E11 3000 2000 5000
13 PUDJIATI RAHAYUNINGSIH 3577032204070494 1 24/11/2015 M36 3000 2000 5000
14 SUWARNO 3577032204076157 1 24/11/2015 M36 3000 2000 5000
15 ALISHA SEKAR 3577032609130004 1 24/11/2015 J11 3000 2000 5000
16 WIJIANTO 3577032204073129 1 24/11/2015 M36 3000 2000 5000
17 SALSABILLA 3577032810140001 1 24/11/2015 J11 3000 2000 5000
18 SUHARTINI 357703212100043 1 24/11/2015 K12 3000 2000 5000
19 YUFIANI PUTRI 3577032204072862 1 24/11/2015 L23 3000 2000 5000
20 SRIATI 3577032204072862 1 24/11/2015 I10 3000 2000 5000
21 ARYA BUNGSU 3577032806130003 1 24/11/2015 I84 3000 2000 5000
22 BAMBANG SUHENDRO 3577032605090004 1 25/11/2015 A16 3000 2000 5000
23 SUGAIRTI 3577032204071893 1 25/11/2015 E11 3000 2000 5000
24 ARYO PANULISAN 3577032204074570 1 25/11/2015 J11 3000 2000 5000
25 GUNARTO 1250029801916 1 25/11/2015 E11 3000 2000 5000
JUMLAH TOTAL 75000 50000 125000
Mengetahui

POLI :BP UMUM……
PELKES & BESARAN
TARIF SESUAI PERDA
(RP)
1 2 3 L P L P L P L P L P L P 5 6 7 8 9 10
1 KATINI 3577032004077487 1 25/11/2015 E11 3000 2000 5000
2 KASIYEM 3577032204073193 1 25/11/2015 I10 3000 2000 5000
3 DEVI IKA FANDINI 1250029910705 1 25/11/2015 I95 3000 2000 5000
4 HAMFI TRINDIKA 357703010311100004 1 25/11/2015 A09` 3000 2000 5000
5 AQILAKHANZANIA 3577032003140003 1 25/11/2015 R05 3000 2000 5000
6 KUSNODIHARJO 3577032104079634 1 25/11/205 J45 3000 2000 5000
7 RASIMAN 3577032004075918 1 25/11/2015 Q61 3000 2000 5000
8 MISIRAH 3577032204070050 1 25/11/2015 M36 3000 2000 5000
9 ENGGAR 1250020300204 1 25/11/2015 J11 3000 2000 5000
10 NGADIRIN 3577032204070558 1 25/11/2015 K59 3000 2000 5000
11 ENDAH ASMARANI 3577020411100002 1 25/11/2015 M36 3000 2000 5000
12 SOETJIAMI 3577021103110002 1 25/11/2015 M36 3000 2000 5000
13 PRILA DWI 3577032004076904 1 25/11/2015 L30 3000 2000 5000
14 SUPRIYATUN 3577032204074456 1 25/11/2015 E11 3000 2000 5000
15 HABSYAH AS SIYIFFA 3577032802130003 1 25/11/2015 J11 3000 2000 5000
16 MAHESWARA ARGARESA 3577031007130004 1 25/11/2015 J11 3000 2000 5000
17 MARULI SANTOSO 3577031801110006 1 25/11/2015 M36 3000 2000 5000
18 AUREL HANIF 3577031501090008 1 25/101/2015 J11 3000 2000 5000
19 MUNAIM 3577032004076401 1 25/11/2015 J11 3000 2000 5000
20 MISIRAH 1250029901159 1 M36 3000 2000 5000
21 NOVIKA DEVIN 3577032004076924 1 25/11/2015 J11 3000 2000 5000
22 WARINEM 3577032204070909 1 25/11/2015 G44 3000 2000 5000
23 DEWI HERMIN 3577032004076151 1 25/11/2015 M36 3000 2000 5000
24 MADRIFAH 3577032004076151 1 25/11/2015 J11 3000 2000 5000
25 OEI GEE HIN 3577032310120009 1 25/11/2015 M36 3000 2000 5000
JUMLAH TOTAL 75000 50000 125000
Mengetahui
POLI :BP UMUM……
PELKES & BESARAN
TARIF SESUAI PERDA
(RP)
1 2 3 L P L P L P L P L P L P 5 6 7 8 9 10
1 MEY SINTA 3577032204071523 1 25/11/2015 V20 3000 2000 5000
2 YULIANINGSIH 3577022204070959 1 25/11/2015 E11 3000 2000 5000
3 SUMINEM 3577032204072661 1 25/11/2015 A09 3000 2000 5000
4 DESSY PUTRI 3577032204071197 1 25/11/2015 K29 3000 2000 5000
5 EDWIN ROFI 3577032204076331 1 25/11/2015 B99 3000 2000 5000
6 WINARTO 3577032204073722 1 25/11/2015 M36 3000 2000 5000
7 MISINEM 3577032204071154 1 25/11/2015 L23 3000 2000 5000
8 SEVANANDA BUDI 3577030310140009 1 25/11/2015 K29 3000 2000 5000
9 WIWIN YULIANTI 3577032204075146 1 25//11/2015 M36 3000 2000 5000
10 MOHAMAD ALI 357702210407947 1 25/11/2015 M36 3000 2000 5000
11 NINING PARMINI 1250020500776 1 25/11/2015 M36 3000 2000 5000
12 DEDY PERMADI 3577032204072134 1 26/11/2015 M36 3000 2000 5000
13 SUPARYADI 3577032004076619 1 26/11/2015 E11 3000 2000 5000
14 MUHAMAT P.K 12500030400590 1 26/11/2015 J11 3000 2000 5000
15 SAMI 1250029806782 1 26/11/2015 M36 3000 2000 5000
16 SRIYANI 3577032104079244 1 26//11/2015 M36 3000 2000 5000
17 VANY ANDARA 3577032104079244 1 26/11/2015 K12 3000 2000 5000
18 RORO PRAMESTY 3577031105110006 1 26/11/2015 J11 3000 2000 5000
19 HAMFI TRIDIKA 35770301031110004 1 26/11/2015 A09 3000 2000 5000
20 KUSRAHAYU 3577032204077927 1 26/11/2015 E11 3000 2000 5000
21 SRI AKHIRYANI 3577032411080027 1 26/11/2015 J11 3000 2000 5000
22 ENDANG PURWATI 3577032204070633 1 26/11/2015 M36 3000 2000 5000
23 SYAFIRA EKA 3577032411080024 1 26/11/2015 J11 3000 2000 5000
24 SUMADI 3577032004076965 1 26/11/2015 M36 3000 2000 5000
25 HADI WIYONO 3577032204070230 1 26/11/2015 M36 3000 2000 5000
75000 50000 125000
Mengetahui
POLI :BP UMUM……
PELKES & BESARAN
TARIF SESUAI PERDA
(RP)
1 2 3 L P L P L P L P L P L P 5 6 7 8 9 10
1 FIRDA NURUL 3577032204070215 1 26/11/2015 H10 3000 2000 5000
2 SUPIATUN 3577031911120004 1 26//11/2015 M36 3000 2000 5000
3 PURYANI 3577032708120004 1 26/11/2015 I10 3000 2000 5000
4 SUYITNO 357703201010010 1 26/11/2015 J11 3000 2000 5000
5 SITI SULIYAH 357722104079352 1 26/11/2015 M36 3000 2000 5000
6 SIKOENADI 3577022104079352 1 26/11/2015 E11 3000 2000 5000
7 HERU SUSANTO 3577032204070702 1 26/11/2015 E11 3000 2000 5000
8 DWI ERNAWATI 1250029906254 1 26//11/2015 M36 3000 2000 5000
9 SAMIRIN 3577031903100011 1 26/11/2015 M36 3000 2000 5000
10 HJ JUWARSIH 3577032104076795 1 26/11/2015 E11 3000 2000 5000
11 SALAMAH 3577032204072366 1 26/11/2015 E11 3000 2000 5000
12 WRESTI NINGSIH 3577032204072366 1 26/11/2015 K29 3000 2000 5000
13 NYAMI 3577032204072361 1 26/11/2015 M36 3000 2000 5000
14 EMMY PRASTIWI 3577032204076438 1 26/11/2015 M36 3000 2000 5000
15 WAHYUNINGSIH 3577032204072258 1 26/11/2015 M36 3000 2000 5000
16 SUMADI 357703220076552 1 26/11/2015 M36 3000 2000 5000
17 NAFISAH 3577020307130001 1 26/11/2015 B01 3000 2000 5000
18 ROBERTHA PRIN 3577032204073071 1 26/11/2015 I10 3000 2000 5000
19 NADIL ULUM 3577030701090001 1 26/11/2015 J11 3000 2000 5000
20 MARMIATI 3577032004076593 1 26/11/2015 M36 3000 2000 5000
21 ALI ARYA W 3577032204071875 1 26/11/2015 K29 3000 2000 5000
22 ARKANA ZIDAN N 3577022410080003 1 26/11/2015 J10 3000 2000 5000
23 HARININGSIH 3577022410080003 1 26/11/2015 J11 3000 2000 5000
24 GANGSAR AMI 125009907561 1 27/11/2015 G44 3000 2000 5000
25 WIWIT PUJIANI 35770322040711168 1 27/11/2015 B99 3000 2000 5000
75000 50000 125000
Mengetahui
POLI :BP UMUM……
PELKES & BESARAN
TARIF SESUAI PERDA
(RP)
1 2 3 L P L P L P L P L P L P 5 6 7 8 9 10
1 SUNARTI 3577032204071833 1 27/11/2015 V20 3000 2000 5000
2 MARPUJI 3577032204071833 1 27/11/2015 H81 3000 2000 5000
3 SUMARMI 3577032204075821 1 27/11/2015 E11 3000 2000 5000
4 MARSINI 3577032104079717 1 27/11/2015 E11 3000 2000 5000
5 SOEMARSIH 3577032204072167 1 27/11/2015 E11 3000 2000 5000
6 PONIYEM 3577032204072487 1 27/11/2015 K29 3000 2000 5000
7 LUKITO 3577032204076040 1 27/11/2015 K35 3000 2000 5000
8 ENGGAR MELANI 1250020300204 1 27/11/2015 J11 3000 2000 5000
9 MULYONO 3577032204072118 1 27/11/2015 R05 3000 2000 5000
10 MUHAMMAD GIBRAN 3577032204072234 1 27/11/2015 A09 3000 2000 5000
11 ELKHO ROLYANA 3577032709100005 1 27/11/2015 J11 3000 2000 5000
12 MAYKA AMALIA 3577030307140003 1 27/11/2015 J11 3000 2000 5000
13 SIGIT P 3577033108090008 1 27/11/2015 V20 3000 2000 5000
14 MUDJIONO 3577032204070007 1 27/11/2015 J45 3000 2000 5000
15 SUMARTI 3577022204070228 1 27/11/2015 M36 3000 2000 5000
16 ANY SETYANINGSEH 3577022204071682 27/11/2015 M36 3000 2000 5000
17 HARTINI 3577032204070250 1 27/11/2015 M36 3000 2000 5000
18 ELFA HARGIANTO 3577030905120002 1 27/11/2015 T30 3000 2000 5000
19 OKI AVIAN 3577032104079647 1 27/11/2015 J11 3000 2000 5000
20 ALFINO DAFA 3577031801120014 1 27/11/2015 J11 3000 2000 5000
21 FERNANDO PRATAMA 3577030204120007 1 27/11/2015 V20 3000 2000 5000
22 MEY SINTA 3577032204071523 1 27/11/2015 V20 3000 2000 5000
23 HARNI 3577032204070021 1 27/11/2015 M36 3000 2000 5000
24 KRISNAWATI 3577031201090008 1 27/11/2015 M36 3000 2000 5000
25 MUHAMAD ASUR 3577032211120005 1 27/11/2015 MJ11 3000 2000 5000
75000 50000 125000
Mengetahui

