You are on page 1of 150

RINCIAN KLAIM JAMKESMAS TAHUN 2013

PUSKESMAS TIAKAR BULAN JANUARI


NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL DIAGNOSA PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

1 YETSANTI 5170234855 33 P 2/1/2013 Dermatitis 10,000 10,000


2 SELVIA 517029515 21 P ISPA 10,000 10000
3 YULIANIS 285198903 37 P ISPA 10,000 10,000
4 RIGLA 285185211 2 P ISPA 10,000 10,000
5 ENDARDI 517020997 25 P ISPA 10,000 10000
6 SRI KEMALA 517031021 18 P SCABIES 10,000 10,000
7 ALFINA 517031354 13 P TV 10,000 10,000
8 NASRIL 517031992 12 L ISPA 10,000 10000
9 SISMANEDI 389720769 38 P ISPA 10,000 10,000
10 SAMSUNIDAR 5170505830 54 P FURUNKEL 10,000 10,000
11 JUNAIDI 517011717 53 P HT 10,000 10,000
12 NINGSIH E 517027702 39 P KANKER 10,000 10,000
13 RIDHA 517027741 9 L ISPA 10,000 10,000
14 EKRI NETRA 517035727 33 P ISPA 10,000 10,000
15 RAMADANI 517003441 60 P 3/1/2013 GASTRITIS 10,000 10000
16 HENGKI 517004983 35 L ISPA 10,000 10,000
17 CHANAYA 28520749 22 P ISPA 10,000 10,000
18 ZULHADI 517031089 51 P OBS FEBRIS 10,000 10,000
19 YASRIL 517045346 63 P TV 10,000 10000
20 YUL 5174585377 37 P ISPA 10,000 10,000
21 FITI 517001827 16 P ISPA 10,000 10000
22 GENTA MARIESNA 517001668 8 L 4/1/2013 OMA 10,000 10,000
23 RATIUS 517314937 74 P CP 10,000 10,000
24 NOVIANA 517228592 24 P ISPA 10,000 10,000
TOTAL 180,000 0 20000 0 40000 240,000
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL DIAGNOSA PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD

JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

25 WINDA 517219444 4 P 4/1/2013 ISPA 10,000 10,000


26 ELFI 517001815 38 P CHEPALGIA 10,000 10,000
27 MARTATI 517035718 59 P RA 10,000 10,000
28 FEBBY INGRIANI 517029388 11 P 5/1/2013 ISPA 10,000 10,000
29 INGMA DESWATI 517029344 54 P OBS FEBRIS 10,000 10,000
30 SUDIRMAN M 51721944 51 L ISPA 10,000 10,000
31 SAFNUR 517004019 41 P GASTRITIS 10,000 10,000
32 SOFIA LAJUBA 517024469 9 P Dermatitis 10,000 10,000
33 RAUNIS 517026268 46 P 7/1/2013 ISPA 10,000 10,000
34 RAMADANI 517000683 76 P CHEPALGIA 10,000 10,000
35 SAUNA FLORA 517227009 13 P KANKER 10,000 10,000
36 RANTI P S 517203854 25 P GASTRITIS 10,000 10,000
37 SULASTI 517021651 55 P MALAISE 10,000 10,000
38 DERMI YANTI 51700839 45 P ISPA 10,000 10,000
39 RIFO FERNANDA 517030995 13 L GASTRITIS 10,000 10,000
40 RAMADANIS 517003661 66 P 8/1/2013 ISPA 10,000 10,000
41 NOVIA ENDA 517228593 24 P ISPA 10,000 10,000
42 FIKRI ICHIVIA 517023024 21 P OBS FEBRIS 10,000 10,000
43 ASNIL 517219447 50 L TV 10,000 10000
44 RAKA GUSTI 517208578 16 L 9/1/2013 ISPA 10,000 10,000
45 ANI YUNARDI 5170250129 36 P ISPA 10,000 10,000
46 ASNAWATI 517002006 35 P ISPA 10,000 10,000
47 HALIMAH 5170498712 60 P 10/1/2013 CHEPALGIA 10,000 10,000
48 SUGIMIN 517004038 40 L TV 10,000 10000
49 MONSIARNI 517219492 5 P ISPA 10,000 10,000
50 KASMIATI 517002175 43 P ISPA 10,000 10,000
TOTAL 230,000 10000 20000 260,000
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL DIAGNOSA PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD

JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

51 SANUAR 517209603 55 L 11/1/2013 HYPERTIROID 10,000 10,000


52 ELMA 51700752 3 P ISPA 10,000 10,000
53 QURADIL 517004638 2 P TONSILITIS 10,000 10,000
54 MAULINA 517024787 13 P 12/1/2013 CARSINOMA 10,000 10,000
55 M SYUKRIADI 517030749 9 L ISPA 10,000 10000
56 M NASIR 517005448 60 P DIDPEPSIA 10,000 10000
57 SUDIRMAN M 517219446 55 L OBS FEBRIS 10,000 10,000
58 YET SANTI 517024855 32 P TINEA KRONIS 10,000 10,000
59 DELI OKTAVIA 517021547 20 P 14-1-2013 LUKA 10,000 10,000
60 SYAMSUNIDAR 517030582 56 P ISPA 10,000 10,000
61 NURASNI 517029325 47 P ISPA 10,000 10,000
62 DERMI YENTI 51708390 45 P OBS FEBRIS 10,000 10,000
63 SANUAR 517209803 55 P GASTRITIS 10,000 10,000
64 MARDIANIS 517208550 48 P TV 10,000 10000
65 RAMADANIS 517005601 66 P HT 10,000 10,000
66 RANAI 517008954 70 L RA 10,000 10,000
67 RATINAS 517004431 58 P ISPA 10,000 10,000
68 MONSIARNI 51721992 52 P ISPA 10,000 10,000
69 JUNI 517219334 20 P TAMBAL TETAP 25,000 25000
70 RATIUS 517031493 75 P CARSINOMA 10,000 10,000
71 MURNI P 517024157 60 P 15-1-2013 GASTRITIS 10,000 10,000
72 HENDRIZON 517007193 38 L 16-1-2013 ISPA 10,000 10,000
73 DESMI YENTI 517008921 45 P ISPA 10,000 10,000
74 DESWATI 517218911 38 P HT 10,000 10,000
75 EKA SUPRIADI 51708054 45 P KANKER 10,000 10,000
76 RIZKI FERDINAS 517020087 15 L CARSINOMA 10,000 10,000
TOTAL 210,000 25000 30000 10000 275,000
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL DIAGNOSA PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD

JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

77 CHILA M 517028398 11 P 16-1-2013 Dermatitis 10,000 10,000


78 ENDARD V 517001499 43 P TV 10,000 10000
79 NURNILIS 517027678 54 P 17-1-2013 CARSINOMA 10,000 10,000
80 MONSIARNI 517219481 62 P ISPA 10,000 10,000
81 YUHARMON 517007951 47 P GASTRITIS 10,000 10,000
82 AGUSTINA 517086618 46 L ANEMIA 10,000 10000
83 WINDA HASANAH 517219503 17 P 18-1-2013 ISPA 10,000 10,000
84 ABDULLAH S 517008457 17 L VERTIGO 10,000 10,000
85 ASNAWATI 517002880 35 P CARSINOMA 10,000 10,000
86 MARDANIS 517208556 58 P ISPA 10,000 10,000
87 YETTI 517001501 45 P 19-1-2013 ISPA 10,000 10,000
88 RESKI 517001534 21 L ISPA 10,000 10,000
89 RANTI F 517001534 44 P ISPA 10,000 10,000
90 DERMIYANTI 517008296 37 P GRAVID 10,000 10000
91 LINDA 517219059 57 P 21-1-2013 ISPA 10,000 10,000
92 HAMIDAH 517023021 45 P ISPA 10,000 10,000
93 GUSNA 517022308 47 P 22-1-2013 RA 10,000 10,000
94 DERMI YELTI 517008396 45 P 23-1-2013 GASTRITIS 10,000 10,000
95 MAIRIZAL 284827893 34 L CBT GIGI TETAP 20,000 20000
96 RAWANIS 517021514 53 P VERTIGO 10,000 10,000
97 SUWARDI 285064784 73 L ISPA 10,000 10,000
98 EDO SEPTRIO 285746679 11 L 25-1-2013 MIGRAIN 10,000 10,000
99 HENDRI 28542062 34 L GASTRITIS 10,000 10,000
100 RAMAYUNIS 284210256 65 P DYSPEPSIA 10,000 10,000
101 YUFINIRI 517003929 40 P CARSINOMA 10,000 10,000
102 NELVI FADILA 697094900 22 P ISPA 10,000 10,000
TOTAL 220,000 20000 20000 10000 270,000
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL DIAGNOSA PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD

JAMKESMAS ( THN ) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

103 AFKIA NENGSIH 284769404 30 P 26-1-2013 ISPA 10,000 10,000


104 FRIHATI NINGSIH 517029638 26 P ISPA 10,000 10,000
105 DASTINA 517006018 40 P ISPA 10,000 10000
106 EPI SUSANTI 28981384 33 P GASTRITIS 10,000 10,000
107 SUDIRMAN M 517219440 54 L GRAVID 10,000 10000
108 FEBRIANI AZHARI 285508462 5 P 28-1-2013 ISPA 10,000 10,000
109 AFRIA NINGSIH 284769404 30 P OBS FEBRIS 10,000 10,000
110 MULDAYENTI 284201212 35 P MYALGIA 10,000 10,000
111 RAMADANIS 517003661 76 P ISPA 10,000 10000
112 HENDRISON 1489816752 32 L CHEPALGIA 10,000 10,000
113 DARLISMA 517002963 69 P GASTRITIS 10,000 10,000
114 YUANITA 284791926 45 P KANKER 10,000 10,000
115 ADI NOPUTRA 285203114 18 L ISPA 10,000 10,000
116 HENGKI 517004482 25 L MYALGIA 10,000 10,000
117 ROSTIANI 517031447 71 P KANKER 10,000 10,000
118 M JADAN 517204326 22 L CHEPALGIA 10,000 10,000
119 NOVITA DINI 284899779 19 P 29-1-2013 RA 10,000 10,000
120 FAUZIAH 517219067 53 P CARSINOMA 10,000 10,000
121 WINDA 285507291 4,5 P ISPA 10,000 10,000
122 ERNAWATI 289894896 37 P DM 10,000 10,000
123 DERMIYENTI 285289804 45 P CBT GIGI SUSU 10,000 10,000
124 WIWIT CITRA DEWI 285505064 26 P 30-1-2013 ASMA 10,000 10,000
125 RANGAS R 517028721 13 L CC 10,000 10,000
126 YARMA 517028591 72 P SCABIES 10,000 10,000
127 RITRIA 284589108 45 P BROGHITIS 10,000 10,000
128 M ALHADI S 517006877 11 P 31-1-2013 ASMA 10,000 10,000
TOTAL 220,000 10000 30000 260,000
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL DIAGNOSA PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD

JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

129 MUSLIM 5170221346 54 L 31-1-2013 KANKER 10,000 10,000


130 ARI 5170075151 45 L CARSINOMA 10,000 10,000
131 GUSNETI 517022368 47 P 1/1/2013 ANXIETAS 10,000 10,000
132 SYAMSIDAR 517021773 81 P ARTRITIS 10,000 10,000
133 TIFANI 517025417 10 P ISPA 10,000 10,000
134 LASTRI BR HOMBING 285123791 32 P KB 10,000 10,000
135 DEWI PRIMA DONA 285131261 31 P KB 10,000 10,000
136 SYAMSIDAR 517021773 81 P CC 10,000 10,000
137 SITI AISYAH 285146098 3 P 7/1/2013 TONSILITIS 10,000 10000
138 RADJ PENDI 285123633 38 L RA 10,000 10,000
139 LASTRI BR HOMBING 285123791 32 P ARTRITIS 10,000 10,000
140 GUSNETI 517022368 47 P ANXIETAS 10,000 10,000
141 FIRDAUS AKMAL 517209669 12 L 9/1/2013 ISPA 10,000 10,000
142 LISDARNI 517202480 68 P 10/1/2013 ASMA 10,000 10,000
143 MIRAWATI 517025935 28 P 15-1-2013 INFLUENSA 10,000 10,000
144 M. AKBAR 285187926 5 L LUKA 10,000 10,000
145 M IRVAN 517219029 12 L 17-1-2013 GASTRITIS 10,000 10,000
146 YENI PUSPITA 285180557 30 P 19-1-2013 ALERGI 10,000 10,000
147 ANISA SURYANI 517024541 18 P 22-1-2013 HIPOTENSI 10,000 10,000
148 MIRAWATI 517025935 28 P ISPA 10,000 10,000
149 LIDAR 517008431 42 P ASMA 10,000 10,000
150 RAMAYULIS 517008418 72 P DYSPEPSIA 10,000 10,000
151 WILI 517003929 15 L ABSES 10,000 10,000
152 DERMI 5170221346 45 P ASMA 10,000 10,000
153 AGUSMA 517119425 67 P 29-1-2012 HT 10,000 10,000
154 LIDAR 51700758 42 P BROGHITIS 10,000 10,000
TOTAL 250,000 10000 260,000
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL DIAGNOSA PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD

JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

155 YASMAWATI 5170221270 33 P 29-1-2012 CEPALGIA 10,000 10,000


156 DELFITRI 5170221346 26 P Dermatitis 10,000 10,000
157 FIRMAN 517003571 6 L LUKA 10,000 10,000
158 ABIZAR 5170056839 69 L RA 10,000 10,000
159 YOGA 51700819 18 L SERUMEN P 10,000 10,000
160 LAILA 51753452 7 P INFEKSI LK 10,000 10,000
161 ROHID 517031684 12 L 30-1-2012 BROGHITIS 10,000 10,000
162 EDI HENDRI 28484478 38 L ISPA 10,000 10,000
163 RIVAL 284869822 11 L ABSES 10,000 10,000
164 YANTI 284718335 33 P GASTRITIS 10,000 10,000
165 FAIG 517003846 1,5 L HERPES 10,000 10,000
166 DIANA 284842012 16 P ISPA 10,000 10,000
167 SARIOJI 284921908 64 P ISPA 10,000 10,000
168 HELDA 284802349 30 P Dermatitis 10,000 10000
169 APRI ABDI 284802906 4,5 L ISPA 10,000 10,000
170 ZULKIFLI 270678846 50 L ISPA 10,000 10,000
171 RIDAYAH 27980005 52 P ASMA 10,000 10000
172 NURBAITI 517010545 60 P ASMA 10,000 10,000
173 YANTI 284718339 32 P GASTRITIS 10,000 10,000
174 ABIZAR 517030301 67 L RA 10,000 10,000
175 HELDA 284802399 30 P Dermatitis 10,000 10,000
176 RIVAL 28489822 11 L ISK 10,000 10,000
177 FAZEL 284523326 3 L ISPA 10,000 10000
178 AFRIZAL 285279941 37 L 2/1/2013 ISPA 10,000 10000
179 ARDA FAHRIZAL 285280874 10 L ISPA 10,000 10,000
180 ERIZAL 285344921 32 P 5/1/2013 CC 10,000 10,000
TOTAL 190,000 30000 10000 230,000
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL DIAGNOSA PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD

JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

181 YENDRAWATI 517092603 33 P 5/1/2013 FARINGITIS 10,000 10,000


182 NINA A 517209074 28 P 9/1/2013 ISPA 10,000 10,000
183 AMIRULLAH 285298762 70 L GASTRITIS 10,000 10,000
184 SARI 517204697 25 P 12/1/2013 ASMA 10,000 10,000
185 ZULKARNAINI 28494291 57 L GASTRITIS 10,000 10,000
186 ERTIKA 285336832 46 P 16-1-2013 GASTRITIS 10,000 10,000
187 ERWIN 285336808 45 L 19-1-2013 RA 10,000 10,000
188 SARI 517204697 25 P CC 10,000 10,000
189 AFRIZAL 285179941 37 L 23-1-2013 ISPA 10,000 10,000
190 BY MIRA 489885298 1 P 26-1-2013 ISPA 10,000 10,000
191 YENDRAWATI 517092603 33 P HT 10,000 10,000
TOTAL 100,000 110,000

TOTAL KESELURUHAN 1,935,000

DIKETAHUI PAYAKUMBUH, FEBRUARI 2013


KEPALA PUSKESMAS TIAKAR PELAKSANA PROGRAM

NETI HARTATI DESTY AMELIA,AMD KEB


19750316 200604 2 009 19820103 200501 2 004
RINCIAN KLAIM JAMKESMAS TAHUN 2013
PUSKESMAS TIAKAR BULAN FEBRUARI
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