POLI :BP UMUM……
PELKES & BESARAN
TARIF SESUAI PERDA
(RP)
1 2 3 L P L P L P L P L P L P 5 6 7 8 9 10
1 RAFFA BASTIAN 3577033108090008 1 27/11/2015 J11 3000 2000 5000
2 SITI RETNOWATI 3577033112080003 1 27/11/2015 M36 3000 2000 5000
3 CINTYA DIAH 3577032204071553 1 27/11/2015 J11 3000 2000 5000
4 RIRIN RAHAYU PRIHATI 3577020710090003 1 27/11/2015 M36 3000 2000 5000
5 NURSYASWA REGINA 3577020710090003 1 27/11/2015 J11 3000 2000 5000
6 HARTATIK 3577032204070822 1 27/11/2015 A09 3000 2000 5000
7 SRI LESTARI 35577032204073283 1 30/11/2015 M36 3000 2000 5000
8 SRI MARSINI 3577031306120002 1 30/11/2015 M36 3000 2000 5000
9 LILIK HANDAYANI 3577032402120002 1 30/11/2015 J11 3000 2000 5000
10 YENI WULANDARI 3577032503100006 1 30/11/2015 M36 3000 2000 5000
11 SURANTI 3577032204073277 1 30/11/2015 J45 3000 2000 5000
12 WILLIAM N S 3577022204071009 1 30/11/2015 J10 3000 2000 5000
13 SULASTRI 3577032004076101 1 30/11/2015 M36 3000 2000 5000
14 SEMI 3577030503090005 1 30/11/2015 M36 3000 2000 5000
15 SUNARYONO 3577032204078002 1 30/11/2015 M36 3000 2000 5000
16 MUGI UTOMO 1250039901325 1 30/11/2015 E11 3000 2000 5000
17 AUDY CANTIKA S 3577031202100002 1 30/11/2015 V20 3000 2000 5000
18 TUMINI 3577031001120012 1 30/11/2015 G44 3000 2000 5000
19 ISMINAH 3577022104079375 1 30/11/2015 M36 3000 2000 5000
20 SULISWATI 3577032204071044 1 30/11/2015 G44 3000 2000 5000
21 GALUH ARYA 3577032004076151 1 30/11/2015 J10 3000 2000 5000
22 FIRDAA 3577032004077080 1 30/11/2015 B02 3000 2000 5000
23 ANA WULANDARI 3577032004077080 30/11/2015 M79 3000 2000 5000
24 HANDAYANI 3577032104070247 1 30/11/2015 J11 3000 2000 5000
25 IBNU CAMILA A 3577030601100009 30/11/2015 H10 3000 2000 5000
3 3 5 1 8 3 75000 50000 125000
Mengetahui

POLI :BP UMUM……
PELKES & BESARAN
TARIF SESUAI PERDA
(RP)
1 2 3 L P L P L P L P L P L P 5 6 7 8 9 10
1 SUYITNO 3577032010110010 1 30/11/2015 J45 3000 2000 5000
2 SUNARMI 3577031802100004 1 30/11/2015 M36 3000 2000 5000
3 SUGIANTO 3577032204070850 1 30/11/2015 I10 3000 2000 5000
4 NANIK SUHARTINI 3577030712110008 1 30/11/2015 M36 3000 2000 5000
5 BAMBANG SARJONO 3577030712110008 1 30/11/2015 M36 3000 2000 5000
6 NARDA AJI S 3577022104029146 1 30/11/2015 J11 3000 2000 5000
7 YOHANA 3577032104076160 1 30/11/2015 F28 3000 2000 5000
8 SIE HWIE SIAN 3577032104076160 1 30/11/2015 D 3000 2000 5000
9 ALTAF NEFIS J 3577032510120001 1 30/11/2015 J11 3000 2000 5000
10 CHELSEA K 3577032004077260 1 30/11/2015 J11 3000 2000 5000
11 YULI KRISTIAN 3577030401110043 1 30/11/2015 M36 3000 2000 5000
12 SITI M 3577030811130003 1 30/11/2015 M36 3000 2000 5000
13 PRIHATI 3577032104070343 1 30/11/2015 M36 3000 2000 5000
14 ENDAH S 35770309060190002 1 30/11/2015 M36 3000 2000 5000
15 NINIK N 3577032204076400 1 30/11/2015 M36 3000 2000 5000
16 ILHAM W 3577032204070572 1 30/11/2015 V20 3000 2000 5000
17 JUMILAH 3577032204072869 1 30/11/2015 M36 3000 2000 5000
18 H NAROHMI 3577032004075610 1 30/11/2015 I10 3000 2000 5000
19 SUDARMI 3577029806736000 1 30/11/2015 M36 3000 2000 5000
20 FERNANDO PRATAMA S 3577030204120007 1 30/11/2015 J11 3000 2000 5000
21 KATINI 3577032004076128 1 30/11/2015 M36 3000 2000 5000
22 EKA PUTRI A 3577032802110003 1 30/11/2015 J11 3000 2000 5000
23 AQILA DANIA S P 3577030805120008 1 30/11/2015 J11 3000 2000 5000
24 TEMU RAHAYU 3577030701110081 1 30/11/2015 F28 3000 2000 5000
25 RIZKY ALFIAN F 3577032204077436 1 30/11/2015 V20 3000 2000 5000
1 1 1 3 2 5 3 7 2 75000 50000 125000
Mengetahui

POLI :BP UMUM……
PELKES & BESARAN
TARIF SESUAI PERDA
(RP)
1 2 3 L P L P L P L P L P L P 5 6 7 8 9 10
1 3000 2000 5000
2 3000 2000 5000
3 3000 2000 5000
4 3000 2000 5000
5 3000 2000 5000
6 3000 2000 5000
7 3000 2000 5000
8 3000 2000 5000
9 3000 2000 5000
10 3000 2000 5000
11 3000 2000 5000
12 3000 2000 5000
13 3000 2000 5000
14 3000 2000 5000
15 3000 2000 5000
16 3000 2000 5000
17 3000 2000 5000
18 3000 2000 5000
19 3000 2000 5000
20 3000 2000 5000
21 3000 2000 5000
22 3000 2000 5000
23 3000 2000 5000
24 3000 2000 5000
25 3000 2000 5000
75000 50000 125000
Mengetahui
POLI :BP UMUM……
PELKES & BESARAN
TARIF SESUAI PERDA
(RP)
1 2 3 L P L P L P L P L P L P 5 6 7 8 9 10
1 3000 2000 5000
2 3000 2000 5000
3 3000 2000 5000
4 3000 2000 5000
5 3000 2000 5000
6 3000 2000 5000
7 3000 2000 5000
8 3000 2000 5000
9 3000 2000 5000
10 3000 2000 5000
11 3000 2000 5000
12 3000 2000 5000
13 3000 2000 5000
14 3000 2000 5000
15 3000 2000 5000
16 3000 2000 5000
17 3000 2000 5000
18 3000 2000 5000
19 3000 2000 5000
20 3000 2000 5000
21 3000 2000 5000
22 3000 2000 5000
23 3000 2000 5000
24 3000 2000 5000
25 3000 2000 5000
75000 50000 125000
Mengetahui
PROGRAM JAMKESDA DI PELAYANAN DASAR
BULAN : TAHUN :
POLI :BP UMUM….….
PELKES & BESARAN
NO KARTU PESERTA JNS KLM TANGGAL TOTAL
NO NAMA PASIEN DIAGNOSA BHBS JASPEL
(RP)
JAMKESDA L P KUNJUNGAN BIAYA
1 2 3 4 5 6 7 8 9 10 11
1 RAHAYUNINGSIH 100508032836 1 1 2/11/2015 D17 3000 2000 5000
2 TYOGO P 100508032144 1 1 2/11/2015 V20 3000 2000 5000
3 KATMINI 100508032423 1 1 2/11/2015 M36 3000 2000 5000
4 ADI ARYA K 100508025032 1 1 2/11/2015 J10 3000 2000 5000
5 SUMARDI 100508030964 1 1 2/11/2015 V20 3000 2000 5000
6 SUPENI 100508023763 1 1 2/11/2015 M36 3000 2000 5000
7 SUPARIYEM 100508032593 1 1 3/11/2015 J11 3000 2000 5000
8 MUH KABUL 100508032592 1 1 3/11/2015 E11 3000 2000 5000
9 SATIYEM 100508033286 1 1 3/11/2015 M36 3000 2000 5000
10 AHMAD WAHID 100508034276 1 1 3/11/2015 J10 3000 2000 5000
11 ATSAH 100508024882 1 1 3/11/2015 M36 3000 2000 5000
12 GUNADI 100508032493 1 1 4/11/2015 J11 3000 2000 5000
13 SARIMAN 1000508032315 1 1 4/11/2015 J45 3000 2000 5000
14 MUJIATI 100508032822 1 1 4/11/2015 L23 3000 2000 5000
15 EMANG SETYONO 100508030456 1 1 4/11/2015 F23 3000 2000 5000
16 ENDANG 100508030455 1 1 4/11/2015 M36 3000 2000 5000
17 IIN KUTIAH 100508033234 1 1 5/11/2015 E11 3000 2000 5000
18 KAMBALI 100508020760 1 1 5/11/2015 G44 3000 2000 5000
19 SUPENI 100508023763 1 1 5/11/2015 E11 3000 2000 5000
20 LASMINI 100508034862 1 1 5/11/2015 M36 3000 2000 5000
21 FITRI H 100508032463 1 1 5/11/2015 G44 3000 2000 5000
22 ENDANG S 100508021350 1 1 5/11/2015 M36 3000 2000 5000
23 ISKANDAR 100508021349 1 1 5/11/2015 J45 3000 2000 5000
24 TAMI 100508032246 1 1 6/11/2015 M36 3000 2000 5000
25 SUMARDI 100508030964 1 1 6/11/2015 V20 3000 2000 5000
JUMLAH TOTAL 3 19 3 14 11
Mengetahui Madiun,