1 Novi Sofiah 285162658 35 P 2/1/2013 Dispepsia 10,000 10,000


2 Endang Wahyuni 517001418 42 P Gastritis 10,000 10,000
3 Reni 517007024 31 P Gastritis 10,000 10,000
4 Hamza 285429480 17 L Dispepsia 10,000 10,000
5 Dailan 517493401 73 L Susp OMA 10,000 10,000
6 Eli 2841170720 42 P Mialgia 10,000 10,000
7 Mardianis 517208556 48 P 2/2/2013 Scabies 10,000 10,000
8 Raka Gusrianto 1285518516 16 L Ispa 10,000 10,000
9 Deli Oktavia 517021547 21 P Ispa 10,000 10,000
10 Agusfi bujang 28718471 65 L OA 10,000 10,000
11 Prika 285095858 9 P Dermatitis 10,000 10,000
12 Nola 284021514 25 P Chepalgia 10,000 10,000
13 Sulastri 517020655 55 P DM+Hipertiroid 10,000 10,000
14 Samsunidar 517050581 56 P Psokosomatis 10,000 10,000
15 Sudirman 2851030146 65 L Psokosomatis 10,000 10,000
16 Dekfitri Nengsih 517005405 26 P 2/4/2013 cbt gigi tetap 20,000 20,000
17 Nezila 2847685219 6 P Ispa 10,000 10,000
18 Andri 517020771 26 L Mialgia 10,000 10,000
19 Yanthi 284391926 45 P Tambal 25,000 25,000
20 Endang Wahyuni 517001429 45 P Chepalgia 10,000 10,000
21 Fitriana 517027869 18 P Mialgia 10,000 10,000
22 Anwar 284200143 64 L Asma 10,000 10,000
23 Riswan 285329722 37 L Hipotensi 10,000 10,000
24 Farisyah 285332466 3 P Obs. Febris 10,000 10,000
TOTAL 200,000 55000 10000 0 0 265,000
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

25 Meli 281723945 33 P 2/5/2013 Common Cold 10,000 10,000


26 Ana 517228557 27 P Chepalgia 10,000 10,000
27 Ayumi 285194891 19 P Mialgia 10,000 10,000
28 M.Alhadi salam 517006877 14 L Inf. Kulit 10,000 10,000
29 Nabila Fitria 2855113812 7 P Ispa 10,000 10,000
30 Arif Arianto 285403915 8 L Alergi 10,000 10,000
31 Laila 517007068 5 P Ispa 10,000 10,000
32 Andi Januardi 517028771 27 L Dispepsia 10,000 10,000
33 Dwi Andika 517029298 8 L 2/6/2013 cabut gigi susu 10,000 10,000
34 Upik 517028556 49 P Dispepsia 10,000 10,000
35 Nelma 517001951 72 P Gastritis 10,000 10,000
36 Yuliani Putri 285718836 17 P Ispa 10,000 10,000
37 Fatmawati 284769639 42 P Ispa 10,000 10,000
38 Latifah 28476996 6 P Ispa 10,000 10,000
39 rini mukhtar 284886189 32 P 2/7/2013 Gastritis 10,000 10,000
40 Aka Zara Mesya 285579022 4 L Common Cold 10,000 10,000
41 Arif Arianto 285403915 8 L Ispa 10,000 10,000
42 Noviyanti 285054029 24 P Chepalgia 10,000 10,000
43 Maulusi Sakinah 284887664 8 P Ispa 10,000 10,000
44 Syamsuhida 517032580 54 P Psokosomatis 10,000 10,000
45 Agusfi bujang 28718471 65 L 2/8/2013 OA 10,000 10,000
46 Misdar 517219549 42 P Febris 10,000 10,000
47 Anidar 517002399 78 L Prolap Uteri 10,000 10,000
48 Yatianis 517000705 56 P Chepalgia 10,000 10,000
49 Yuliani Putri 285178816 17 P cabut gigi tetap 20,000 20,000
50 Razaq 517007021 32 L 10,000 10,000
TOTAL 220,000 30,000 20000 0 270,000
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL DIAGNOSA PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD

JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

51 Ria 517003161 32 P 2/9/2013 Chepalgia 10,000 10,000


52 Hamzah Fansuri 284926116 14 L Gastritis 10,000 10,000
53 dermiyenti 285389804 45 P tambah obat 10,000 10,000
54 Nofri Enisa 284830648 16 P Ispa 10,000 10,000
55 Sudirman 2851030146 65 L Psokosomatis 10,000 10,000
56 Rahmad Kurnia 285262391 8 L 2/11/2013 Gastritis 10,000 10,000
57 M.Tahalib Ifani 285263087 6 L Ispa 10,000 10,000
58 Aidal Akbar 285439746 3 L Obs. Febris 10,000 10,000
59 Mainir 517029942 47 P Vulnus dgn inf 10,000 10,000
60 Ezi 517029945 15 L Alergi 10,000 10,000
61 Mitrawardi 284789801 51 L Gastritis 10,000 10,000
62 Junaidi 285715290 69 L Chepalgia 10,000 10,000
63 Enida 285603906 44 P anemia 10,000 10,000
64 Mardiana 517022030 35 P HT 10,000 10,000
65 Muryadi 289205890 56 L Gastritis 10,000 10,000
66 Afrizal 517007750 32 L Febris 10,000 10,000
67 Lutfia 517009086 6 P 2/12/2013 Febris 10,000 10,000
68 Mona Diana 285160599 17 P Gastritis 10,000 10,000
69 Hamzah Fansuri 284926116 13 L Ispa 10,000 10,000
70 Yeli kamaruddin 517029941 38 P Ispa 10,000 10,000
71 Misailis 284204621 42 P CC 10,000 10,000
72 Zulnaida 284205249 49 P CC 10,000 10,000
73 Betti 279649359 35 P 2/13/2013 CC 10,000 10,000
74 Rianza Andra 279649798 16 L Ispa 10,000 10,000
75 Marlius 517029322 28 L Ispa 10,000 10,000
76 Reynaldi 987534977 11 L Ispa 10,000 10,000
TOTAL 220,000 10000 30000 0 260,000
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL DIAGNOSA PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD

JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

77 Dwi Fani Adinda 284204428 2 P 2/14/2013 Obs. Febris 10,000 10,000


78 Usma 517006901 75 P Chest pain 10,000 10,000
79 Yulfitri 284747084 37 P GE akut 10,000 10,000
80 Agusfi bujang 28718471 65 L OA 10,000 10,000
81 Alif 517019916 14 L Chepalgia 10,000 10,000
82 Ridho 585029251 5 L Ispa 10,000 10,000
83 Nursani 51719449 60 P RA 10,000 10,000
84 Muhazifa 284748726 5 P Febris 10,000 10,000
85 Novi 284357079 12 P 2/15/2013 SKD 10,000 10,000
86 Rozi 284155718 17 L Gastritis 10,000 10,000
87 Nurma 517024471 58 P Gastritis 10,000 10,000
88 Yulia vera 285117039 60 L asma 10,000 10,000
89 Yosna olivia 284958599 31 P Mialgia 10,000 10,000
90 M.Nabil 279017141 6 L Alergi 10,000 10,000
91 Dhina Marzama 284197944 4 P 2/16/2013 Dermatitis 10,000 10,000
92 Muslim 284900299 76 L asma 10,000 10,000
93 Shifa Virenza 284151846 16 P Ispa 10,000 10,000
94 Ermita 284353328 45 P RA 10,000 10,000
95 Wis dewita 284771294 30 P GE akut 10,000 10,000
96 Hengki 517004482 28 L Skizofrenia 10,000 10,000
97 Betti 279649359 35 P Chepalgia 10,000 10,000
98 Rianza Andra 279649798 16 L Tonsilitis 10,000 10,000
99 Marlius 517029322 28 L Mialgia 10,000 10,000
100 Asniwati 517030885 47 P Gastritis 10,000 10,000
101 Mariana Putri 284317108 6 P Tambal 25,000 25,000
102 Kartini 284715595 32 P Gastritis 10,000 10,000
TOTAL 200,000 45000 30000 0 275,000
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL DIAGNOSA PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD

JAMKESMAS ( THN ) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

103 Ramadanil 284185765 25 L Febris 10,000 10,000


104 Voni pertiwi 517002928 20 P Febris 10,000 10,000
105 Nindi Oktantia 284583115 19 P 2/18/2013 Ispa 10,000 10,000
106 Fitri dewi 2844821168 29 P Ispa 10,000 10,000
107 Nurhadina 285662801 15 P Chepalgia 10,000 10,000
108 Zulmita adewi 5170227836 45 P herpes zoozter 10,000 10,000
109 Dea apriani 284481314 8 P Ispa 10,000 10,000
110 Yusron Fahroiri 284481178 15 L Ispa 10,000 10,000
111 Rawinas 284839907 43 P RA 10,000 10,000
112 Naila Maldina 285077531 2 P Obs. Febris 10,000 10,000
113 Risnawati 285077261 33 P Gastritis 10,000 10,000
114 Dea Ifanka 285077406 9 P sscabies 10,000 10,000
115 Ezi 517030391 14 L Ispa 10,000 10,000
116 Deni sagita 517000724 29 P Psokosomatis 10,000 10,000
117 Samsunidar 517030582 64 P Psokosomatis 10,000 10,000
118 Laylatul Rahmi 5170237754 16 P asma 10,000 10,000
119 Ayumi 285194891 19 P Ispa 10,000 10,000
120 alvian perdana zega 285506842 2 L 2/19/2013 Febris 10,000 10,000
121 Jefri tanjung 285655869 16 L OA 10,000 10,000
122 Harun 285285857 2 L askariasis 10,000 10,000
123 Agung Rizaldi 285285497 8 L Ispa 10,000 10,000
124 Desi Isrami 517031043 16 P Ispa 10,000 10,000
125 Rahmat Hidayat 285074142 9 L Ispa 10,000 10,000
126 Lioni Suherman 284820018 16 P Gastritis 10,000 10,000
127 Dwitami 284024428 2 P Dermatitis 10,000 10,000
128 Isnandi 284080274 27 L Dermatitis 10,000 10,000
TOTAL 200,000 10000 40000 10000 260,000
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL DIAGNOSA PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD

JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

129 Syaiful 2851981151 37 L chepalgia 10,000 10,000


130 Mayos Oktuma 284774471 17 L CP 10,000 10,000
131 Lisni suherman 284820021 10 P Chepalgia 10,000 10,000
132 Mulyadi 284858131 46 L Chepalgia 10,000 10,000
133 Riama 279649798 16 P CP 10,000 10,000
134 Joice R 2796651385 47 P 2/20/2013 RA 10,000 10,000
135 Siswanto 284191457 17 L Gastritis 10,000 10,000
136 Agusfi bujang 28718471 65 L OA 10,000 10,000
137 Deli Oktavia 517021347 21 P Ispa 10,000 10,000
138 Andrisah 285660797 45 L Dermatitis 10,000 10,000
139 Fikri 2848962923 16 L chepalgia 10,000 10,000
140 Netrawati 285134076 10 L Febris 10,000 10,000
141 Fariz F 517004278 10 L 10,000 10,000
142 Sari Oktavia 285483366 19 P Ispa 10,000 10,000
143 Mainar 284750627 38 P Gastritis 10,000 10,000
144 Fatimah 285625754 6 P cabut 20,000 20,000
145 Fani fadillah 2837663308 2 P ILI 10,000 10,000
146 Ismawati 284855141 43 P Hamil 10,000 10,000
147 Tuti Indriani 2848211158 25 P Ispa 10,000 10,000
148 Fatmawati 28418344493 40 P Dermatitis 10,000 10,000
149 Murlizza 285070331 39 P Gastritis 10,000 10,000
150 Aqil Rahmat 284739862 5 L Ispa 10,000 10,000
151 Darlisma 284159294 57 P Gastritis 10,000 10,000
152 Rubama 284778696 37 P Gastritis 10,000 10,000
153 Wiwin 285055367 28 P Gastritis 10,000 10,000
154 Aini 284909466 28 P Ispa 10,000 10,000
TOTAL 210,000 50000 10000 270,000
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL DIAGNOSA PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD

JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

155 Betria Susila 285525753 39 P 2/21/2013 Suntik KB 10000 10,000


156 Nurana 285307694 70 P Ispa 10,000 10,000
157 Elvi naimar 285259869 44 P Mialgia 10,000 10,000
158 Raka Gustivono 285518318 16 L Scabies 10,000 10,000
159 Kamaruddin 285517844 54 L Scabies 10,000 10,000
160 Syafnidar 517208681 61 P RA 10,000 10,000
161 Yeni sustika 2853077449 23 P Scabies 10,000 10,000
162 Mardianis 285517967 49 P Scabies 10,000 10,000
163 Jhohanes satria 285526754 5 L Ispa 10,000 10,000
164 Andika Putra 247581566 28 L Ispa 10,000 10,000
165 Hendra 2852700854 32 L Ispa 10,000 10,000
166 Yendrawati 285345011 31 P KB 10,000 10,000
167 Zulkarnaini 284498291 47 P 2/22/2013 Ispa 10,000 10,000
168 Yeni sustika 285307749 23 P Asma 10,000 10,000
169 Suharti 285247462 45 P Inf. Luka 10,000 10,000
170 Nurana 285407694 73 P Vertigo 10,000 10,000
171 Rijal 285514806 35 L Disentri 10,000 10,000
172 Nazwa Athira 285517743 6 P Dermatitis 10,000 10,000
173 Putri Aisyah 285268836 6 P Gastritis 10,000 10,000
174 Mislimin 284920209 74 L Scabies 10,000 10,000
175 Kamaruddin 285517844 54 L Scabies 10,000 10,000
176 Mardianis 285517844 44 P Scabies 10,000 10,000
177 Raka Gustivono 285518318 16 L 2/23/2013 Abses 10,000 10,000
178 Dira dwi candra 285327549 8 P Abses 10,000 10,000
179 Risnawati 285517743 35 P KB 10,000 10,000
180 Gusneti 51702368 47 P Anxietas 10,000 10,000
TOTAL 230,000 0 30000 0 260,000
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL DIAGNOSA PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD

JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

181 Syamsidar 5170201773 81 P Artritis 10000 10000


182 Tiffani 517025417 10 P Ispa 10000 10000
183 Lastri 285123791 32 P Suntik KB 10000 10000
184 Dewi Primadona 285131261 31 P Suntik KB 10000 10000
185 syamsidar 517021773 81 P chepalgia 10000 10000
186 Siti Aisyah 285146098 3 P Tonsilitis 10000 10000
187 Pendi 285512633 38 L 2/25/2013 RA 10000 10000
188 Lastri 285123791 32 P Artritis 10000 10000
189 Gusneti 51702368 47 P Anxietas 10000 10000
190 Firdaus 517209669 12 L Ispa 10000 10000
191 Lisdarni 517202400 68 P Asma 10000 10000
192 Misrawati 517025935 28 P Influenza 10000 10000
193 M.akbar 285187920 5 L Inf luka 10000 10000
194 M.Irvan 285180557 12 L Gastritis 10000 10000
195 Yeni Puspita 517024541 30 P Alergi 10000 10000
196 Anisa suryani 518025735 18 P 2/26/2013 Hipotensi 10000 10000
197 Misrawati 517025935 28 P Ispa 10000 10000
198 Husni Lowe 284886080 65 P Ispa 10000 10000
199 Agusma 517008137 68 P Gastritis 10000 10000
200 erlina 279645996 44 P Asma 10000 10000
201 Resna 517007954 40 P GE akut 10000 10000
202 Abizar 517218491 67 L RA 10000 10000
203 Deni 284719364 4.5 L Caries 10000 10000
204 Rangga 2853736975 4 L Luka Infeksi 10000 10000
205 Delfitri 517005415 27 P Ispa 10000 10000
206 Salman 274646225 5 L Abses 10000 10000
TOTAL 210000 10000 40000 260000
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL DIAGNOSA PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD

JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

207 Helda 284802399 30 P Tinea 10000 10000


208 Selvira 284918382 3 P Ispa 420000 10000 10000
209 Marco 284901377 11 L Febris 10000 10000
210 Yuharmen 2853736975 43 L Tinea 10000 10000
211 Asyfa 285361334 4 P Hematoma 10000 10000
212 Saydul 284917915 14 L Abses 10000 10000
213 Dermi 285389864 44 P asma 10000 10000
214 Lidar 517008431 41 P Asma 10000 10000
215 Hani 284485948 11 P 2/27/2013 Ispa 10000 10000
216 Deri 285123791 37 P Ispa 10000 10000
217 Radil 285406154 3 L CC 10000 10000
218 Saydil 284917915 14 L Abses 10000 10000
219 Miftahul 284896066 2 P Diare 10000 10000
220 erlina 279645996 43 P Abses 10000 10000
221 Stevi 517005426 7 L Caries 10000 10000
222 Wasna 284791926 36 P Hamil 10000 10000
223 Nuradila 285203114 32 P Hamil 10000 10000
224 Salman 274646225 5 L Abses 10000 10000
225 Elfi 285123633 33 P Hamil 10000 10000
226 Laaila 284918567 7 P Luka Infeksi 10000 10000
227 Aidal 285439746 3 L Scabies 10000 10000
228 Atika 289894896 16 P Luka Infeksi 10000 10000
229 Jumaidil 285289804 10 L Ispa 10000 10000
230 Deri 285505064 36 L Ispa 10000 10000
231 Rafka 285387298 3 L 2/28/2013 Ispa 10000 10000
232 Lidar 284589108 41 P Asma 10000 10000
TOTAL 610000 10000 60000 260000
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL DIAGNOSA PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD

JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

233 M.Habil 279617141 6 L Asma 10000 10000


234 Aidal 285439746 3 L Ispa 10000 10000
235 Yendri 284825171 36 P chepalgia 10000 10000
236 Mildawati 284438722 42 P Caries 10000 10000
237 dermi 285389848 45 P Asma 10000 10000
238 Ismika 284818048 19 P Tonsilitis 10000 10000
239 Rosmaniwar 279646795 81 P RA 10000 10000
240 erlina 279645996 43 P Asma 10000 10000
241 Radil 285406154 3 L Ispa 10000 10000
242 Arini 517204697 7.5 P GE akut 10000 10000
243 Lismaderi 517021773 36 P Febris 10000 10000
TOTAL 80000 10000 20000 110,000
TOTAL KESELURUHAN 2,490,000

DIKETAHUI PAYAKUMBUH, MARET 2013


KEPALA PUSKESMAS TIAKAR PELAKSANA PROGRAM

dr.NETI HARTATI DIANI FERDIANTI,A.Md Keb


19750316 200604 2 009 19841222 201001 2 007
RINCIAN KLAIM JAMKESMAS TAHUN 2013
PUSKESMAS TIAKAR BULAN MARET
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

1 Samaniah 285607146 60 P 3/1/2013 Chepalgia 10,000 10,000


2 Ratima 517000442 59 P Chepalgia 10,000 10,000
3 Hara 285007179 9 P Febris 10,000 10,000
4 Randan 517024877 6 L ispa 10,000 10,000
5 Latifah 284750089 14 P ispa 10,000 10,000
6 Zulfajri 284791195 10 L cc 10,000 10,000
7 Mitrawati 284789801 52 P Utikaria 10,000 10,000
8 Deli 517021547 21 P cc 10,000 10,000
9 Ritawati 284838131 36 P 3/2/2013 Gastritis 10,000 10,000
10 M.Ega david 28489078 2 L ispa 10,000 10,000
11 Fransdito 284417198 10 L ispa 10,000 10,000
12 Midawati 284516501 41 P RA 10,000 10,000
13 Ermita 517201887 50 P Dyspepsia 10,000 10,000
14 Timah 284343890 84 P Asma 10,000 10,000
15 Aqil R 284739862 5 L Febris 10,000 10,000
16 Risqa A 279199791 16 P ispa 10,000 10,000
17 Rafi Kurma 284815565 15 L ispa 10,000 10,000
18 Asniyati 285198155 50 P Tinea 10,000 10,000
19 Yusnizar 285494826 71 P RA 10,000 10,000
20 Alexa Fitria 987535473 18 L Myalgia 10,000 10,000
21 Suharin 285699925 41 P Susp.Limfadentis 10,000 10,000
22 Rustian 285071491 71` L Asma 10,000 10,000
23 Mia dahlia 284833801 43 P gastritis 10,000 10,000
24 Salma 284892454 50 P Gastritis 10,000 10,000
TOTAL 210,000 0 30000 0 0 240,000
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL DIAGNOSA PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD

JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

25 Olivia 285606999 14 P ispa 10,000 10,000


26 Ermita 284355021 50 P RA 10,000 10,000
27 Yatinas 290754507 54 P 3/4/2013 Gastritis 10,000 10,000
28 Asni 284701653 40 P RA 10,000 10,000
29 Deni Mayasari 517021817 20 P ispa 10,000 10,000
30 Epi Susanti 284054289 30 P Chepalgia 10,000 10,000
31 Joni 284883317 45 L Dyspepsia 10,000 10,000
32 Yosmawati 285495614 33 P Vertigo 10,000 10,000
33 Ratius 517031493 75 P Asma 10,000 10,000
34 Andika 284896945 25 L ispa 10,000 10,000
35 Nengli 284165419 35 P Febris 10,000 10,000
36 Dwi Andika 517192900 8 L Febris 10,000 10,000
37 Rama Matriza 284790194 17 L Febris 10,000 10,000
38 Yusni 284737792 67 P 3/5/2013 ispa 10,000 10,000
39 Chinjtia 285616916 6 P CC 10,000 10,000
40 priharti ningsih 285637891 26 P Gastritis 10,000 10,000
41 Sarfina 285107520 77 P Chepalgia 10,000 10,000
42 Hendra 285429262 34 L Stomatitis 10,000 10,000
43 Yusni 284737792 67 P DM 10,000 10,000
44 Dailani Gampoalan 517219345 67 P Vertigo 10,000 10,000
45 Putri Renasari 284776762 18 P ispa 10,000 10,000
46 Nurjasman 517021096 46 L Asma 10,000 10,000
47 Priharti 517029685 26 P Gastritis 10,000 10,000
48 Laylatul Rahmi 517023775 26 P Gastritis 10,000 10,000
49 Lisdarni 517024484 70 P Vertigo 10,000 10,000
50 Upik 517028556 50 P Vertigo 10,000 10,000
TOTAL 260,000 0 0 260,000
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL DIAGNOSA PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD

JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

51 Gusniati Nur 284823384 42 P Gastritis 10,000 10,000


52 M. Arifin 284824866 6.5 L Febris 10,000 10,000
53 Syafni 285641166 47 L RA 10,000 10,000
54 Nofrianti 284775063 15 P ispa 10,000 10,000
55 Roni Abadi 584826374 8 L 3/6/2013 Febris 10,000 10,000
56 Wildan 284156122 9 L Febris 10,000 10,000
57 Wendra 284172996 19 L ispa 10,000 10,000
58 Arini M 284770157 5 P ispa 10,000 10,000
59 Dwi Fani Adinda 284204428 29 P gastritis 10,000 10,000
60 Febrinayeni 285072164 22 P CC 10,000 10,000
61 Chintia 285614160 6 P CC 10,000 10,000
62 Yuanita 284791940 45 P Stomatitis 10,000 10,000
63 Okaruma 284794851 18 L ispa 10,000 10,000
64 Metrival 285150074 39 P Chepalgia 10,000 10,000
65 Syamsimar 285522480 48 P Chepalgia 10,000 10,000
66 Fikri Fedla 284812501 4 L 3/7/2013 ispa 10000 10,000
67 Fizi Razaka 284575585 6 P febris 10,000 10,000
68 Hendra yuda 284701010 18 L Chepalgia 10,000 10,000
69 Yulia 284207174 30 P Chepalgia 10,000 10,000
70 Kasma 284794181 17 P Febris 10,000 10,000
71 Laylatul Rahmi 517023775 16 P Febris 10,000 10,000
72 desma 517023715 46 P RA 10,000 10,000
73 Darlima 284441791 59 P RA 10,000 10,000
74 Yuspitali 284817080 36 P ispa 10,000 10,000
75 Karima 517337001 11 P ispa 10,000 10,000
76 Syafri 285141100 48 L ispa 10,000 10,000
TOTAL 250,000 0 10000 0 260,000
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL DIAGNOSA PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD

JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

77 Armen 517007935 44 L 3/8/2013 dermatitis 10,000 10,000


78 Aidal Akbar 285939745 3.5 L ispa 10000 10000
79 Bunga lestari 284201001 10 P Febris 10,000 10,000
80 Abdullah 517005115 17 L ispa 10,000 10,000
81 Salsabila 2848022009 6 P Febris 10,000 10,000
82 Dimas Fernando 284203740 10 L Gastritis 10000 10000
83 Leo Handiko 284103855 8 L ispa 10,000 10,000
84 Khairul 284745530 45 L RA 10,000 10,000
85 M.Saga 285190896 7 L 3/9/2013 CC 10,000 10,000
86 M.Defrant 285191990 4 L ispa 10000 10,000
87 Lelinar 517024754 52 P RA 10,000 10,000
88 Hani Febrian 285790044 15 P Stomatitis 10,000 10,000
89 Erna 285090009 45 P Gastritis 10,000 10,000
90 Laila 285095070 5 P ispa 10000 10000
91 Arini 286770052 6 P Febris 10,000 10,000
92 Itraval 517023022 45 L ispa 10,000 10,000
93 Wahyu 284215583 4 L Febris 10,000 10,000
94 Bunga lestari 284201001 10 P Febris 10,000 10,000
95 Warneli 517006861 62 P Gastritis 10000 10000
96 Ermiyal 285514349 57 P Chepalgia 10,000 10,000
97 Riri Karlina 284373390 17 P 3/11/2012 Stomatitis 10,000 10,000
98 Nuna Khatih 284112003 5 P vulnus 10000 10,000
99 jospinto 285204270 10 L ispa 10,000 10,000
100 Dimas Fernando 284203721 10 L ispa 10,000 10,000
101 Aldo 285107290 5 L Febris 10000 10,000
102 efrizon 284139743 45 L vulnus 10000 10,000
TOTAL 210,000 0 30000 20000 260,000
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL DIAGNOSA PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD

JAMKESMAS ( THN ) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

103 Rohana 517597590 50 P Asma 10,000 10,000


104 Rangga 284890002 26 L tambal 20000 20,000
105 Ernawati 284890046 38 P ispa 10000 10000
106 M.Egadavid 284890070 2 L ispa 10000 10,000
107 Yuhardi 517000585 17 L febris 10000 10000
108 Nuria Habib 284826003 15 P 3/13/2013 Asma 10,000 10,000
109 Yul febria 285162659 11 P ispa 10,000 10,000
110 Egi Ardianssyah 284806055 13 L luka lecat 10000 10,000
111 Roslina 284890249 68 P Gastritis 10000 10000
112 Ismaldi 285076005 42 L Chepalgia 10,000 10,000
113 Frandilis 284907108 10 L Varicella 10,000 10,000
114 Oma Syatifa 284677089 2 P Febris 10000 10,000
115 Irsyad 2840755860 10 L ispa 10,000 10,000
116 Wira Yohana 284830398 11 P ispa 10,000 10,000
117 Chika Andriani 517028343 11 P Febris 10,000 10,000
118 Asni 517029926 10 P 3/14/2013 Febris 10,000 10,000
119 Mulda yenti 284201212 34 P Gastritis 10,000 10,000
120 Bunga lestari 284201001 10 P ispa 10,000 10,000
121 Quratul aini 285144035 22 P Hamil 10000 10,000
122 Helena 285465212 11 P cabut 25000 25,000
123 Ermita 284155718 17 P ispa 10000 10,000
124 Iqbal 284750728 5 L Febris 10,000 10,000
125 Chika Andriani 285752191 11 P ispa 10,000 10,000
126 Sefridal 284787911 11 L Gastritis 10,000 10,000
127 Epiyanti 284854189 34 P Stomatitis 10,000 10,000
128 Asni 517029926 10 P Stomatitis 10,000 10,000
TOTAL 200,000 45000 30000 10000 285,000
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL DIAGNOSA PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD

JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

129 Nola 284845519 25 P 3/15/2013 Chepalgia 10,000 10,000


130 Winda 287789091 12 P Febris 10,000 10,000
131 Fani fadila 285720333 10 P ispa 10,000 10,000
132 Fitri Handayani 284176272 17 P Gastritis 10,000 10,000
133 Alkhri 284719891 40 L RA 10,000 10,000
134 Zulkfli 284822208 35 L ispa 10,000 10,000
135 Mitradewi 284822071 25 P Suntik 10000 10,000
136 Resi alindra 284701009 31 P ispa 10,000 10,000
137 Rendi jumadi 517040059 10 L Febris 10000 10000
138 Agil 284759702 5 L CC 10,000 10,000
139 Sulastri 517038811 60 P 3/16/2013 Chepalgia 10,000 10,000
140 Salma 284192004 46 P RA 10,000 10,000
141 Yurisanti 284747009 37 P Febris 10,000 10,000
142 Meyla 284880749 28 P Suntik 10000 10,000
143 Rini 284886279 33 P Chepalgia 10000 10,000
144 Gusrial 517029971 20 L ispa 10,000 10,000
145 Refo 284640291 13 L ispa 10,000 10,000
146 Yulianis 285797960 28 P Chepalgia 10000 10,000
147 Toni Jasmita 284882433 16 L 3/18/2013 Gastritis 10,000 10,000
148 Pitmawati 284813493 40 P Suntik KB 10000 10,000
149 Jusmaniar 987534707 60 P Hipotensi 10,000 10,000
150 Rabiawilis 284739096 26 P Ispa 10,000 10,000
151 Maiyarlis 987534617 41 P Suntik KB 10000 10,000
152 Witra 284133014 36 P Chepalgia 10,000 10,000
153 Nuria Habibullah 284826003 5 L heacting off 10,000 10,000
154 Raihan Riski 285015367 9 L ispa 10,000 10,000
TOTAL 200,000 60000 260,000
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL DIAGNOSA PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD

JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

155 Emriati 285517967 33 P 3/19/2013 Gastritis 10,000 10,000


156 Resma Nelwita 285143275 43 P ispa 10,000 10,000
157 Veronica 284762913 28 P Chepalgia 10,000 10,000
158 Gusneti 284762913 47 P Anxietas 10,000 10,000
159 Leni 285191807 33 P Suntik KB 10000 10,000
160 Sofi nandes oktafia 285193798 2 P ispa 10000 10,000
161 Nurfadila 285187634 9 P ispa 10,000 10,000
162 Desi saputri 284758762 33 P 3/20/2013 Hamil 10000 10,000
163 Emriati 285517967 33 P Gastritis 10,000 10,000
164 Misdar 285407694 41 P Sntik KB 10000 10,000
165 M.Raudatul Ikhsan 284750005 7 L ispa 10,000 10,000
166 Gusneti 284762913 47 P Anxietas 10,000 10,000
167 Ofria Ningsih 284769404 30 P Hipotensi 10,000 10,000
168 Syusraini 285335291 50 P Suntik KB 10000 10000
169 Yeni Puspita 285180557 31 P dermatitis 10,000 10,000
170 Lastri 285123791 33 P Suntik KB 10000 10,000
171 Nina Angraini 285530848 25 P Diare 10000 10000
172 Muslimin 284920209 74 L 3/21/2013 Asma 10,000 10,000
173 Arda farrizal 285280874 10 L Luka Infeksi 10,000 10,000
174 Muslimin 284920209 74 L Asma 10,000 10,000
175 Nazwa Atahirda 285517743 6 P febris 10,000 10,000
176 Yeni Sustika 285307749 26 P ispa 10000 10,000
177 Risnawati 285517967 35 P ispa 10000 10000
178 Mardianis 285517967 44 P Scabies 10000 10000
179 Marta Gia 285247405 27 P ispa 10,000 10,000
180 Yeni yustika 285307749 23 P Asma 10,000 10,000
TOTAL 200,000 0 60000 0 260,000
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL DIAGNOSA PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD

JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

181 Resti 285531737 9 P 3/22/2013 Febris 10000 10000


182 Bima putra 285343659 4 L luka 10,000 10000
183 Vivil 284908206 10 P Caries 10000 10000
184 Yeni Sustika 285307749 26 P ispa 10000 10,000
185 Fatria 284917959 27 P Hipotensi 10000 10000
186 Rini 28533399 20 P Gastritis 10000 10000
187 Dira yuliani 285341591 19 P heacting off 10000 10000
188 Yulfera 285391113 34 P Scabies 10000 10000
189 Ridayati 279690005 54 P 3/23/2013 Asma 10000 10000
190 Icdar 284802399 42 P asma 10000 10000
191 Marco 284901372 11 L ispa 10000 10000
192 Rafqi 284912335 3 L cc 10000 10000
193 Fahri 285394893 3 L Scabies 10000 10000
194 Erlinda 284500893 36 p caries 10000 10000
195 Rosmaniwar 279646795 81 P dermatitis 10000 10000
196 Erlina 279645996 42 P 3/25/2013 asma 10000 10000
197 Reza 285403206 16 L ispa 10000 10000
198 Sarioji 284921908 65 P RA 10000 10000
199 Helda 284802399 30 P dermatitis 10000 10000
200 Akamani 284928895 85 L RA 10000 10000
201 Nurasia 285203114 8 P ispa 10000 10000
202 Apri abdi 284802906 5 L dermatitis 10000 10000
203 M.syafiq 284826475 3 L ispa 10000 10000
204 Rani 285414535 15 P 3/26/2013 ispa 10000 10000
205 Rakiah 987535991 75 P Gastritis 10000 10000
206 afdal 284851269 14 L ispa 10000 10000
TOTAL 220000 30000 260000
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL DIAGNOSA PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD

JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

207 Sahrul 285432941 8 L ispa 10000 10000


208 Laras 279645118 9 P ispa 10000 10000
209 Erlina 279645496 44 P Dismenorhoe 10000 10000
210 Sintia 787535945 25 P ispa 10000 10000
211 Reza 285403206 16 L ispa 10000 10000
212 dinda 279633570 8 P Faringitis 10000 10000
213 Rafqi 284412335 3 L Faringitis 10000 10000
214 Deswita 284830582 43 P ispa 10000 10000
215 Icdar 284802399 42 P asma 10000 10000
216 Asyfa 285361334 4 P ispa 10000 10000
217 Afla 284861316 4 P ispa 10000 10000
218 Yunita 284861316 26 P Hamil 10000 10000
219 Sharul 285432941 8 L dermatitis 10000 10000
220 Nuraini 987536696 60 P RA 10000 10000
221 Nadira 279655209 4 P 3/27/2013 ispa 10000 10000
222 Yusrita 279654928 27 P ispa 10000 10000
223 Siti 279646176 8 P ispa 10000 10000
224 Erlina 279646996 44 P Asma 10000 10000
225 nurasiah 2575325912 9 P ispa 10000 10000
226 Aidal Akbar 285439746 4 L dermatitis 10000 10000
227 Takya 285358173 2 P Febris 10000 10000
228 Tia 274646225 44 P Chepalgia 10000 10000
229 Icdar 284802399 42 P asma 10000 10000
230 Helda 284802399 42 P caries 10000 10000
231 Gusdepan 987536171 36 P mialgia 10000 10000
TOTAL 190000 60000 250000

NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL DIAGNOSA PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD

JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

232 Wasna 279645996 36 P Hamil 10000 10000


233 Nuradila 284802399 32 P Hamil 10000 10000
234 yanti 284918382 27 P Faringitis 10000 10000
235 Mulyasri 284897338 40 L Ispa 10000 10000
236 Zulkifli 284803299 35 L Inf. Kulit 10000 10000
237 Icdar 284802399 42 P asma 10000 10000
238 Arif 285403915 8 L Febris 10000 10000
239 Ridwan 285392915 13 L dermatitis 10000 10000
240 Nulfera 285391113 36 P Ispa 10000 10000
241 Putri 285394893 3 P 3/28/2013 Ispa 10000 10000
242 Radi 285415108 8 L Ispa 10000 10000
243 Eri 279630909 13 L Scabies 10000 10000
244 Dani 279603538 17 L Febris 10000 10000
245 Salman 2853736975 4 L Febris 10000 10000
246 M.Alfi 987535989 7 L Ispa 10000 10000
247 M.Agung 284834834 8 L Scabies 10000 10000
248 Arini 284897867 8 P Febris 10000 10000
249 Amril Yanto 285389291 45 L Ispa 10000 10000
250 Dermi 285389864 44 P Ispa 10000 10000
251 Reka 284867864 13 P Ispa 10,000 10,000
252 Gurda halim 284899397 38 L caries 10,000 10,000
253 Delfitri 987535631 27 P dermatitis 10,000 10,000
254 Zulkifli 284803299 55 L Inf. kulit 10,000 10,000
255 Wirna 285460468 48 P Vomitus 10,000 10,000
256 Deswita 279677913 25 P Ispa 10,000 10,000
TOTAL 210,000 40000 250,000

NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL DIAGNOSA PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD

JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

257 Erlina 279645996 44 P asma 10000 10000


258 Rosmaniwar 279646745 81 P scabies 10000 10000
259 ernita 279681838 40 P luka Bakar 10000 10000
260 M.Fahrul 279649966 4 L dermatitis 10000 10000
261 Rakiah 287535991 75 P gastritis 10000 10000
262 Yuliana 278093531 35 P Faringitis 10000 10000
263 Ahmad julian 279681838 2 L Ispa 10000 10000
264 Yola 284694112 5 P Ispa 10000 10000
265 Delia 285198571 10 P tambal 25000 25000
266 Arini 284770157 5 P Ispa 10000 10000
267 kasmina 285555345 54 P RA 10000 10000
268 Rusman 987558715 80 L asma 10000 10000
269 Marni 284720769 28 P Febris 10000 10000
270 Maya sari oktavia 284773421 17 P Ispa 10000 10000
271 Ratius 517031493 68 L asma 10000 10000
272 Reyhan 284161465 8 L Febris 10000 10000
273 yulia Fitri 285718836 17 P Ispa 10000 10000
274 Henrdri yuda 284701012 17 L 3/30/2013 Febris 10000 10000
275 Putri 284838090 12 P dermatitis 10000 10000
276 Usman 517006901 80 L asma 10000 10000
277 Roslina 2840944049 68 P RA 10000 10000
278 Erlinda 284901781 36 P Ispa 10000 10000
279 Yasni 285723781 40 P Ispa 10000 10000
280 Aqil 284739862 5 L Ispa 10000 10000
281 Erlina 279645996 44 P asma 10000 10000
total 220000 25000 20000 265000

NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL DIAGNOSA PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD

JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

282 Dea Ifanka 285077406 9 P sscabies 10,000 10,000


283 Ezi 517030391 14 L Ispa 10,000 10,000
284 Deni sagita 517000724 29 P Psokosomatis 10,000 10,000
285 Samsunidar 517030582 64 P Psokosomatis 10,000 10,000
286 Laylatul Rahmi 5170237754 16 P asma 10,000 10,000
287 Ayumi 285194891 19 P Ispa 10,000 10,000
TOTAL 60,000 0 60,000

TOTAL KESELURUHAN 2,910,000

DIKETAHUI PAYAKUMBUH, 1 april 2013


KEPALA PUSKESMAS TIAKAR PELAKSANA PROGRAM

dr. NETI HARTATI DIANI FERDIANTI,A.Md Keb


19750316 200604 2 009 19841222 201001 2 007
RINCIAN KLAIM JAMKESMAS TAHUN 2013
PUSKESMAS TIAKAR BULAN APRIL
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

1 SUSANTI 285120786 24 P 30-3-2013 MYALGIA 10,000 10,000


2 AFRIZAL 285120706 25 P 31-3-2013 GASTRITIS 10,000 10,000
3 USLINAR 44 P KB 10,000 10,000
4 VONI 284762766 27 P S,KEPALA 10,000 10,000
5 CITRA VANHESTI 284763240 9 P 2/4/2013 VARICELA 10,000 10,000
6 VICKI SANDRA 2874762766 32 L VARICELA 10,000 10,000
7 SOFI 8 P VARICELA 10,000 10,000
8 DESI SAPUTRI 284758762 33 P 4/4/2013 ISPA 10,000 10,000
9 SYIFA 2484763249 2 P 5/5/2013 VARICELA 10,000 10,000
10 VONI 285123791 37 P HIPOTENSI 10,000 10,000
11 LASTRI 285335291 33 P ALERGI 10,000 10,000
12 SYTUSRAINI 285335291 50 P ALERGI 10,000 10,000
13 GUSNETI 285178318 47 P ANXIETAS 10,000 10,000
14 GUSNETI 285178318 47 P 16-4-2013 ANXIETAS 10,000 10,000
15 DESI SAPUTRI 284758762 33 P 17-4-2013 ISPA 10,000 10,000
16 SRI OLIVIA 285153928 4 P PARINGITIS 10,000 10,000
17 LIDYA NOVA 285118997 23 P 20-4-2013 ANEMIA 10,000 10,000
18 NAPI ILYAS 285185182 80 L DIARE 10,000 10,000
19 MIRAWATI 285186429 28 P 22-4-2013 GASTRITIS 10,000 10,000
20 JOAN IBNU SALEH 285186429 6 L ISPA 10,000 10,000
21 ADITIA FAHREZA 285143804 10 L ISPA 10,000 10,000
22 RESMANELWITA 285143275 43 P ARTRITIS 10,000 10,000
23 NURAINI 285095788 42 P 1/4/2013 KB 10,000 10,000
24 ILHAM AFDAL 285499034 22 L 2/4/2013 CC 10,000 10,000
P 220,000 0 20000 0 0 240,000
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL DIAGNOSA PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD

JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

25 ZAITUL AINI 284901906 23 P 2/4/2013 KB 10,000 10,000


26 ROSNINI 987534382 50 P CEPALGIA 10,000 10,000
27 FRDI PERMANA OKI 284207174 15 L CEPALGIA 10,000 10,000
28 YULIA 285498191 30 P HIPOTENSI 10,000 10,000
29 NETI DAHLIANTI 2849498191 36 P KB 10,000 10,000
30 WITRA 284133014 36 P KB 10,000 10,000
31 ELMAWATI 284816812 41 P HIPERTENSI 10,000 10,000
32 WILDAHUSNI 42 P KB 10,000 10,000
33 HENDRI JULIA 284882736 12 L ISPA 10,000 10,000
34 DARLISMA 284159294 59 P GASTRITIS 10,000 10,000
35 ETI YULIA 285280694 36 P 2/4/2013 GASTRITIS 10,000 10,000
36 PUTRI AISAH 285268836 6 P 2/4/2013 GASTRITIS 10,000 10,000
37 JASRIL 285326739 70 L 4/4/2013 ISPA 10,000 10,000
38 GERHANA 284909499 5 L 5/4/2013 CC 10,000 10,000
39 MUSLIM 284920209 74 L PSIKOMATIK 10,000 10,000
40 RIJAL 285514806 33 L CARIES 10,000 10,000
41 YURMILATI 285291685 50 P 6/4/2013 GASTRITIS 10,000 10,000
42 RIKO 285530139 28 L SUSP.TIPOID 10,000 10,000
43 M YUSUF 28522339 9 L 9/4/2013 CARIES 10,000 10,000
44 NURDESMERI 285510295 34 P KB 10,000 10,000
45 HILDALINI 285329349 36 P KB 10,000 10,000
46 IFRA YANTO 285341927 36 L KB 10,000 10,000
47 ETI YULIA 285280694 36 P 13-4-2013 INF.LUKA 10,000 10,000
48 NINA ANGGRAINI 285530848 28 P KB 10,000 10,000
49 MUSLIM 284920209 73 L GASTRITIS 10,000 10,000
50 TITI MONIKA 285231849 15 P 19-4-2013 ANEMIA 10,000 10,000
TOTAL 180,000 80000 0 260,000
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL DIAGNOSA PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD

JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

51 SAMSURILAS 284920694 68 P 20-4-2013 MYALGIA 10,000 10,000


52 AFRIZAL 285279941 40 L 22-4-2013 CEPALGIA 10,000 10,000
53 ERWIN 285336808 45 L LUKA LECET 10,000 10,000
54 DELMAWATI 285221709 18 P 23-4-2013 OMA 10,000 10,000
55 NURBAYANI 285262121 42 P 25-4-2013 GASTRITIS 10,000 10,000
56 APRILAYANTI 285277599 33 P GASTRITIS 10,000 10,000
57 RESTI 285531737 9 P 26-4-2013 ISPA 10,000 10,000
58 RINI 285533399 20 P KB 10,000 10,000
59 ELIA FISNORA 284897294 34 P 27-3-2013 scabies 10,000 10,000
60 ALDI 285368084 5 L asma 10,000 10,000
61 ASNIMAR 285366458 32 P asma 10,000 10,000
62 AMRIL YANTO 285389291 46 L 10,000 10,000
63 SAMSI 285434638 60 P 28-3-2013 cc 10,000 10,000
64 KHAILA 285459658 4 P 1/4/2013 scabies 10,000 10,000
65 RENDI 285458872 9 L CARIES 10,000 10,000
66 HELMA 284820502 30 P dermatitis 10,000 10,000
67 YULIANA 279630448 38 P asma 10,000 10,000
68 NAIRA 279630933 1 P ISPA 10,000 10,000
69 FAISAL 7 L ra 10,000 10,000
70 ZULKIFLI 284803299 55 L dermatitis 10,000 10,000
71 WASNA 2796161619 37 P ra 10,000 10,000
72 ERLINDA 279616577 29 P ISPA 10,000 10,000
73 NOFIANDI 184861619 35 L 2/4/2013 dermatitis 10,000 10,000
74 RIO 284904123 19 L CC 10,000 10,000
75 FATIH NURUL 279634448 5 P 3/4/2013 ISPA 10,000 10,000
76 DELFITRI 987535631 27 P GASTRITIS 10,000 10,000
TOTAL 250,000 0 10000 0 260,000
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL DIAGNOSA PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD

JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

77 NONA 284856221 2 P 3/4/2013 CC 10,000 10,000


78 RIFI 284811862 16 P 5/4/2013 ISPA 10,000 10,000
79 NAIRA 279630937 1 P ISPA 10,000 10,000
80 YULIANA 279630448 38 P DESMINORE 10,000 10,000
81 WASNA 37 P ISPA 10,000 10,000
82 MITO 28 L ISPA 10,000 10,000
83 RAMALIS 987535877 75 P 13-4-2013 FARINGITIS 10,000 10,000
84 ERLINA 979645996 41 P FARINGITIS 10,000 10,000
85 LIDARNIS 42 P ISPA 10,000 10,000
86 RIDWAN 285392046 13 L 15-4-2013 CARIES 10,000 10,000
87 RIFAN 285392801 9 L ISPA 10,000 10,000
88 PUTRI 285399893 3 P ISPA 10,000 10,000
89 YLFERA 28539413 35 P ISPA 10,000 10,000
90 DAMBRA 285445787 70 L 16-4-2013 dermatitis 10,000 10,000
91 MISLAINI 285446924 66 P RA 10,000 10,000
92 WIMALAILI 285460468 50 P ISPA 10,000 10,000
93 RAHMADI 2848405873 16 L ISPA 10,000 10,000
94 HANI 284845940 12 P ISPA 10,000 10,000
95 LIDARNIS 42 P 18-4-2013 asma 10,000 10,000
96 VINI 285325324 17 P ISPA 10,000 10,000
97 SARIOJI 28494908 62 P dermatitis 10,000 10,000
98 ZULMAIHAR 285374248 70 P RA 10,000 10,000
99 BAGIO 284802344 38 L 19-4-2013 LUKA 10,000 10,000
100 AFRIDA 39 P scabies 10,000 10,000
101 MANDA 11 P TINEA 10,000 10,000
102 WILY 285390189 16 L 6/4/2013 ABSES 10,000 10,000
TOTAL 260,000 0 0 0 260,000
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL DIAGNOSA PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD

JAMKESMAS ( THN ) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

103 RANGGA 284901039 14 P 6/4/2013 dermatitis 10,000 10,000


104 SAYDUL 15 L 8/4/2013 INFKS KULIT 10,000 10,000
105 SAMSIDAR 987535203 85 P CC 10,000 10,000
106 NURAINI 987535596 60 P 9/4/2013 RA 10,000 10,000
107 VIONI 2848540048 11 P dermatitis 10,000 10,000
108 UFACRA 284824708 3 P ISPA 10,000 10,000
109 ERNA 284855005 44 P TINEA 10,000 10,000
110 SARUL 285432941 9 L GE 10,000 10,000
111 M SAFIQ 284826475 2 L ABSES 10,000 10,000
112 ELFI 33 P 10/4/2013 ISPA 10,000 10,000
113 M.WAZIR 284841292 54 L GE 10,000 10,000
114 FAZEL 284923326 3 L ISPA 10,000 10,000
115 LIDRAWATI 279641316 40 P CEPALGIA 10,000 10,000
116 WASNA 38 P FARINGITIS 10,000 10,000
117 YANTI 26 P ISPA 10,000 10,000
118 ASTUTI 30 P 11/4/2013 scabies 10,000 10,000
119 RATIH 28908162 26 P ABSES 10,000 10,000
120 NAZIRHA 284909545 5 P CC 10,000 10,000
121 DERMI 285389864 45 P 12/4/2013 dermatitis 10,000 10,000
122 RAFLI 284912335 2 L 20-4-2013 INFKS KULIT 10,000 10,000
123 SYAMSI 285434638 50 P 22-4-2013 dermatitis 10,000 10,000
124 FIRMAN 987535613 6 L HERPES 10,000 10,000
125 RATNA 987535743 20 P 23-4-2013 ISPA 10,000 10,000
126 INDRAVERI 284862936 43 L LUKA ROBEK 10,000 10,000
127 ABIZAR 68 L 24-4-13 GE 10,000 10,000
128 RAMAYULIS 987535877 71 P MYALGIA 10,000 10,000
TOTAL 260,000 0 0 260,000
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL DIAGNOSA PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD

JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

129 NABILA 7 P 1/4/2013 Ispa 10,000 10,000


130 NURLILIS 517024743 53 P Mialgia 10,000 10,000
131 ANTONI 284793322 19 L Scabies 10,000 10,000
132 ERMAWITA 289918065 70 P Scabies 10,000 10,000
133 BASTI T 284859348 11 P RA 10,000 10,000
134 SANIYEM 5170277 48 P Scabies 10,000 10,000
135 RENI SARTIKA 285641112 22 P STK KB 10,000 10,000
136 RAMADANI 284848661 12 P TMBL TETAP 25,000 25,000
137 BAYUNI 385439791 45 P RA 10,000 10,000
138 FEBI 285927889 12 P Artritis 10,000 10,000
139 DARLISMA 517032956 55 P Anxietas 10,000 10,000
140 RAMAYULIS 585083449 65 P Ispa 10,000 10,000
141 CIKA MELISA 517031993 11 P Asma 10,000 10,000
142 JERISTA 284578957 23 P 3/4/2013 Influenza 10,000 10,000
143 YELLI 285457559 37 P Inf luka 10,000 10,000
144 NEPI ERAWATI 2814431345 43 P 4/4/2013 Gastritis 10,000 10,000
145 MILA WAHYU 284895480 18 P Alergi 10,000 10,000
146 SOVIA 284165569 P Hipotensi 10,000 10,000
147 FAUZIAH 284163783 51 P 5/4/2013 Ispa 10,000 10,000
148 WANIS 285682757 49 P CABUT GIGI TETAP 20,000 20,000
149 BASRI TANDO 285610702 49 L Faringitis 10,000 10,000
150 MUSMAR 495490194 50 P Ispa 10,000 10,000
151 ERMAWITA 285729096 52 P Inf. Kulit 10,000 10,000
152 DIKA PRATAMA 285718836 11 P 7/4/2013 asma 10,000 10,000
153 MUTIARA SENJA 285307806 15 P Febris 10,000 10,000
154 SALMI 284845427 40 P dermatitis 10,000 10,000
TOTAL 230,000 45000 10000 285,000
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL DIAGNOSA PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD

JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

155 LELINEL 285596177 42 P 7/4/2013 RA 10,000 10,000


156 FIFI DEWI 517018329 29 P ARTRITIS 10,000 10,000
157 SAFNI J 517028758 48 P 9/4/2013 ANXIETAS 10,000 10,000
158 USMAN 517006906 87 L ISPA 10,000 10,000
159 NORA 517002478 12 P ASMA 10,000 10,000
160 NURAMI 517002434 44 P INFLUENSA 10,000 10,000
161 YUSNIDAR 517001477 LUKA 10,000 10,000
162 PUTRILELIANA 517001894 GASTRITIS 10,000 10,000
163 SAMSUNIDAR 517030582 64 P ALERGI 10,000 10,000
164 MARTALIZA 517028174 32 P HIPOTENSI 10,000 10,000
165 NABILA 507022201 6 P 10/4/2012 CABUT GIGI SUSU 10,000 10,000
166 MUSMAR 1233773548 6,5 P asma 10,000 10,000
167 ERMITA 5170010101 50 P scabies 10,000 10,000
168 ROSTI 517218445 50 P luka Bakar 10,000 10,000
169 ROSNETI 517030064 62 P dermatitis 10,000 10,000
170 MURDIANA 517032033 60 P 11/4/2013 gastritis 10,000 10,000
171 NASRIAL 517032123 43 L Faringitis 10,000 10,000
172 LELINER 517024754 50 P Ispa 10,000 10,000
173 BENHUR 517024653 42 L Ispa 10,000 10,000
174 YUSRINA 479816695 44 P CABUT GIGI TETAP 20,000 20,000
175 RANI F 517004278 9 L Asma 10,000 10,000
176 SITI NURLIANA 517010185 45 P 12/4/2013 Ispa 10,000 10,000
177 ASNIWATI 51703085 49 L chepalgia 10,000 10,000
178 CHIKA MELISA 517028398 11 P Caries 10,000 10,000
179 NURHALIFAH 517028861 12 P Asma 10,000 10,000
180 NURHAYATI 517619049 68 P Tonsilitis 10,000 10,000
TOTAL 230,000 30000 10000 270,000
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL DIAGNOSA PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD

JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

181 RAHMAD H 517021154 20 L 13-4-2013 ISPA 10,000 10,000


182 WARNETI 517004486 62 P ISPA 10,000 10,000
183 DINDA 517269041 12 P Scabies 10,000 10,000
184 ISNA 517023696 58 P Febris 10,000 10,000
185 MITRA DEWI 517219323 28 P 16-4-2013 Febris 10,000 10,000
186 USMAN 517006901 80 L ISPA 10,000 10,000
187 YASMAWATI 51008306 32 P ISPA 10,000 10,000
188 LAILA 517228738 7 P CABUT GIGI SUSU 10,000 10,000
189 SAFNIJA 517028758 48 L ISPA 10,000 10,000
190 MURLIZA 517004201 47 P ASMA 10,000 10,000
191 MUSNAR 33173548 50 P 17-4-2013 DYSPEPSIA 10,000 10,000
192 MARTALIZA 517028207 30 P ABSES 10,000 10,000
193 SUGIMIN 517004638 48 L ASMA 10,000 10,000
194 HARADI 517021176 44 L 18-4-2013 TMBL TETAP 25,000 25,000
195 NINGSIH ERIKA 517007702 38 P ISPA 10,000 10,000
196 ROSTIA 517031447 70 P Faringitis 10,000 10,000
197 NASRIAL 517032123 43 L Ispa 10,000 10,000
198 MURLIZA 517004210 48 P Inf. Kulit 10,000 10,000
199 SWARNI 517027803 63 P 19-4-2013 ISPA 10,000 10,000
200 ABDUL HINDI 517005905 15 L ISPA 10,000 10,000
201 RENI SARTIKA 5149552346 22 P 20-4-2013 GASTRITIS 10,000 10,000
202 MARUSMAR 5170255518 44 P CABUT GIGI TETAP 20,000 20,000
203 DIKA PRATAMA 517219626 11 L 21-4-2013 FEBRIS 10,000 10,000
204 BUYUNG NARO 517219604 46 P ISPA 10,000 10,000
205 SAMSUNIDAR 517030583 54 P GASTRITIS 10,000 10,000
206 JUMADI 517013717 53 L MYALGIA 10,000 10,000
TOTAL 220,000 55000 10000 285,000
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL DIAGNOSA PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD

JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

207 YASPITA LINI 517028905 35 P 21-4-2013 10,000 10,000


208 NEVIERAMAN 517028769 45 P ISPA 10,000 10,000
209 ROKO RAMA 517028815 13 L ISPA 10,000 10,000
210 JUMADI 517013717 53 L 23-4-2013 GASTRITIS 10,000 10,000
211 AFDIL R 517219672 13 L GASTRITIS 10,000 10,000
212 FRAN FEBRIANUR 517029410 7 L FEBRIS 10,000 10,000
213 YARNELI 517028591 72 P ISPA 10,000 10,000
214 TITIS MISRAWATI 123373760 17 P ISPA 10,000 10,000
215 LAILATUL KHAIR 517030738 12 P FEBRIS 10,000 10,000
216 RENO S 517018376 19 L 24-4-2013 GASTRITIS 10,000 10,000
217 YOLI S 517007968 18 L ISPA 10,000 10,000
218 JELVIN F 51700779 14 L ISPA 10,000 10,000
219 PONI P 517032019 18 P dermatitis 10,000 10,000
220 MELANISA 517024462 22 P ISPA 10,000 10000
221 LIDARNIS 517005819 40 P 25-4-2013 ISPA 10,000 10,000
222 RAHMAT 517021154 13 L CHEPALGIA 10,000 10,000
223 AMILIANTI 517001556 11 P GASTRITIS 10,000 10,000
224 ASWANDI 517001859 46 L KANKER 10,000 10,000
225 ENAWATI 517003751 37 P ISPA 10,000 10,000
226 NOVIA 517000702 87 L MYALGIA 10,000 10,000
227 USMAN 5170061701 38 P 28-4-2013 ISPA 10,000 10,000
228 YELLY K 517029941 48 P dermatitis 10,000 10,000
229 SOSMANIRA 517004572 31 P Inf. kulit 10,000 10,000
230 ELINAR 517030773 28 L GASTRITIS 10,000 10,000
231 DENI S 517000724 8 P ISPA 10,000 10,000
232 MELDA 517030964 9 P GASTRITIS 10,000 10,000
TOTAL 250,000 0 10000 0 260,000
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL DIAGNOSA PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD

JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

233 ADIT 517024563 43 L 29-4-2012 MYALGIA 10,000 10,000


234 REMA 517024539 48 P ISPA 10,000 10,000
235 SYAFNI YUPITER 517020758 48 L chepalgia 10,000 10,000
236 JUMADI 517007059 P CC 10,000 10,000
237 URILY A 517007060 8 P FEBRID 10,000 10,000
238 LAILA O 517007358 4,5 L ISPA 10,000 10,000
239 FAUZANR 517004594 23 L RA 10,000 10,000
240 RAHMAD T 517004594 7 P CC 10,000 10,000
241 RAMADANIS 517003661 66 P 30-4-2013 dermatitis 10,000 10,000
242 NURLINDA 548917208 45 L ASMA 10,000 10,000
243 RAMAD H 517021158 14 L FEBRIS 10,000 10,000
244 LELINAR 517024754 51 P ISPA 10,000 10,000
245 ASNIWATI 517030885 47 P ISPA 10,000 10,000
246 REFNITA 517204315 42 P dermatitis 10,000 10,000
247 VELAN 517025946 9 L dermatitis 10,000 10,000
TOTAL 140,000 10000 150,000

TOTAL KESELURUHAN 2,530,000


DIKETAHUI PAYAKUMBUH,13 MAI 2013
KEPALA PUSKESMAS TIAKAR PELAKSANA PROGRAM

NETI HARTATI DESTYAMELIA,A.Md Keb


19750316 200604 2 009 19841222 201001 2 007
RINCIAN KLAIM JAMKESMAS TAHUN 2013
PUSKESMAS TIAKAR BULAN MAI

NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

1 ZAITUL AINI 284901906 23 P 5/1/2013 KB 10,000 10,000


2 ROSNINI 987534382 50 P CEPALGIA 10,000 10,000
3 FRDI PERMANA OKI 284207174 15 L CEPALGIA 10,000 10,000
4 YULIA 285498191 30 P HIPOTENSI 10,000 10,000
5 NETI DAHLIANTI 2849498191 36 P KB 10,000 10,000
6 WITRA 284133014 36 P KB 10,000 10,000
7 ELMAWATI 284816812 41 P 5/2/2013 HIPERTENSI 10,000 10,000
8 SAMSURILAS 284920694 68 P MYALGIA 10,000 10,000
9 AFRIZAL 285279941 40 L CEPALGIA 10,000 10,000
10 ERWIN 285336808 45 L LUKA LECET 10,000 10,000
11 DELMAWATI 285221709 18 P 5/3/2013 OMA 10,000 10,000
12 NURBAYANI 285262121 42 P GASTRITIS 10,000 10,000
13 APRILAYANTI 285277599 33 P GASTRITIS 10,000 10,000
14 RESTI 285531737 9 P 5/4/2013 ISPA 10,000 10,000
15 RINI 285533399 20 P KB 10,000 10,000
16 ELIA FISNORA 284897294 34 P scabies 10,000 20,000
17 ALDI 285368084 5 L 5/6/2013 asma 10,000 10,000
18 ASNIMAR 285366458 32 P asma 10,000 10,000
19 AMRIL YANTO 285389291 46 L ISPA 10,000 10,000
20 SAMSI 285434638 60 P cc 10,000 10,000
21 KHAILA 285459658 4 P scabies 10,000 10,000
22 RENDI 285458872 9 L CARIES 10,000 10,000
23 HELMA 284820502 30 P dermatitis 10,000 10,000
24 YULIANA 279630448 38 P 7-May asma 10,000 10,000
TOTAL 190,000 0 40000 0 10000 240,000
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

25 Nola 284845519 25 P 5/7/2013 Chepalgia 10,000 10,000


26 Winda 287789091 12 P Febris 10,000 10,000
27 Fani fadila 285720333 10 P ispa 10,000 10,000
28 Fitri Handayani 284176272 17 P 5/8/2013 Gastritis 10,000 10,000
29 Alkhri 284719891 40 L RA 10,000 10,000
30 Zulkfli 284822208 35 L ispa 10,000 10,000
31 Mitradewi 284822071 25 P Suntik KB 10000 10,000
32 Resi alindra 284701009 31 P ispa 10,000 10,000
33 Rendi jumadi 517040059 10 L Febris 10000 10,000
34 Agil 284759702 5 L 5/10/2013 CC 10,000 10,000
35 Sulastri 517038811 60 P Chepalgia 10,000 10,000
36 Salma 284192004 46 P RA 10,000 10,000
37 Yurisanti 284747009 37 P Febris 10,000 10,000
38 Meyla 284880749 28 P 5/11/2013 Suntik KB 10000 10,000
39 Rini 284886279 33 P Chepalgia 10000 10,000
40 Gusrial 517029971 20 L ispa 10,000 10,000
41 Refo 284640291 13 L ispa 10,000 10,000
42 Yulianis 285797960 28 P Chepalgia 10000 10,000
43 Toni Jasmita 284882433 16 L 5/11/2013 Gastritis 10,000 10,000

44 Pitmawati 284813493 40 P Suntik KB 10000 10,000

45 Jusmaniar 987534707 60 P Hipotensi 10,000 10,000

46 Rabiawilis 284739096 26 P Ispa 10,000 10,000


47 Maiyarlis 987534617 41 P Suntik KB 10000 10,000
48 Witra 284133014 36 P 5/13/2013 Chepalgia 10,000 10,000
49 Yuliani Putri 285178816 17 P cabut gigi tetap 20,000 20,000
50 Razaq 517007021 32 L 10,000 10,000
TOTAL 190,000 20,000 60000 0 270,000
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL DIAGNOSA PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD

JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

51 RANGGA 284901039 14 P 5/13/2013 dermatitis 10,000 10,000


52 SAYDUL 15 L INFKS KULIT 10,000 10,000
53 SAMSIDAR 987535203 85 P CC 10,000 10,000
54 NURAINI 987535596 60 P RA 10,000 10,000
55 VIONI 2848540048 11 P dermatitis 10,000 10,000
56 UFACRA 284824708 3 P ISPA 10,000 10,000
57 ERNA 284855005 44 P TINEA 10,000 10,000
58 SARUL 285432941 9 L GE 10,000 10,000
59 M SAFIQ 284826475 2 L 14-May ABSES 10,000 10,000
60 ELFI 287456788 33 P ISPA 10,000 10,000
61 M.WAZIR 284841292 54 L GE 10,000 10,000
62 Junaidi 285715290 69 L Chepalgia 10,000 10,000
63 Enida 285603906 44 P anemia 10,000 10,000
64 Mardiana 517022030 35 P HT 10,000 10,000
65 Muryadi 289205890 56 L Gastritis 10,000 10,000
66 Afrizal 517007750 32 L 5/15/2013 Febris 10,000 10,000
67 Lutfia 517009086 6 P Febris 10,000 10,000
68 Mona Diana 285160599 17 P Gastritis 10,000 10,000
69 Hamzah Fansuri 284926116 13 L Ispa 10,000 10,000
70 Yeli kamaruddin 517029941 38 P Ispa 10,000 10,000
71 Misailis 284204621 42 P CC 10,000 10,000
72 Zulnaida 284205249 49 P CC 10,000 10,000
73 Betti 279649359 35 P 5/16/2013 CC 10,000 10,000
74 Rianza Andra 279649798 16 L Ispa 10,000 10,000
75 Marlius 517029322 28 L Ispa 10,000 10,000
76 Reynaldi 987534977 11 L Ispa 10,000 10,000
TOTAL 240,000 0 20000 0 260,000
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL DIAGNOSA PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD

JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

77 Khairul 284745530 45 L 17-May RA 10,000 10,000


78 M.Saga 285190896 7 L CC 10,000 10,000
79 M.Defrant 285191990 4 L ispa 10000 10,000
80 Lelinar 517024754 52 P RA 10,000 10,000
81 Hani Febrian 285790044 15 P 18-May Stomatitis 10,000 10,000
82 Erna 285090009 45 P Gastritis 10,000 10,000
83 Laila 285095070 5 P ispa 10000 10,000
84 Arini 286770052 6 P Febris 10,000 10,000
85 Itraval 517023022 45 L 5/20/2013 ispa 10,000 10,000
86 Wahyu 284215583 4 L Febris 10,000 10,000
87 Bunga lestari 284201001 10 P Febris 10,000 10,000
88 Warneli 517006861 62 P Gastritis 10000 10,000
89 Ermiyal 285514349 57 P Chepalgia 10,000 10,000
90 Riri Karlina 284373390 17 P Stomatitis 10,000 10,000
91 Nuna Khatih 284112003 5 P vulnus 10,000 10,000
92 Muslim 284900299 76 L asma 10,000 10,000
93 Shifa Virenza 284151846 16 P Ispa 10,000 10,000
94 Ermita 284353328 45 P 21-May RA 10,000 10,000
95 Wis dewita 284771294 30 P GE akut 10,000 10,000
96 Hengki 517004482 28 L Skizofrenia 10,000 10,000
97 Betti 279649359 35 P INFEKSI GUSI 10,000 10,000
98 Rianza Andra 279649798 16 L INFEKSI GUSI 10,000 10,000
99 Marlius 517029322 28 L 22-May Mialgia 10,000 10,000
100 Asniwati 517030885 47 P Gastritis 10,000 10,000
101 Mariana Putri 284317108 6 P Tambal 25,000 25,000
102 Kartini 284715595 32 P Gastritis 10,000 10,000
TOTAL 210,000 45000 20000 0 275,000
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL DIAGNOSA PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD

JAMKESMAS ( THN ) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

103 SUSANTI 285120786 24 P 5/23/2013 MYALGIA 10,000 10,000


104 AFRIZAL 285120706 25 P GASTRITIS 10,000 10,000
105 USLINAR 286579044 44 P KB 10,000 10,000
106 VONI 284762766 27 P 24-May S,KEPALA 10,000 10,000
107 CITRA VANHESTI 284763240 9 P VARICELA 10,000 10,000
108 VICKI SANDRA 2874762766 32 L 5/25/2013 VARICELA 10,000 10,000
109 SOFI 2876324212 8 P VARICELA 10,000 10,000
110 DESI SAPUTRI 284758762 33 P ISPA 10,000 10,000
111 SYIFA 2484763249 2 P VARICELA 10,000 10,000
112 VONI 285123791 37 P 27-May HIPOTENSI 10,000 10,000
113 LASTRI 285335291 33 P ALERGI 10,000 10,000
114 SYTUSRAINI 285335291 50 P ALERGI 10,000 10,000
115 GUSNETI 285178318 47 P ANXIETAS 10,000 10,000
116 Deni sagita 517000724 29 P Psokosomatis 10,000 10,000
117 Samsunidar 517030582 64 P Psokosomatis 10,000 10,000
118 Laylatul Rahmi 5170237754 16 P asma 10,000 10,000
119 Ayumi 285194891 19 P Ispa 10,000 10,000
120 alvian perdana zega 285506842 2 L 5/28/2013 Febris 10,000 10,000
121 Jefri tanjung 285655869 16 L OA 10,000 10,000
122 Harun 285285857 2 L askariasis 10,000 10,000
123 Agung Rizaldi 285285497 8 L Ispa 10,000 10,000
124 Desi Isrami 517031043 16 P Ispa 10,000 10,000
125 Rahmat Hidayat 285074142 9 L 29-May Ispa 10,000 10,000
126 Lioni Suherman 284820018 16 P Gastritis 10,000 10,000
127 Dwitami 284024428 2 P Dermatitis 10,000 10,000
128 Isnandi 284080274 27 L SAKIT GIGI 10,000 10,000
TOTAL 210,000 10000 40000 10000 260,000
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL DIAGNOSA PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD

JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

129 Dwi Fani Adinda 284204428 2 P 5/30/2013 Obs. Febris 10,000 10,000
130 Usma 517006901 75 P Chest pain 10,000 10,000
131 Yulfitri 284747084 37 P GE akut 10,000 10,000
132 Agusfi bujang 28718471 65 L 31-May OA 10,000 10,000
133 Alif 517019916 14 L Chepalgia 10,000 10,000
134 Ridho 585029251 5 L Ispa 10,000 10,000
135 Nursani 51719449 60 P RA 10,000 10,000
136 Muhazifa 284748726 5 P 4/27/2013 Febris 10,000 10,000
137 Novi 284357079 12 P Ispa 10,000 10,000
138 Rozi 284155718 17 L 4/29/2013 Gastritis 10,000 10,000
139 Nurma 517024471 58 P Gastritis 10,000 10,000
140 Yulia vera 285117039 60 L 4/30/2013 asma 10,000 10,000
141 Yosna olivia 284958599 31 P Mialgia 10,000 10,000
142 M.Nabil 279017141 6 L Alergi 10,000 10,000
143 Mainar 284750627 38 P 5/1/2013 Gastritis 10,000 10,000
144 Fatimah 285625754 6 P cabut 20,000 20,000
145 Fani fadillah 2837663308 2 P ILI 10,000 10,000
146 Ismawati 284855141 43 P 3-May Hamil 10,000 10,000
147 Tuti Indriani 2848211158 25 P 4-May Ispa 10,000 10,000
148 Fatmawati 28418344493 40 P 6-May Dermatitis 10,000 10,000
149 Murlizza 285070331 39 P Gastritis 10,000 10,000
150 Aqil Rahmat 284739862 5 L Ispa 10,000 10,000
151 Darlisma 284159294 57 P 7-May Gastritis 10,000 10,000
152 Rubama 284778696 37 P Gastritis 10,000 10,000
153 Wiwin 285055367 28 P 13-May Gastritis 10,000 10,000
154 Aini 284909466 28 P Ispa 10,000 10,000
TOTAL 240,000 20000 10000 270,000
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL DIAGNOSA PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD

JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

155 Ramadanil 284185765 25 L 15-May Febris 10,000 10,000


156 Voni pertiwi 517002928 20 P Febris 10,000 10,000
157 Nindi Oktantia 284583115 19 P 5/18/2013 Ispa 10,000 10,000
158 Fitri dewi 2844821168 29 P Ispa 10,000 10,000
159 Nurhadina 285662801 15 P Chepalgia 10,000 10,000
160 Zulmita adewi 5170227836 45 P herpes zoozter 10,000 10,000
161 Dea apriani 284481314 8 P 5/20/2013 Ispa 10,000 10,000
162 Yusron Fahroiri 284481178 15 L Ispa 10,000 10,000
163 Rawinas 284839907 43 P RA 10,000 10,000
164 Naila Maldina 285077531 2 P 24-May Obs. Febris 10,000 10,000
165 Risnawati 285077261 33 P Gastritis 10,000 10,000
166 Dea Ifanka 285077406 9 P sscabies 10,000 10,000
167 Ezi 517030391 14 L 29-Apr Ispa 10,000 10,000
168 Deni sagita 517000724 29 P Psokosomatis 10,000 10,000
169 Samsunidar 517030582 64 P 4/30/2013 Psokosomatis 10,000 10,000
170 Laylatul Rahmi 5170237754 16 P asma 10,000 10,000
171 Ayumi 285194891 19 P 3-May Ispa 10,000 10,000
172 Nazwa Athira 285517743 6 P Dermatitis 10,000 10,000
173 Putri Aisyah 285268836 6 P 7-May Gastritis 10,000 10,000
174 Mislimin 284920209 74 L Scabies 10,000 10,000
175 Kamaruddin 285517844 54 L 11-May Scabies 10,000 10,000
176 Mardianis 285517844 44 P Scabies 10,000 10,000
177 Raka Gustivono 285518318 16 L 5/14/2013 Abses 10,000 10,000
178 Dira dwi candra 285327549 8 P 5/16/2013 Abses 10,000 10,000
179 Risnawati 285517743 35 P KB 10,000 10,000
180 Gusneti 51702368 47 P 5/20/2013 Anxietas 10,000 10,000
TOTAL 240,000 0 20000 0 260,000
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL DIAGNOSA PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD

JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

181 M.Egadavid 284890070 2 L 20-May ispa 10000 10000


182 Yuhardi 517000585 17 L febris 10000 10000
183 Nuria Habib 284826003 15 P 5/22/2013 Asma 10,000 10000
184 Yul febria 285162659 11 P ispa 10,000 10000
185 Egi Ardianssyah 284806055 13 L 5/24/2013 luka lecat 10000 10000
186 Roslina 284890249 68 P Gastritis 10000 10000
187 Ismaldi 285076005 42 L Chepalgia 10,000 10000
188 Frandilis 284907108 10 L 26-May Varicella 10,000 10000
189 Oma Syatifa 284677089 2 P Febris 10000 10000
190 Irsyad 2840755860 10 L 29-Apr ispa 10,000 10000
191 Wira Yohana 284830398 11 P ispa 10,000 10000
192 Chika Andriani 517028343 11 P 2-May Febris 10,000 10000
193 M.akbar 285187920 5 L Inf luka 10000 10000
194 M.Irvan 285180557 12 L 6-May Gastritis 10000 10000
195 Yeni Puspita 517024541 30 P Alergi 10000 10000
196 Anisa suryani 518025735 18 P Hipotensi 10000 10000
197 Misrawati 517025935 28 P Ispa 10000 10000
198 Husni Lowe 284886080 65 P 7-May Ispa 10000 10000
199 Agusma 517008137 68 P Gastritis 10000 10000
200 erlina 279645996 44 P Asma 10000 10000
201 Resna 517007954 40 P 8-May GE akut 10000 10000
202 Abizar 517218491 67 L RA 10000 10000
203 Deni 284719364 4.5 L Caries 10000 10000
204 Rangga 2853736975 4 L 10-May Luka Infeksi 10000 10000
205 Delfitri 517005415 27 P Ispa 10000 10000
206 Salman 274646225 5 L Abses 10000 10000
TOTAL 200000 10000 40000 10,000 260000
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL DIAGNOSA PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD

JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

207 Fitri Handayani 284176272 17 P 11-May Gastritis 10,000 10000


208 Alkhri 284719891 40 L RA 10,000 10000
209 Zulkfli 284822208 35 L ispa 10,000 10000
210 Mitradewi 284822071 25 P 22-May Suntik 10000 10000
211 Resi alindra 284701009 31 P ispa 10,000 10000
212 Rendi jumadi 517040059 10 L Febris 10000 10000
213 Agil 284759702 5 L CC 10,000 10000
214 Sulastri 517038811 60 P 5/24/2013 Chepalgia 10,000 10000
215 Salma 284192004 46 P RA 10,000 10000
216 Yurisanti 284747009 37 P Febris 10,000 10000
217 Radil 285406154 3 L CC 10000 10000
218 Saydil 284917915 14 L 20-May Abses 10000 10000
219 Miftahul 284896066 2 P Diare 10000 10000
220 erlina 279645996 43 P Abses 10000 10000
221 Stevi 517005426 7 L Caries 10000 10000
222 Wasna 284791926 36 P 13-May Hamil 10,000 10000
223 Nuradila 285203114 32 P Hamil 10,000 10000
224 Salman 274646225 5 L Abses 10000 10000
225 Elfi 285123633 33 P Hamil 10,000 10000
226 Laaila 284918567 7 P 14-May Luka Infeksi 10000 10000
227 Aidal 285439746 3 L Scabies 10000 10000
228 Atika 289894896 16 P Luka Infeksi 10000 10000
229 Jumaidil 285289804 10 L 16-May Ispa 10000 10000
230 Deri 285505064 36 L Ispa 10000 10000
231 Rafka 285387298 3 L 5/18/2013 Ispa 10000 10000
232 Lidar 284589108 41 P Asma 10000 10000
TOTAL 170000 10000 80000 260000
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL DIAGNOSA PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD

JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

233 RENO S 285143275 19 L 20-May GASTRITIS 10,000 10000


234 YOLI S 284762913 18 L ISPA 10,000 10000
235 JELVIN F 284762913 14 L ISPA 10,000 10000
236 PONI P 285191807 18 P 22-May dermatitis 10,000 10000
237 MELANISA 285193798 22 P ISPA 10,000 10000
238 LIDARNIS 285187634 40 P ISPA 10,000 10000
239 RAHMAT 284758762 13 L 24-May CHEPALGIA 10,000 10000
240 AMILIANTI 285517967 11 P GASTRITIS 10,000 10000
241 ASWANDI 517001859 46 L 26-May KANKER 10,000 10000
242 Arini 517204697 7.5 P GE akut 10000 10000
243 LISMADERI 517021773 36 P Febris 10000 10000
TOTAL 110,000 110,000
TOTAL KESELURUHAN 2,465,000

DIKETAHUI PAYAKUMBUH, JUNI 2013


KEPALA PUSKESMAS TIAKAR PELAKSANA PROGRAM
dr.NETI HARTATI Desty amelia,A.Md Keb
19750316 200604 2 009 19820103 200501 2 004
RINCIAN KLAIM JAMKESMAS TAHUN 2013
PUSKESMAS TIAKAR BULAN JUNI
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

1 ERLINA 279645996 44 P 6/1/2013 DESMINORE 10,000 10,000


2 SITI HANA 279646176 9 P ISPA 10,000 10,000
3 YAZID 279664277 13 L ABSES 10,000 10,000
4 M ILHAM 285449139 9 L ISPA 10,000 10,000
5 LIDAR 2849498191 43 P ASMA 10,000 10,000
6 DANI 284133014 18 L INFS.KULIT 10,000 10,000
7 HERI 284816812 12 L ISPA 10,000 10,000
8 YOLA 981535956 5 P ISPA 10,000 10,000
9 YULIANIS 278093531 34 P MASTITIS 10,000 10,000
10 PUTRI 2815394893 3 P 6/3/2013 ISPA 10,000 10,000
11 YULTERA 285391113 35 P ISPA 10,000 10,000
12 SYAMSI 285434638 55 P dermatitis 10,000 10,000
13 SELVIA YENTI 284913382 4 P ISPA 10,000 10,000
14 REZA 285403206 16 P 6/4/2013 ISPA 10,000 10,000
15 M FARUL 279621966 4.5 L CC 10,000 10,000
16 NORIZA MELA 284836318 22 P ASMA 10,000 10,000
17 YULIANIS 278093531 30 P MASTITIS 10,000 10,000
18 ZULKIFLI 284803295 55 L INFS.KULIT 10,000 10,000
19 RATNA 987535743 19 P FARINGITIS 10,000 10,000
20 M SAFIQ 284826475 2.5 L ISPA 10,000 10,000
21 M ALIF 285383575 9 L ILI 10,000 10,000
22 YOPI 284807935 10 P ISPA 10,000 10,000
23 HERI 2796130909 13 L 6/5/2013 TONSILITIS 10,000 10,000
24 RAFQI 284912335 2.5 L CC 10,000 10,000
TOTAL 180,000 0 60000 0 0 240,000
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

25 ZAHRIAL 285340977 44 L 6/5/2013 ISPA 10,000 10,000


26 PUTRA 279630538 18 L 6/8/2013 ABSES 10,000 10,000
27 DERMI 285720333 45 P 6/10/2013 ISPA 10,000 10,000
28 WINA 278103921 25 P DYSPEPSIA 10,000 10,000
29 DESWITA 284830582 38 P ISPA 10,000 10,000
30 ANUGRAH 284833091 5 L ISPA 10,000 10,000
31 SENANG 284832404 7 P ISPA 10,000 10,000
32 RAFQI 284912335 2.5 L TONSILITIS 10000 10,000
33 KHALID 517040059 3 L URTIKARIA 10,000 10,000
34 KHAILA 285459658 4 P ISPA 10000 10,000
35 DELFITRI 987535631 28 P TINEA 10,000 10,000
36 FIRMAN 987535653 7 L ISPA 10,000 10,000
37 NENG 28548510991 38 P 6/11/2013 DYSPEPSIA 10,000 10,000
38 ZULKIFLI 284803299 55 L ISPA 10,000 10,000
39 ERLINDA 284900923 36 P ISK 10,000 10,000
40 DELFITRI 987535631 28 P FARINGITIS 10,000 10,000
41 HANI 284640291 12 P OMA 10,000 10,000
42 LIDAR 285797960 43 P FARINGITIS 10,000 10,000
43 RANGGA 278095400 5 L 6/12/2013 ABSES 10,000 10,000
44 KARIMA 284813493 16 P Gastritis 10,000 10,000
45 YULFERA 285391113 36 P ISPA 10,000 10,000
46 YEN 284739096 37 P FARINGITIS 10,000 10,000
47 YULIANIS 278093531 35 P Chepalgia 10,000 10,000
48 NAYRA 279030931 2 P 6/13/2013 CC 10000 10,000
49 DANI 285178816 18 P TONSILITIS 10,000 10,000
50 HANI 285406154 12 L TONSILITIS 10,000 10,000
TOTAL 220,000 0 40000 0 260,000
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL DIAGNOSA PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD

JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

51 DERMI 285389864 43 P 6/13/2013 KONJUNGTIVITIS 10,000 10,000


52 SINTIA 279655205 11 L 6/14/2013 ASMA 10,000 10,000
53 NILDAWATI 987535203 39 P Gastritis 10,000 10,000
54 RADIL 285406154 4 P LUKA 10000 10,000
55 SYAMSI 2848540048 50 P dermatitis 10,000 10,000
56 WIRNA LAILI 285460468 49 P 6/15/2013 MYALGIA 10,000 10,000
57 NILAM 279610755 9 P ISPA 10,000 10,000
58 M HABIL 279617121 6.5 L ISPA 10,000 10,000
59 NIRDAWATI 987535815 24 L FLORALBUS 10,000 10,000
60 ELFI 287456788 35 P 6/16/2013 CEPALGIA 10,000 10,000
61 WINANTA 284894166 22 L 6/17/2013 ABSES 10,000 10,000
62 YANTI 284718339 33 L CEPALGIA 10,000 10,000
63 SILVIA 284842236 12 P ISPA 10,000 10,000
64 YANTI 2847138339 36 P 6/18/2013 Gastritis 10,000 10,000
65 DENI 284719364 5 L ISPA 10,000 10,000
66 LAILA 284918567 7 L ISPA 10,000 10,000
67 HELDA 284802339 31 P TINEA 10,000 10,000
68 MELA 284836310 22 P ASMA 10,000 10,000
69 M JUSMAN 285385915 12 L ISPA 10,000 10,000
70 WASNI 28540034 52 P 6/20/2013 MYALGIA 10,000 10,000
71 LIDARNIS 284204621 43 P ASMA 10,000 10,000
72 AMRIL 285396619 45 P 6/22/2013 ISPA 10,000 10,000
73 ASNI 284909466 29 P 6/1/2013 ULTIKARIA 10,000 10,000
74 RIVAL 284145669 4.5 L VOMITUS 10,000 10,000
75 AISYAH 284143116 7 P Obs. Febris 10,000 10,000
76 NENI YULITA 284770078 32 P Ispa 10,000 10,000
TOTAL 240,000 0 20000 0 260,000
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL DIAGNOSA PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

77 INDRA LESMANA 2847700001 34 L 3-Jun Gastritis 10,000 10,000


78 RISKI GUSTI 284770708 8 L Gastritis 10,000 10,000
79 MAIYARLIS 987534617 41 P 6/8/2013 KB 10000 10,000
80 NURHAYATI 284833912 36 P HIPOTENSI 10,000 10,000
81 PARMI 285790044 25 P KB 10,000 10,000
82 SYAMSULIZAR 285646724 56 L Gastritis 10,000 10,000
83 WAHID RAHMANDA 285647062 11 L ispa 10000 10,000
84 ZAITUL ASNI 284901906 22 P 6/25/2013 KB 10000 10,000
85 MIRAWATI 285185182 28 P 6/1/2013 Gastritis 10,000 10,000
86 Yeni Puspita 285180557 32 P S KEPALA 10,000 10,000
87 RIKI ANTONI 27828943 25 L LUKA 10,000 10,000
88 GUSNETI 285178318 47 P 6/2/2013 ISPA 10000 10,000
89 ANWAR 285112809 37 L 6/12/2013 ASMA 10,000 10,000
90 NURBAYA 285219639 90 P ALERGI 10,000 10,000
91 NABILA 28543812 8 P 6/13/2013 DIARE 10,000 10,000
92 GUSNETI 285178318 47 P ANXIETAS 10,000 10,000
93 GUSNETI 285178318 47 L 6/23/2013 ANXIETAS 10,000 10,000
94 SYAMSINAR 285288006 70 P 1-Jun DEKUBITUS 10,000 10,000
95 RANDA 2848990559 27 L KOLIK ABDOMEN 10,000 10,000
96 M ADITYA 284923269 2 L 3-Jun CC 10,000 10,000
97 SAMSURILAS 284920694 68 P MYALGIA 10,000 10,000
98 TUSRAINI 285335291 48 P KB 10,000 10,000
99 URNIATI 24758301 36 P 6-Jun ISPA 10,000 10,000
100 BIMA P 285343659 4 L FARINGITIS 10000 10,000
101 ILHAM 285338147 7 L 7-Jun LUKA 10,000 10,000
102 ELFI M 28529869 49 P 8-Jun CC 10,000 10,000
TOTAL 190,000 0 50000 20000 260,000
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL DIAGNOSA PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD

JAMKESMAS ( THN ) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

103 NURMAWATI 285343209 36 P 6/8/2013 HIPOTENSI 10,000 10,000


104 BETRIA S 285525753 24 P 10-Jun DEKUBITUS 10,000 10,000
105 SYAMSINAR 285288006 66 P 11-Jun KOLIK ABDOMEN 10,000 10,000
106 YUSNIMAR 285286959 39 P KB 10,000 10,000
107 HILDA LINI 285329349 36 P 6/13/2013 KB 10,000 10,000
108 MAYA MENJEL 284910557 29 P LUKA 10,000 10,000
109 IFRAYANTO 285341927 36 L 17-Jun ISPA 10,000 10,000
110 ETI YULIA 285280694 36 P ISPA 10,000 10,000
111 MAYA MENJEL 284910559 29 P HIPOTENSI 10,000 10,000
112 ILHAM 285338147 7 L 18-Jun MYALGIA 10,000 10,000
113 REFNITA 285510723 42 P 6/19/2013 KB 10,000 10,000
114 JENITA 284916407 23 P ABSES 10,000 10,000
115 JENITA 284916407 23 P 21-Jun ISPA 10,000 10,000
116 AGUNG 285285497 9 L ISPA 10,000 10,000
117 NUR EFENDI 284895281 29 L LUKA 10,000 10,000
118 SALMA 285493059 11 P 22-Jun Ispa 10,000 10,000
119 M YUSUF 28522339 9 L GE akut 10,000 10,000
120 Nazwa Athira 285517743 6 P HT 10,000 10,000
121 ARDIN P 285333243 31 L 25-Jun Gastritis 10,000 10,000

122 NURSYAMSI 28528459 37 P ispa 10,000 10,000

123 DAHLELI 285503163 36 P 27-Jun Gastritis 10,000 10,000

124 RANI 2853295553 20 P 6/28/2013 ispa 10,000 10,000


125 YUSNIMAR 285286959 39 P ispa 10,000 10,000
126 RINI AFRIANTI 285333399 25 P 29-Jun KB 10,000 10,000
127 Ramadanil 284790194 18 P 1-Jun Dermatitis 10,000 10,000
128 WENI YULIANA 285588437 15 P SAKIT GIGI 10,000 10,000
TOTAL 200,000 10000 50000 10000 260,000
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL DIAGNOSA PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

129 QAINAL 284212258 32 P 6/3/2013 Obs. Febris 10,000 10,000


130 RINI MUKHTAR 284881189 34 P Chest pain 10,000 10,000
131 ASNAT 284814516 39 P GE akut 10,000 10,000
132 EMA SEPTIANA 284779934 45 P OA 10,000 10,000
133 SUHARDI 285012345 72 P Chepalgia 10,000 10,000
134 FATIMAH 279625228 71 P Ispa 10,000 10,000
135 OKTA 287512367 30 P RA 10,000 10,000
136 MUTIA 987534988 7 P Febris 10,000 10,000
137 M FERRY 284980654 12 L Ispa 10,000 10,000
138 MITRA DEWI 284822178 17 P Gastritis 10,000 10,000
139 SOFIA ENA 517029457 49 P Gastritis 10,000 10,000
140 ASRIL 28488929 53 L 6/4/2013 asma 10,000 10,000
141 ASWAD 28588051 45 P Mialgia 10,000 10,000
142 ADI CHANDRA 28477550 43 P Alergi 10,000 10,000
143 Ramadanil 284791194 18 P Gastritis 10,000 10,000
144 BUJANG 987535102 54 L 5-Jun cabut 20,000 20,000
145 ILHAM 285110098 6 P ILI 10,000 10,000
146 MUDANAR 285154218 71 P Hamil 10,000 10,000
147 ROSTIAN 286571496 71 P Ispa 10,000 10,000
148 AZIMATUL ZAHRA 285061274 55 P 7-Jun Dermatitis 10,000 10,000
149 JUMADI 149/11.05/0413 37 P Gastritis 10,000 10,000
150 SRI HANDAYANI 284154524 9 P Ispa 10,000 10,000
151 MAULUSI 284887664 43 L Gastritis 10,000 10,000
152 INDRA D 285656962 33 P Gastritis 10,000 10,000
153 AMELIA K 285284157 33 P Gastritis 10,000 10,000
154 Nuria Habib 2848260003 5.5 P Ispa 10,000 10,000
TOTAL 240,000 20000 10000 270,000
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL DIAGNOSA PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD

JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

155 NOVIA ERITA 285503624 25 P 7-Jun Febris 10,000 10,000


156 YULIANIS 28198906 38 P 8-Jun Febris 10,000 10,000
157 MHD RAMADAN 987535056 6 L Ispa 10,000 10,000
158 AFRIA N 284769404 30 P Ispa 10,000 10,000
159 RESMA N 285143275 44 P Chepalgia 10,000 10,000
160 YUSNIMAR 284717191 67 P 10-Jun herpes zoozter 10,000 10,000
161 ISRIL 279217791 48 L Ispa 10,000 10,000
162 YULIA 284811783 36 P Ispa 10,000 10,000
163 YURNALIS 285503297 50 P RA 10,000 10,000
164 LELINEL 284723548 51 P Obs. Febris 10,000 10,000
165 SUHAIDI 285117482 10 L Gastritis 10,000 10,000
166 PRIHATI NINGSIH 285657979 26 P 11-Jun sscabies 10,000 10,000
167 DAWAN NURPADI 284842157 23 L Ispa 10,000 10,000
168 SURTINI 284841911 38 P Psokosomatis 10,000 10,000
169 SYAFRIAL 285159879 45 P Psokosomatis 10,000 10,000
170 SYAFA 285597309 40 L asma 10,000 10,000
171 NURNILA 517027078 53 P Ispa 10,000 10,000
172 OYON 28562554 42 L Dermatitis 10,000 10,000
173 KHAILA 285459658 4 P Gastritis 10,000 10,000
174 RANDI 285458872 9 L Scabies 10,000 10,000
175 ANFI 285646443 4.5 P Scabies 10,000 10,000
176 MIRAWATI 284784801 52 P Scabies 10,000 10,000
177 NABILA 284755858 28 P 6/13/2013 Abses 10,000 10,000
178 PUTRI RAHAYU 28512209 21 P Abses 10,000 10,000
179 AZIMATUL ZAHRA 285061274 3 P KB 10,000 10,000
180 HAIKAL YASIR 285457893 3 L 6/14/2013 Anxietas 10,000 10,000
TOTAL 240,000 0 20000 0 260,000
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL DIAGNOSA PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD

JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

181 MULIA HAFRIDA 285457375 31 P 14-Jun ispa 10000 10000


182 OSNITA 285719231 35 P febris 10000 10000
183 SYAMSURIZAL 2856466724 60 L 6/15/2013 Asma 10,000 10000
184 HANIFAH 284845948 12 P ispa 10,000 10000
185 ASNAR 284880516 1 L 6/17/2013 luka lecat 10000 10000
186 AMELIA K 285051165 30 P Gastritis 10000 10000
187 AFNAR 285199305 46 P Chepalgia 10,000 10000
188 ELFI S 284906136 38 P Varicella 10,000 10000
189 TRI 284904785 65 P Febris 10000 10000
190 BETI 2827964955 36 P ispa 10,000 10000
191 ISMAIL 285270857 41 L ispa 10,000 10000
192 INGMA 2856976758 40 P Febris 10,000 10000
193 FANI FADILA 283766308 2 P 18-Jun Inf luka 10000 10000
194 RIANA 278904979 17 L Gastritis 10000 10000
195 NIC0 285119582 25 L Alergi 10000 10000
196 RIVAL JUNAIDI 987559855 13 L Hipotensi 10000 10000

197 ARNA 284234178 37 L Ispa 10000 10000


198 INDRAVAL 279091511 45 P Ispa 10000 10000
199 RIVAL 282756788 17 L Gastritis 10000 10000
200 ZULKIFLI 289834567 44 L Asma 10000 10000
201 SESMARENI 284720769 18 P GE akut 10000 10000

202 ASEP SAPUTRA 285470932 8 L 20-Jun RA 10000 10000

203 USMAN 284141957 34 L Caries 10000 10000


204 RAHAYU 285192557 45 P Luka Infeksi 10000 10000
205 RAFI ANUGRAH 285115958 3 L Ispa 10000 10000
206 ZULKARNA 284894291 23 L Abses 10000 10000
TOTAL 200000 10000 40000 10,000 260000
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL DIAGNOSA PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD

JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

207 WINAL 284211567 32 P 20-Jun Gastritis 10,000 10000


208 PUTRI S 284910750 5 P RA 10,000 10000
209 ARNA 285194158 49 P ispa 10,000 10000
210 BUYUNG 987535102 34 L Suntik 10000 10000
211 KHAIRUL 285603884 48 P 22-Jun ispa 10,000 10000
212 HAFID 285637779 5 P Febris 10000 10000
213 DARISNA 284159291 59 P 24-Jun CC 10,000 10000
214 RENI SUFITRI 289910061 30 P Chepalgia 10,000 10000
215 PUTRI 28491755 5 P RA 10,000 10000
216 SUSI O 285298007 29 P Febris 10,000 10000
217 WINA A 278103971 25 P CC 10000 10000
218 ARIF 285678489 7 L Abses 10000 10000
219 GUSNIAL 2848235674 43 P Diare 10000 10000
220 JONI U 284823568 45 L Abses 10000 10000
221 SUCI 284856142 8 P Caries 10000 10000
222 RIVAL 987534287 17 L Hamil 10,000 10000
223 BUYUNG 284189076 70 L Hamil 10,000 10000
224 AFNA N 284769904 30 P Abses 10000 10000
225 NINGSIH 287908765 33 P Hamil 10,000 10000
226 FADI 517067748 11 L Luka Infeksi 10000 10000
227 LUSI 517004417 21 P 25-Jun Scabies 10000 10000
228 M ARIFIN 284824866 7 L Luka Infeksi 10000 10000
229 SERASI 285095347 42 P Ispa 10000 10000
230 RAHMAD 205162567 9 L Ispa 10000 10000
231 M TULIP 285205887 6 L Ispa 10000 10000
232 LELI K 284855059 45 P Asma 10000 10000
TOTAL 170000 10000 80000 260000
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL DIAGNOSA PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD

JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

233 KHAIRUL 285603885 49 L 25-Jun Gastritis 10,000 10000


234 ROSHID 284760044 7 P 26-Jun RA 10,000 10000
235 IGMA DESWAL 286775897 44 P ispa 10,000 10000
236 HANIFAH 289845998 1 L Suntik 10000 10000
237 WAHIUD 285647062 11 L ispa 10,000 10000
238 LEHAIR 287029876 57 L Febris 10000 10000
239 LASTRI 285123791 33 P CC 10,000 10000
240 CHANAYANG 285217219 27 P Chepalgia 10,000 10000
241 NORI S 517029589 17 P RA 10,000 10000
242 IKHSAN H 3760312005 8 L Febris 10,000 10000
243 OSNITA 285719231 35 P 27-Jun CC 10000 10000
244 Ramadanil 284826074 9 L Abses 10000 10000
245 MUHARI 279650258 10 P Diare 10000 10000
246 JUICE 279651381 43 P Abses 10000 10000
247 ANDRISAH 285660797 46 L Caries 10000 10000
248 M EBAR 284996788 3 L Hamil 10,000 10000
249 NUSID 284708765 7 L Hamil 10,000 10000
250 EPI S 284854184 33 P 28-Jun Abses 10000 10000
251 EDI S 28565394 46 P Hamil 10,000 10000
252 WIWIT 285505064 30 P Luka Infeksi 10000 10000
253 NOVILA D 284899709 20 P Scabies 10000 10000
254 RAFI AHMAD 284900534 2 P Luka Infeksi 10000 10000

255 HENGKI 284165414 35 L Ispa 10000 10000


256 ROZI S 284355718 17 L Ispa 10000 10000
257 RAPI BAKBAR 284357079 11 L Ispa 10000 10000
258 BURSINA 284151299 60 P 29-Jun Asma 10000 10000
TOTAL 170000 10000 80000 260000
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL DIAGNOSA PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD

JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

259 SYAFA 285598178 37 P 29-Jun Gastritis 10,000 10000


260 GUSNETI 285178318 48 P RA 10,000 10000

TOTAL 20,000 20,000

TOTAL KESELURUHAN 2,610,000

DIKETAHUI PAYAKUMBUH, JUNI 2013

KEPALA PUSKESMAS TIAKAR PELAKSANA PROGRAM

dr.NETI HARTATI Desty amelia,A.Md Keb

19750316 200604 2 009 19820103 200501 2 004


RINCIAN KLAIM JAMKESMAS TAHUN 2013
PUSKESMAS TIAKAR BULAN JULI
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

1 GUSNETI 285178318 48 P 7/1/2013 ISPA 10,000 10,000


2 ADI S 28652394 47 L CABUT GIGI PERMANEN 20,000 20,000
3 RESMA 285143275 44 L RA 10,000 10,000
4 ADITYA 285143804 10 L CABUT GIGI SUSU 10,000 10,000
5 EMI OKTAVIA 987534966 33 P OBS FEBRIS 10,000 10,000
6 MUTIA AULIA 987534988 7 P ISPA 10,000 10,000
7 REHAN FADILA 284763058 8 L GASTRITIS 10,000 10,000
8 MARINA 517006664 20 P Dermatitis 10,000 10,000
9 MUDAWIR 285154211 85 L CHEPALGIA 10,000 10,000
10 RAFI AHMAD 284900534 2 L ISPA 10,000 10,000
11 YUDELMI 284770495 11 P CABUT GIGI SUSU 10,000 10000
12 DARIUS 298755541 57 L GASTRITIS 10,000 10,000
13 ANDYAN P 789207477 12 L MALAISE 10,000 10,000
14 KEYLA 284749545 32 P ISPA 10,000 10,000
15 DHINAR 284719149 73 P GASTRITIS 10,000 10,000
16 ZULNADE 284205249 50 P ISPA 10,000 10,000
17 YEN FITRI 284751723 31 P ISPA 10,000 10,000
18 M SYAFRIL 285221452 20 P 7/2/2013 OBS FEBRIS 10,000 10,000
19 M DIKO RIVAKO 2856276033 12 P TV 10,000 10000
20 RAMAYULIS 284210256 30 P ISPA 10,000 10,000
21 DARMAWATI 285436967 29 P ISPA 10,000 10,000
22 YULDALITA 284831943 35 P ISPA 10,000 10,000
23 RICO MONIKA 285626901 16 P CHEPALGIA 10,000 10,000
TOTAL 190,000 40000 0 10000 240,000
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