BULAN : TAHUN :
PELKES & BESARAN
(RP)
1 2 3 4 5 6 7 8 9 10 11
1 DIASPRIYATNA 100508032937 1 1 9/11/2015 J11 3000 2000 5000
2 ENDANG JATI MANIK 100508032584 1 1 9/11/2015 M36 3000 2000 5000
3 TJATUR SUSANTO A 100508032583 1 10/11/2015 E11 3000 2000 5000
4 ACHMAD SUTOMO 100508024907 1 1 10/11/2015 M36 3000 2000 5000
5 SOERONO 100508023909 1 1 10/11/2015 R05 3000 2000 5000
6 SRI SUPIAH 100508033530 1 1 10/11/2015 J11 3000 2000 5000
7 SUMADI 100508032327 1 1 10/11/2015 H52 3000 2000 5000
8 ENDANG 100508024470 1 1 10/11/2015 M36 3000 2000 5000
9 SITI FATONAH 100508026850 1 1 10/11/2015 E11 3000 2000 5000
10 RAHAYUNINGSIH 100508032836 1 10/11/2015 D17 3000 2000 5000
11 YULIA SETYA P 100508032091 1 1 11/11/2015 E11 3000 2000 5000
12 ETIN T S 100508032090 1 1 11/11/2015 M36 3000 2000 5000
13 SATRIA DEVA S B 100508024021 1 1 12/11/2015 L23 3000 2000 5000
14 SALIYO 100508030893 1 1 12/11/2015 M36 3000 2000 5000
15 ISTILAH 100508030863 1 1 12/11/2015 N92 3000 2000 5000
16 SUMARDI 100508030964 1 1 12/11/2015 V20 3000 2000 5000
17 ISMIATI 1005080267987 1 12/11/2015 M36 3000 2000 5000
18 FERY H 100508033764 1 1 13/11/2015 L23 3000 2000 5000
19 SITI R 100508033763 1 1 13/11/2015 J11 3000 2000 5000
20 ISMIATI 100508024403 1 1 13/11/2015 M36 3000 2000 5000
21 DIAS PRIATNA 100508032937 1 1 16/11/2015 F28 3000 2000 5000
22 SIWI PENI 100508032687 1 1 16/11/2015 J11 3000 2000 5000
23 DARWIS RIYANTO 100508034327 1 1 16/11/2015 J11 3000 2000 5000
24 HAZEL BELVA AD 100508034329 1 1 16/11/2015 H60 3000 2000 5000
25 BUDI PRAYETNO 100508024469 1 1 16/11/2015 M36 3000 2000 5000
JUMLAH TOTAL
Mengetahui Madiun,

BULAN : TAHUN :
PELKES & BESARAN
(RP)
1 2 3 4 5 6 7 8 9 10 11
1 TOTOK Y 100508033950 1 1 16/11/2015 M36 3000 2000 5000
2 SUMARDI 100508030964 1 1 16/11/2015 V20 3000 2000 5000
3 KAMBALI 1000508020760 1 1 17/11/2015 J10 3000 2000 5000
4 BUDI PRAYITNO 100508028664 1 1 18/11/2015 E11 3000 2000 5000
5 BIBIT 100508033169 1 1 18/11/2015 M36 3000 2000 5000
6 TAMI 100508032246 1 1 19/11/2015 M36 3000 2000 5000
7 DJOEANG F C 100508031467 1 1 19/11/2015 R05 3000 2000 5000
8 MIFTAHUDIN 100508027094 1 1 19/11/2015 J10 3000 2000 5000
9 KATIRAH 100508023940 1 1 20/11/2015 M36 3000 2000 5000
10 EMANG S 100508030456 1 1 20/11/2015 M36 3000 2000 5000
11 ENDANG S 100508030455 1 20/11/2015 M36 3000 2000 5000
12 SUPRIYONO 100508010423 1 20/11/2015 M36 3000 2000 5000
13 YETIN 100508023823 1 23/11/2015 I84 3000 2000 5000
14 SAIKEM 100508034395 1 23/11/2015 I50 3000 2000 5000
15 ILHAM GW 100508024607 1 1 23/11/2015 J11 3000 2000 5000
16 KARTINI 100508024606 1 23/11/2015 M36 3000 2000 5000
17 RISKI MARDIANTI 100508034721 1 23/11/2015 I95 3000 2000 5000
18 MIFTAHUDIN A 100508027094 1 1 23/11/2015 M36 3000 2000 5000
19 ENDANG JATI MANIK 100508032584 1 24/11/2015 E11 3000 2000 5000
20 KAMBALI 100508020760 1 1 24/11/2015 M36 3000 2000 5000
21 TITIK SULISTYANINGS100508030857 1 1 25/11/2015 M36 3000 2000 5000
22 SITI PATONAH 100508032386 1 1 26/11/2015 M36 3000 2000 5000
23 SUGIMUN 100508024275 1 1 23/11/2015 M36 3000 2000 5000
24 SUMADI 100508032327 1 1 26/11/2015 I25 3000 2000 5000
25 SULASMI 100508034694 1 26/11/2015 M36 3000 2000 5000
JUMLAH TOTAL
Mengetahui Madiun,
BULAN : NOVEMBER TAHUN : 2015
PELKES & BESARAN
(RP)
1 2 3 4 5 6 7 8 9 10 11
1 ENDANG JATI MANIK 100508032584 1 1 26/11/2015 M36 3000 2000 5000
2 TAMI 100508032246 1 1 27/11/2015 M36 9000 6000 15000
3 SALIYO 100508030893 1 1 27/11/2015 K40 3000 2000 5000
4 RIYONO 100508033359 1 1 27/11/2015 G44 3000 2000 5000
5 DIAS PRIATNA 100508032937 1 1 30/11/2015 F28 9000 6000 15000
6 3000 2000 5000
7 3000 2000 5000
8 3000 2000 5000
9 3000 2000 5000
10 3000 2000 5000
11 3000 2000 5000
12 3000 2000 5000
13 3000 2000 5000
14 3000 2000 5000
15 3000 2000 5000
16 3000 2000 5000
17 3000 2000 5000
18 3000 2000 5000
19 3000 2000 5000
20 3000 2000 5000
21 3000 2000 5000
22 3000 2000 5000
23 3000 2000 5000
24 3000 2000 5000
25 3000 2000 5000
JUMLAH TOTAL
Mengetahui Madiun,
BULAN : TAHUN :
PELKES & BESARAN
(RP)
1 2 3 4 5 6 7 8 9 10 11
1 3000 2000 5000
2 3000 2000 5000
3 3000 2000 5000
4 3000 2000 5000
5 3000 2000 5000
6 3000 2000 5000
7 3000 2000 5000
8 3000 2000 5000
9 3000 2000 5000
10 3000 2000 5000
11 3000 2000 5000
12 3000 2000 5000
13 3000 2000 5000
14 3000 2000 5000
15 3000 2000 5000
16 3000 2000 5000
17 3000 2000 5000
18 3000 2000 5000
19 3000 2000 5000
20 3000 2000 5000
21 3000 2000 5000
22 3000 2000 5000
23 3000 2000 5000
24 3000 2000 5000
25 3000 2000 5000
JUMLAH TOTAL
Mengetahui Madiun,
BULAN : TAHUN :
PELKES & BESARAN
(RP)
1 2 3 4 5 6 7 8 9 10 11
1 3000 2000 5000
2 3000 2000 5000
3 3000 2000 5000
4 3000 2000 5000
5 3000 2000 5000
6 3000 2000 5000
7 3000 2000 5000
8 3000 2000 5000
9 3000 2000 5000
10 3000 2000 5000
11 3000 2000 5000
12 3000 2000 5000
13 3000 2000 5000
14 3000 2000 5000
15 3000 2000 5000
16 3000 2000 5000
17 3000 2000 5000
18 3000 2000 5000
19 3000 2000 5000
20 3000 2000 5000
21 3000 2000 5000
22 3000 2000 5000
23 3000 2000 5000
24 3000 2000 5000
25 3000 2000 5000
JUMLAH TOTAL
Mengetahui Madiun,

BULAN : TAHUN :
PELKES & BESARAN
(RP)
1 2 3 4 5 6 7 8 9 10 11
1 3000 2000 5000
2 3000 2000 5000
3 3000 2000 5000
4 3000 2000 5000
5 3000 2000 5000
6 3000 2000 5000
7 3000 2000 5000
8 3000 2000 5000
9 3000 2000 5000
10 3000 2000 5000
11 3000 2000 5000
12 3000 2000 5000
13 3000 2000 5000
14 3000 2000 5000
15 3000 2000 5000
16 3000 2000 5000
17 3000 2000 5000
18 3000 2000 5000
19 3000 2000 5000
20 3000 2000 5000
21 3000 2000 5000
22 3000 2000 5000
23 3000 2000 5000
24 3000 2000 5000
25 3000 2000 5000
JUMLAH TOTAL
Mengetahui Madiun,
BULAN : TAHUN :
PELKES & BESARAN
(RP)
1 2 3 4 5 6 7 8 9 10 11
1 3000 2000 5000
2 3000 2000 5000
3 3000 2000 5000
4 3000 2000 5000
5 3000 2000 5000
6 3000 2000 5000
7 3000 2000 5000
8 3000 2000 5000
9 3000 2000 5000
10 3000 2000 5000
11 3000 2000 5000
12 3000 2000 5000
13 3000 2000 5000
14 3000 2000 5000
15 3000 2000 5000
16 3000 2000 5000
17 3000 2000 5000
18 3000 2000 5000
19 3000 2000 5000
20 3000 2000 5000
21 3000 2000 5000
22 3000 2000 5000
23 3000 2000 5000
24 3000 2000 5000
25 3000 2000 5000
JUMLAH TOTAL
Mengetahui Madiun,
BULAN : TAHUN :
PELKES & BESARAN
(RP)
1 2 3 4 5 6 7 8 9 10 11
1 3000 2000 5000
2 3000 2000 5000
3 3000 2000 5000
4 3000 2000 5000
5 3000 2000 5000
6 3000 2000 5000
7 3000 2000 5000
8 3000 2000 5000
9 3000 2000 5000
10 3000 2000 5000
11 3000 2000 5000
12 3000 2000 5000
13 3000 2000 5000
14 3000 2000 5000
15 3000 2000 5000
16 3000 2000 5000
17 3000 2000 5000
18 3000 2000 5000
19 3000 2000 5000
20 3000 2000 5000
21 3000 2000 5000
22 3000 2000 5000
23 3000 2000 5000
24 3000 2000 5000
25 3000 2000 5000
JUMLAH TOTAL
Mengetahui Madiun,
BULAN : TAHUN :
PELKES & BESARAN
(RP)
1 2 3 4 5 6 7 8 9 10 11
1 3000 2000 5000
2 3000 2000 5000
3 3000 2000 5000
4 3000 2000 5000
5 3000 2000 5000
6 3000 2000 5000
7 3000 2000 5000
8 3000 2000 5000
9 3000 2000 5000
10 3000 2000 5000
11 3000 2000 5000
12 3000 2000 5000
13 3000 2000 5000
14 3000 2000 5000
15 3000 2000 5000
16 3000 2000 5000
17 3000 2000 5000
18 3000 2000 5000
19 3000 2000 5000
20 3000 2000 5000
21 3000 2000 5000
22 3000 2000 5000
23 3000 2000 5000
24 3000 2000 5000
25 3000 2000 5000
JUMLAH TOTAL
Mengetahui Madiun,

BULAN : TAHUN :
PELKES & BESARAN
(RP)
1 2 3 4 5 6 7 8 9 10 11
1 3000 2000 5000
2 3000 2000 5000
3 3000 2000 5000
4 3000 2000 5000
5 3000 2000 5000
6 3000 2000 5000
7 3000 2000 5000
8 3000 2000 5000
9 3000 2000 5000
10 3000 2000 5000
11 3000 2000 5000
12 3000 2000 5000
13 3000 2000 5000
14 3000 2000 5000
15 3000 2000 5000
16 3000 2000 5000
17 3000 2000 5000
18 3000 2000 5000
19 3000 2000 5000
20 3000 2000 5000
21 3000 2000 5000
22 3000 2000 5000
23 3000 2000 5000
24 3000 2000 5000
25 3000 2000 5000
JUMLAH TOTAL
Mengetahui Madiun,

BULAN : TAHUN :
PELKES & BESARAN
(RP)
1 2 3 4 5 6 7 8 9 10 11
1 3000 2000 5000
2 3000 2000 5000
3 3000 2000 5000
4 3000 2000 5000
5 3000 2000 5000
6 3000 2000 5000
7 3000 2000 5000
8 3000 2000 5000
9 3000 2000 5000
10 3000 2000 5000
11 3000 2000 5000
12 3000 2000 5000
13 3000 2000 5000
14 3000 2000 5000
15 3000 2000 5000
16 3000 2000 5000
17 3000 2000 5000
18 3000 2000 5000
19 3000 2000 5000
20 3000 2000 5000
21 3000 2000 5000
22 3000 2000 5000
23 3000 2000 5000
24 3000 2000 5000
25 3000 2000 5000
JUMLAH TOTAL
Mengetahui Madiun,
PROGRAM RUJUKAN DARI UKS DI PELAYANAN DASAR
KOTA : MADIUN PUSKESMAS : POLI: BP UMUM…..
BULAN : TAHUN :
PENGOBATAN/ TOTAL TANDA TANGAN
NAMA SEKOLAH JNS KLM TANGGAL
NO NAMA PASIEN UMUR DIAGNOSA TINDAKAN BHBS JASPEL
BIAYA
L P KUNJUNGAN PASIEN
1 2 3 4 5 6 7 8 9 10 11 12
1 SEAVA TK DARUL ULUM 5 1 2/11/2015 H60 3000 2000 5000
2 DIMAS BAGUS SMAN 4 16 1 5/11/2015 L23 3000 2000 5000
3 WINDY KURNIA PONDOK AL MUJADIYAH 20 1 5/11/2015 J10 3000 2000 5000
4 MUCHLIS AMARTA MAN 1 16 1 5/11/2015 B02 3000 2000 5000
5 ALIF MUSTIKA Y PONDOK DEMANGAN 18 1 6/11/2015 J10 3000 2000 5000
6 RISKA WAHYU MAN 1 18 1 9/11/2015 J11 3000 2000 5000
7 FAISAL BAGUS PONDOK JOSENAN 16 1 10/11/2015 L23 3000 2000 5000
8 AMALINDA SMKN 2 16 1 10/11/2015 J10 3000 2000 5000
9 MARADEN MAN 1 16 1 11/11/2015 H60 3000 2000 5000
10 SATRIA MAN 1 16 1 12/11/2015 T16 3000 2000 5000
11 ALFITA TK DEMANGAN 6 1 13/12/2015 J11 3000 2000 5000
12 AHMAD F MAN1 16 1 13/12/2015 J10 3000 2000 5000
13 MUHAMMAD R MAN1 15 1 13/12/2015 J10 3000 2000 5000
14 BAGUS CAHYO SDTAMAN 10 1 17/11/2015 J10 3000 2000 5000
15 DIAN MARNI SD TAMAN 8 1 17/11/2015 J10 3000 2000 5000
16 ALDO KURNIAWAN SD DEMANGAN 2 12 1 18/11/2015 J10 3000 2000 5000
17 SATRIYIO BIMO SDN 03 TAMAN 12 1 20/11/2015 H10 3000 2000 5000
18 ALIF NUR R MAN 1 MADIUN 16 1 23/11/2015 V20 3000 2000 5000
19 AHMAT ASROFIL MAN 1 DEMANGAN 16 1 23/11/2015 V20 3000 2000 5000
20 SULIS DEWI PONDOK DEMANGAN 16 1 25/11/2015 J10 3000 2000 5000
21 HABIB PONDOK DEMANGAN 14 1 26/11/2015 V20
22 DILA PONDOK JOSENAN 18 1 30/11/2015 L23
23
24
25
JUMLAH TOTAL
Mengetahui Madiun,
LAPORAN PELAYANAN
BPJS CABANG MADIUN
BULAN NOVEMBER TAHUN 2015
NAMA DOKTER :
KODE PPK :
POLI : BP UMUM……
JENIS PELAYANAN RUJUK TANDA
KETERANG
NO NAMA PASIEN NO. KARTU DIAGNOSA DIRUJUK KE BALIK TANGAN
PEMERIKSAAN TINDAKAN LABORAT AN
DARI PESERTA
1 REDDY Y 0001865591796 I10 1
2 BAJURI 0001624732086 I10 1
3 TRI SANTUN 0000105373811 I10 1
4 RUDI S 0001883968615 J32 SOEDONO
5 SADJIMIN 0001302639309 A18 1
6 NURUL HIDAYAH 0000106115332 K29 1
7 SUMARWATI 0000786636268 A18.2 SEODONO
8 LASMINI 0000078551065 M36 1
9 SUSANTO 0000787478523 A16 MANGUNHARJO
10 MUTMAINAH 0001387728753 K30 SUDONO
11 PAERAH 0001315883441 I50 SOEDONO
12 SUJOTO 0000078544484 K29 SOEDONO
13 SUNARTI 0000078544495 E11 SOEDONO
14 SITI NOERMEI 0000116353157 M81.9 SOEDONO
15 TUTIK TRIYANI 0000078537791 M36 1
16 SUMIRAH 0000078755354 J44.0 SOEDONO
17 DEWI UTAMI 0001846990822 J11 1
18 SOEPINI 0000078545867 J44.0 SOEDONO
19 TRI ENDANG 0001083662706 M36 1
20 HERA PRIYANTINA 0001277784268 J11 1
21 SRI HANDAYANI 0001106650348 M36 1
22 UMI SUPIYAH 0000116357499 M36 1
23 NASYA ANINDYA 0001814890555 J11 1
24 SUGIARTO 0001399540443 M36 1
25 SRI ISNARNI 0000787422249 M36 1
JUMLAH TOTAL
Mengetahui Madiun,
LAPORAN PELAYANAN
BPJS CABANG MADIUN
NAMA DOKTER :
KODE PPK :
KETERANG
DARI PESERTA
1 IQBALTRI 00007874222734 G44 1
2 JUMIRAN 00010303200797 M36 1
3 IPAH 0000106359614 E11 SOEDONO
4 EVA NOVITASARI 0000786858524 H18 SOEDONO
5 KATINEM 0000078732336 M36
6 SRI REJEKI 0000078767392 M36 1
7 SUGIYO 0000106421949 E11 SOEDONO
8 SARBINI 0000078753453 I10 1
9 SOELICHAH 0000104791612 E11 SOEDONO
10 HASYIM 0001127753965 H52 1
11 PARNO SASTRO 0001281366775 M545 SOGATEN
12 SUPINAH 0000106390563 M36 1
13 SUNARTI 0001797843879 Q61.9 SOEDONO
14 WAGIMAN 0000116357591 M36 1
15 TAJEM 0000786165039 E11 1
16 PANJI PUTRO W 0001619802562 J11 1
17 KANDIWATI 0000078550176 I10 1
18 MUDJI RAHAYU 0000078476365 E11 1 SOEDONO
19 KEN INDARTI 0000106430354 B37 SOEDONO
20 SUKINI 0000078771352 N60.2 SOEDONO
21 KARSINEM 0000078527586 M36 1
22 ATININGSIH 0000206440075 E11 1
23 MULYANINGSIH 0000105442132 E11 SOGATEN
24 YATIMAN 0000106350647 E11 1
25 KATIRIN 0001105269726 M20 SOEDONO
JUMLAH TOTAL
Mengetahui Madiun,
LAPORAN PELAYANAN
BPJS CABANG MADIUN
NAMA DOKTER :
KODE PPK :
KETERANG
DARI PESERTA
1 BURHAN S 0001638250165 R50 1
2 TUKIYEM 0001843057888 I10 1
3 DJUWANI 0001078783211 E11 1
4 ENDANG LASMINI 0000786870494 E11 SOGATEN
5 SULASTRI 0001295171818 I10 SOEDONO
6 SUGENG 0000106278816 I50 SODONO
7 ENDANG LASMINI 0000170013058 M36 1
8 JUJUK IDAYANI 0001619798894 M36 1
9 SUNARTI 0000786737046 M36 1
10 ANGGRAINI 0000106480528 A16 1
11 SUWARNI 0001828215123 R01 1
12 SUBAGJO 0000105410553 M36 1
13 AHMAD ABDULLAH 0000786449441 J10 1
14 MARJOKO 0001858962688 K29 1
15 SUDARSEH 0001825202711 I10 1
16 ERNA MUSTIKAM 0000786813761 I25 SOGATEN
17 ROESMINI 0001427451309 M36 1
18 SARINEM 0001427090613 I10 SOEDONO
19 RAHYACINTHA P S 0000208234631 L23 SOEDONO
20 ENDANG LASMINI 0000786870494 V20 1
21 TRI SUWARNO 0000786870371 J10 1
22 AISYA VARISH R M 0001885648926 L23 1
23 MARIYEM 0000078534516 E11 SOGATEN
24 UMI SUPIYAH 0000116357499 E11 1
25 MAHSUN 0000106283103 H52 RSI
JUMLAH TOTAL
Mengetahui Madiun,
LAPORAN PELAYANAN
BPJS CABANG MADIUN
NAMA DOKTER :
KODE PPK :
KETERANG
DARI PESERTA
1 DHIYAA AYU M 0001542973533 V20 1
2 DWI SRI WAHYUNI 0000106437611 L30 1
3 KAMARI 0000100472051 E11 1
4 ERNI WULANDARI 0001272543614 B18.1 RSI
5 SOEKARDJO 0001341266354 E11 1
6 YOLLANDA LARASATI 0001264931515 J11 1
7 HERMAWAN 0000786424893 L23 1
8 MAHSUN 0000106283103 H52 SOGATEN
9 SUKINI 0000078771352 H26 SOEDONO
10 SUTIKAH JD S 0000078560504 M36 1
11 SUMI HARTONO 0000078772329 G44 1
12 GUNARTI 0000106292733 H52 SOGATEN
13 MURYATI 0000106293486 52 1
14 REZA ARIFIANTO 0001328535325 E11 1
15 USWATUL K 0000010572128 M54 SOEDONO
16 TAJEM 0000786165039 E11 SOGATEN
17 SUMARMI 0000116357602 M36 1
18 SUKIMIN 0000104935184 J11 1
19 SOEDARINAH 0000078542785 M36 1
20 TUKIYEM 0000786421067 M36 1
21 NABILA NUR K 0001476158758 J10 1
22 SURATMIN 0000105045974 B02 1
23 LANIMUN 0000106286769 I10 1
24 ISMIYATI ,0000158401181 E11 1
25 DJAJJANAH 0000078719038 J11 1
JUMLAH TOTAL
Mengetahui Madiun,
LAPORAN PELAYANAN
BPJS CABANG MADIUN
NAMA DOKTER :
KODE PPK :
KETERANG
DARI PESERTA
1 TAPSIRAH 0000105515008 I50 DR SOEDONO
2 PUDJI R 0000169431039 M36 1
3 UJI ASIH 0001830972295 K12 1
4 MAYA INDITA 0001830972879 J10 1
5 PARSINI 0001806925331 H26 SOEDONO
6 SUMENI 0000106490439 M36 1
7 LUTHFI ALI H 0001274993728 J10 1
8 SUMINEM 0001083359597 M36 1
9 SUMINI 0000078772601 M36 1
10 SUGIANTO 0001264930828 H60 1
11 ENDANG I S 0001885670594 M36 1
12 EKO BUDIONO 0001311382146 M54 SOGATEN
13 KUSTATIK 0000106346856 H40 SOEDONO
14 ENDRO JOKO S 0000106292373 G43 1
15 MINARSIH 0001383940157 M36 1
16 YULIA 0001300590549 J11 1
17 NATASYA CAHYA H 0001300643133 J11 1
18 SUGIANTO 000106465386 M36 1
19 TUKIYEM 0000786421067 M36 1
20 WINARDI 0000786421192 F23 1
21 SUMIRAH 0000078740548 I25 SOEDONO
22 MUCH KASIRAN 0000078740537 M15 SOEDONO
23 MURTINI 0000078741764 M36 SOEDONO
24 MIHARSIH 0000170000392 M36 1
25 AMIRAH 0000104935195 E11 1
JUMLAH TOTAL
Mengetahui Madiun,
LAPORAN PELAYANAN
BPJS CABANG MADIUN
NAMA DOKTER :
KODE PPK :
KETERANG
DARI PESERTA
1 SUKIMIN 0000104935184 M36 1
2 MOEHARSIYAH 0001445104631 I10 1
3 SUMBULATIN 0000104996171 H10 SOEDONO
4 SUWARDI 0000105136029 V20 1
5 MARIYAH 0001316260855 J11 1
6 OCHA MELDY 0001538415641 R50 1
7 AISYA VARISH 0001885648926 J10 1
8 SUMI HARTONO 0000078772329 J10 1
9 UYSWATUL 00000105721288 I10 SOEDONO
10 OCHA MELDY A 0001538415641 J11 1
11 SARBINI 0000078753453 I10 1
12 SUDARMI 00000787510326 M79 1 SOGATEN
13 KATENO BASUKI 0000976893401 M36 1
14 UNTUNG 0000078780183 I10 1
15 SUYATI 0001623285494 M36 1
16 ERNY L 0000976678806 M36 1
17 M ARSYA A 0000201962182 B05 1
18 PUJI RAHAYU 0001439585414 V20 1
19 SUMINEM 000108359597 L23 1
20 LISTYA TRI 0001901271159 J10 1
21 SUAWRNI 0001828215123 J11 1
22 PUJO SUWITO 00010828876498 M36 1
23 MESINEM 0000078547689 M36 1
24 KARSIATI 0001302641054 E11 1
25 SADJIMIN 0001302639309 E11 1
JUMLAH TOTAL
Mengetahui Madiun,
LAPORAN PELAYANAN
BPJS CABANG MADIUN
NAMA DOKTER :
KODE PPK :
KETERANG
DARI PESERTA
1 AFRINA DEWI 0001820212053 J11 1
2 MOCH CHAIRUL 0000106331613 E11 1
3 PARIDA 0000106477094 L23 1
4 SOETOPO 0000106294577 I25 SUDONO
5 NOEZIAR 0000106272641 E11 SOGATEN
6 EKO PRASOJO 0001132583207 M36 1
7 SITI NOERMEI 0000116353157 H26 SUDONO
8 UMI SUPIYAH 0000116357499 M36 1
9 SULASTRI 0001295171818 J11 1
10 SUDJIATI 000078549153 H52 SUDONO
11 BAMBANG SURYONO 0001824454181 K30
12 IMAM MACHFUD 0000078727634 I69 SUDONO
13 ATIK 0000787275696 M36 1
14 KARSINEM 0000078427586 I50 SUDONO
15 ATININGSIH 0000206440075 J11 1
16 SULISTYANINGSIH 0001841093673 J11 1
17 SUPARTI 0001080944706 M36 1
18 IKSAN 0000078528172 J11 1
19 SUMIYATUN 0000105077496 M36 1
20 ERY WULANDARI 0001311384306 M36 1
21 EKO BUDIONO 0001311382148 M36 1
22 NASYA 0001814890555 J11 1
23 AMALIA 0001814893132 J11 1
24 FITRI SETIADI 0001797643405 R50 1
25 SOEMARSNI 0000169999233 M36 1
JUMLAH TOTAL
Mengetahui Madiun,
LAPORAN PELAYANAN
BPJS CABANG MADIUN
NAMA DOKTER :
KODE PPK :
KETERANG
DARI PESERTA
1 RENDI TRI 0001273980137 J11 1
2 TRI WAHYUNI 0001536392878 M79 1
3 ENDANG PURYANTI 0000170013058 K29 1
4 SUYOTO 0001846742409 H26 SOGATEN
5 SUPANGAT 0000078773264 I84 1
6 SUKARTINI 0000078543628 E11 1
7 SUWARNI 0001828215123 J11 1
8 SOEMI 0000078724462 E11 1
9 NUNUK SRI S 0000078539084 G44 1
10 MALEEKA HAIFA 0001899090167 J11 1
11 SUDARTO 0001049784221 H60 1
12 DJAIS 0000078718983 I50 SOEDONO
13 UMI SUPIYAH 0000116357499 E04 SOGATEN
14 SUPARNO 0001541041773 M36 1
15
16
17
18
19
20
21
22
23
24
25
JUMLAH TOTAL
Mengetahui Madiun,
LAPORAN PELAYANAN
BPJS CABANG MADIUN
NAMA DOKTER :
KODE PPK :
KETERANG
DARI PESERTA
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
JUMLAH TOTAL
Mengetahui Madiun,
LAPORAN PELAYANAN
BPJS CABANG MADIUN
NAMA DOKTER :
KODE PPK :
KETERANG
DARI PESERTA
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
JUMLAH TOTAL
Mengetahui Madiun,

BP Demangan November 2015

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DAFTAR TAGIHAN KLAIM RAWAT JALAN JAMKESMAS DI PELAYANAN DASAR

PROPINSI : JAWA TIMUR BULAN November

DAFTAR TAGIHAN KLAIM RAWAT JALAN JAMKESMAS DI PELAYANAN DASAR

PROPINSI : JAWA TIMUR BULAN November

PROPINSI : JAWA TIMUR BULAN November

PROPINSI : JAWA TIMUR BULAN November

PROPINSI : JAWA TIMUR BULAN November

DAFTAR TAGIHAN KLAIM RAWAT JALAN JAMKESMAS DI PELAYANAN DASAR

DAFTAR TAGIHAN KLAIM RAWAT JALAN JAMKESMAS DI PELAYANAN DASAR

DAFTAR TAGIHAN KLAIM RAWAT JALAN JAMKESMAS DI PELAYANAN DASAR

DAFTAR TAGIHAN KLAIM RAWAT JALAN

DAFTAR TAGIHAN KLAIM RAWAT JALAN

DAFTAR TAGIHAN KLAIM RAWAT JALAN

DAFTAR TAGIHAN KLAIM RAWAT JALAN

BULAN NOVEMBER TAHUN : 2015

DAFTAR TAGIHAN KLAIM RAWAT JALAN

DAFTAR TAGIHAN KLAIM RAWAT JALAN

DAFTAR TAGIHAN KLAIM RAWAT JALAN

DAFTAR TAGIHAN KLAIM RAWAT JALAN

DAFTAR TAGIHAN KLAIM RAWAT JALAN

DAFTAR TAGIHAN KLAIM RAWAT JALAN

DAFTAR TAGIHAN KLAIM RAWAT JALAN

DAFTAR TAGIHAN KLAIM RAWAT JALAN

DAFTAR TAGIHAN KLAIM RAWAT JALAN

DAFTAR TAGIHAN KLAIM RAWAT JALAN

DAFTAR TAGIHAN KLAIM RAWAT JALAN

DAFTAR TAGIHAN KLAIM RAWAT JALAN

DAFTAR TAGIHAN KLAIM RAWAT JALAN

DAFTAR TAGIHAN KLAIM RAWAT JALAN

DAFTAR TAGIHAN KLAIM RAWAT JALAN

DAFTAR TAGIHAN KLAIM RAWAT JALAN

DAFTAR TAGIHAN KLAIM RAWAT JALAN

DAFTAR TAGIHAN KLAIM RAWAT JALAN

DAFTAR TAGIHAN KLAIM RAWAT JALAN

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