24 FATIMAH ZAHRA 285628754 6 P 7/2/2013 Dispepsia 10,000 10,000


25 ASNUR 284836656 45 P 7/3/2013 Gastritis 10,000 10,000
26 WASNA 288448408 36 P Gastritis 10,000 10,000
27 M.IRFAN 284813585 9 L Dispepsia 10,000 10,000
28 WAHYU YULINA 284812762 5 L Susp OMA 10,000 10,000
29 FAUZI 285719231 45 L Mialgia 10,000 10,000
30 ANDIKA P 285311013 28 L Scabies 10,000 10,000
31 ROZI SAPUTRA 284355718 17 L Ispa 10,000 10,000
32 RANGGA SETIA 285457555 7 L Ispa 10,000 10,000
33 HAIKAL YASIR 285457893 3 L OA 10,000 10000
34 RISA M 284861632 4 L Dermatitis 10,000 10000
35 YANDI K 2848195145 37 L Chepalgia 10,000 10,000
36 FUSRA NURIYA 284141205 10 P 7/4/2013 DM+Hipertiroid 10,000 10,000
37 MUCHTAR AFANDI 284211617 35 L Psokosomatis 10,000 10,000
38 EKI SUSANTI 2879664249 32 L Psokosomatis 10,000 10,000
39 DENI MAYASARI 2851204387 21 L cbt gigi tetap 10,000 10,000
40 RANTI 285149819 17 P Ispa 10,000 10,000
41 MITRA DEWI 284801673 24 P 7/5/2013 Mialgia 10,000 10,000
42 MURNI LENEN 285009913 50 P Tambal 10,000 10,000
43 RIVAL 284326263 9 L Chepalgia 10,000 10,000
44 ADE KURMA 286547897 19 L Mialgia 10,000 10,000
45 DASRISAL 287535102 47 L 7/6/2013 Asma 10,000 10,000
46 MURNIATI 284825081 32 P Hipotensi 10,000 10,000
47 SARNISIH 299677068 60 L ISPA 10,000 10,000
48 DIAN 284837471 17 P ISPA 10,000 10,000
TOTAL 230,000 20000 250,000
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

49 ELVI S 279624249 78 P 7/8/2013 MYALGIA 10,000 10,000


50 SUNARSIH 279677068 60 P GASTRITIS 10,000 10,000
51 IDA BUNDA 284840896 35 P KB 10,000 10,000
52 FAUZI ANA 284374423 8 L S,KEPALA 10,000 10,000
53 DESMAINAR 285121822 50 P VARICELA 10,000 10,000
54 YUNI 284737792 67 P VARICELA 10,000 10,000
55 M MUNIR 299077020 62 L CABUT GIGI PERMANEN 20,000 20,000
56 GISKA 285746142 24 P ISPA 10,000 10,000
57 M FAUZAN 289218742 4 L 7/9/2013 VARICELA 10,000 10000
58 ANDIKA P 289202472 13 L HIPOTENSI 10,000 10,000
59 KAIRUL 285281857 2 L ALERGI 10,000 10000
60 RENI NADIR 285185091 37 P ALERGI 10,000 10,000
61 KHAIRUL 285281857 49 L 7/10/2013 ANXIETAS 10,000 10,000
62 YUSLA 283456234 5 P ISPA 10,000 10000
63 MUCHTAR 284895285 61 L ISPA 10,000 10,000
64 M TAHER 285159211 77 P PARINGITIS 10,000 10,000
65 DAWAN NURFADLI 2824842157 35 L ANEMIA 10,000 10,000
66 RANI SAFITRI 285059812 17 P DIARE 10,000 10,000
67 MAL ANSHOR 285060363 11 L GASTRITIS 10,000 10,000
68 ASNA 2847694048 32 P 7/11/2013 ISPA 10,000 10,000
69 ASNIWAT 284818980 46 P ISPA 10,000 10,000
70 SUNARDI 279677068 60 P ARTRITIS 10,000 10,000
71 RONI 284359489 3 L Ispa 10,000 10000
72 PUJA 284912759 5 P CC 10,000 10000
73 ELVI YENTI 285402464 37 P Ispa 10,000 10,000
TOTAL 190,000 20000 50000 260,000
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

74 REZA AVIAN 285403202 16 P 7/11/2013 ispa 10,000 10,000


75 YUKA 284811783 32 P 7/12/2013 RA 10,000 10,000
76 MULYANI 285747104 6 P Gastritis 10,000 10,000
77 EDO SEPTO 285746679 10 L RA 10,000 10,000
78 ELVI 2841751587 61 P ispa 10,000 10,000
79 WASNA 285448408 41 P Chepalgia 10,000 10,000
80 BUDI 284532167 38 L Dyspepsia 10,000 10,000
81 FITRI HANDAYANI 284176570 17 P 7/13/2013 Vertigo 10,000 10,000
82 M NUR 284839912 42 L 7/15/2013 Asma 10,000 10,000
83 NURHASANAH 285228901 5 P TAMBAL SEMENTARA 10,000 10000
84 DASRISAL 287535012 57 L Febris 10,000 10,000
85 DEWI MAYA 285122643 21 P Febris 10,000 10,000
86 M HAJIR 285757683 19 L TAMBAL SEMENTARA 10,000 10,000
87 REFNALILA 285662744 29 L 7/16/2013 ispa 10,000 10,000
88 YUSNA 284172759 48 P CC 10,000 10,000
89 RAKA 284144747 6 L Gastritis 10,000 10,000
90 PRIHATI N 285037591 26 P Chepalgia 10,000 10,000
91 SYAFWAN 285591369 39 P Stomatitis 10,000 10,000
92 DESMANIAR 285121822 50 P DM 10,000 10,000
93 ANDHIKA S 28489645 10 L 7/17/2013 CC 10,000 10,000
94 ERNAWATI 284896945 38 P ispa 10,000 10,000
95 FITRI RAMADANI 284898216 32 P Asma 10,000 10,000
96 AMELIA KRISTIANTI 284755803 33 P Gastritis 10,000 10,000
97 SYAFIRA R 285284057 11 P Gastritis 10,000 10,000
98 SYAMSIDAR 285284092 70 P Vertigo 10,000 10,000
TOTAL 230,000 20000 0 250,000
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

99 AINI DWI PUTRI 284779124 6 P 7/17/2013 dermatitis 10,000 10,000


100 KHAIRUL 517028826 51 L 7/18/2013 INFKS KULIT 10,000 10,000
101 WARNETI 284727519 57 P 7/19/2013 CC 10,000 10,000
102 IRNA IRAWATI 285726587 18 P RA 10,000 10,000
103 MUTIA 287534980 7 P dermatitis 10,000 10,000
104 MUTI 284857848 12 P ISPA 10,000 10,000
105 ZULKIFLI 284822008 36 L TINEA 10,000 10,000
106 FAJAR 284175023 10 L 7/20/2013 GE 10,000 10,000
107 MASNI 284807755 45 P ABSES 10,000 10,000
108 FITRIA 517027869 19 P ISPA 10,000 10,000
109 NURASNA 285645643 20 P GE 10,000 10,000
110 REKI TERHAN 284781936 16 L Chepalgia 10,000 10,000
111 ZULKARNAEN 28489929 51 L anemia 10,000 10,000
112 USMAN 284141957 81 P HT 10,000 10,000
113 YOGA 285722199 57 L Gastritis 10,000 10,000
114 SYAMSUAR 28565157 41 L Febris 10,000 10,000
115 NURHASNA 285228902 5 P Febris 10,000 10000
116 ROZI SAPUTRA 284355718 27 L Gastritis 10,000 10,000
117 ERNITA 284355221 50 P Ispa 10,000 10,000
118 ASNIMAR 284814881 46 P Ispa 10,000 10,000
119 LAYLA 28509676 8 P CC 10,000 10,000
120 M IQBAL 284751788 11 P CC 10,000 10,000
121 RAMADANI 284790194 18 P CC 10,000 10,000
122 DELMI 285077407 20 P Ispa 10,000 10,000
123 NURAINMI 284099779 19 P 7/23/2013 ispa 10,000 10,000
TOTAL 240,000 10000 250,000
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

124 OSRA 285625326 42 L 7/23/2013 Chepalgia 10,000 10,000


125 ANGGI 284194706 14 L Gastritis 10,000 10,000
126 YULISMAR 285440433 62 P tambah obat 10,000 10,000
127 RUSNI ARIFIN 284199321 66 P Ispa 10,000 10,000
128 MAWARDI 287553489 43 L 7/24/2013 Psokosomatis 10,000 10,000
129 YUDI FERNANDI 285162265 11 L Gastritis 10,000 10,000
130 FASNI MANDALA 289175022 10 L Ispa 10,000 10,000
131 YODALITA 28983194 46 P Obs. Febris 10,000 10,000
132 DELIA 284160912 33 L 7/25/2013 Vulnus dgn inf 10,000 10,000
133 NURISNI 285125253 47 P Alergi 10,000 10,000
134 ALIYA 285095589 9 P Gastritis 10,000 10,000
135 ASNI S 284897867 8 P Chepalgia 10,000 10,000
136 ERNAWATI 285096699 46 P anemia 10,000 10,000
137 MUHADI 270646795 43 L HT 10,000 10,000
138 ROSMANIDAR 284373393 80 P Gastritis 10,000 10,000
139 RIRIN K 284373393 17 P Febris 10,000 10,000
140 RATIUS 285672789 68 L 7/26/2013 Febris 10,000 10,000
141 CHINTIA 285616916 6 P Gastritis 10,000 10,000
142 ALAN 285601195 13 L Ispa 10,000 10,000
143 MULIADI 284839233 43 L Ispa 10,000 10,000
144 ROSMANETI 285683949 34 P CC 10,000 10,000
145 SURADI 284861608 45 L CC 10,000 10,000
146 JONI ISWANDI 284855848 12 P CC 10,000 10,000
147 NEFI IRKAT 285648847 32 P 7/27/2013 Ispa 10,000 10,000
148 SEPTIMAN 284821098 38 L CC 10,000 10,000
TOTAL 240,000 10000 250,000
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

149 HENGKI 284165414 34 L 7/27/2013 HYPERTIROID 10,000 10,000


150 SILVIA 284809449 15 P ISPA 10,000 10,000
151 MITRA WATI 284868527 38 P TONSILITIS 10,000 10,000
152 ADE WAHYUDI 284790791 12 L CARSINOMA 10,000 10,000
153 MITRA 284789801 52 P ISPA 10,000 10,000
154 NURIAH HABIBULAH 284826003 5 L DIDPEPSIA 10,000 10000
155 IGMA SIWA 285177858 49 P OBS FEBRIS 10,000 10,000
156 SAMSIDAR 284135567 71 P TINEA KRONIS 10,000 10,000
157 ANI 284897867 8 P 7/29/2013 LUKA 10,000 10000
158 ADO R 285317793 17 L ISPA 10,000 10,000
159 BEBALIA S 284920986 34 P ISPA 10,000 10,000
160 NUR ASNI 285125153 46 P OBS FEBRIS 10,000 10,000
161 KELI M 285283679 35 P GASTRITIS 10,000 10,000
162 HARUN 285185857 62 L TV 10,000 10000
163 BETRIA S 285525753 39 P HT 10,000 10,000
164 MULIADI 284839733 43 L RA 10,000 10,000
165 OKVIA 285606999 14 P 7/30/2013 ISPA 10,000 10,000
166 KAYLA 285095676 6 P ISPA 10,000 10,000
167 JANIA 285620264 80 P RA 10,000 10000
168 NUR 284855891 12 P 7/31/2013 Ispa 10,000 10,000
169 HAYATUL 284859118 13 P CC 10,000 10,000
170 RINGGA 283423564 26 P Ispa 10,000 10,000
171 NATIUS 285671798 75 P RA 10,000 10,000
172 TUTI INDRIANI 284821558 26 P 7/4/2013 KB 10,000 10000
173 WITRA 284133014 36 P 7/11/2013 ISPA 10,000 10,000
TOTAL 210,000 0 20000 20000 250,000
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

174 MULNAWATI 284725214 32 P 7/11/2013 ISPA 10,000 10,000


175 HAFIZA A 284725438 3 P ISPA 10,000 10,000
176 ROSNAWATI 285077261 34 P 7/13/2013 GASTRITIS 10,000 10,000
177 ERMAN 284880947 42 L 7/15/2013 GASTRITIS 10,000 10,000
178 ERMAYULIS 284705739 53 P HIPOTENSI 10,000 10,000
179 ERDIMAN 284705605 55 L ALERGI 10,000 10,000
180 PUTRI 285086338 7 P 7/17/2013 ISPA 10,000 10,000
181 RANGGA 285086619 3 L PNEOMONI 10,000 10000
182 NOFIA 285086136 9 P ISPA 10,000 10,000
183 WIWIN 285054985 29 P 7/18/2013 CC 10,000 10,000
184 M FADIL 284473288 12 L 7/2/2013 LUKA 10,000 10,000
185 JAFRI 285109211 50 L ISPA 10,000 10,000
186 GUSNETI 285178318 47 P ANXIETAS 10,000 10,000
187 FITRAWATI 285196959 38 P GASTRITIS 10,000 10,000
188 YANI P 285118997 33 P GASTRITIS 10,000 10,000
189 ANNISA 285143275 18 P 7/5/2013 LUKA 10,000 10000
190 M FADIL 284473588 12 L LUKA 10,000 10000
191 BENI RISKI 285127064 27 L ILI 10,000 10,000
192 IFIT F 285127481 26 P 7/8/2013 ALERGI 10,000 10,000
193 HENGKI 284758727 37 L 7/10/2013 RA 10,000 10,000
194 MIRAWATI 285185182 29 P CHEPALGIA 10,000 10,000
195 JOAN IBNU 285186429 6 L 7/12/2013 ISPA 10,000 10,000
196 GUSNETI 285178318 47 P 7/16/2013 ANXIETAS 10,000 10,000
197 RAJA P 285123633 39 L RA 10,000 10,000
198 NURASNI 285125253 47 P GASTRITIS 10,000 10,000
TOTAL 220,000 10000 20000 250,000
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

199 GUSNETI 285178318 47 P 7/22/2013 ANXIETAS 10,000 10,000


200 FIRDAUS AKMAL 285173573 12 L LUKA 10,000 10000
201 RANGGI ARDI 284893255 32 L 7/1/2013 TONSILITIS 10,000 10,000
202 OKTRIYA 284893317 30 P CANDIDA 10,000 10,000
203 ABD aziz 285523119 4 L 7/2/2013 ISPA 10,000 10000
204 gazali 285495129 53 L CARIES 10,000 10000
205 m saddam 285511465 17 L CC 10,000 10,000
206 KAMANTARAJO 285226244 70 L FARINGITIS 10,000 10,000
207 RUSMAN 285217975 62 L 7/3/2013 HYPERCOLESTEROL 10,000 10,000
208 MAYA MANJEL 284910557 27 P GASTRITIS 10,000 10,000
209 JOHANES 285526754 5 L FARINGITIS 10,000 10000
210 MARTIUS 285531772 37 L 7/4/2013 TV 10,000 10000
211 JUSWITA 285532569 31 P CANDIDA 10,000 10,000
212 SYOFIANTI 285349882 33 P CARIES 10,000 10,000
213 CAHYA 285567966 10 P 7/5/2013 CC 10,000 10,000
214 M ZIKRI 285165112 4 L 7/6/2013 CC 10,000 10000
215 SYAMSINAR 285288006 66 L DEKUBITUS 10,000 10,000
216 BAMBANG HADI 285248441 15 L CC 10,000 10,000
217 DANUN 285347395 65 L 7/8/2013 DERMATITIS 10,000 10,000
218 MUKHLIS 285334615 65 L CC 10,000 10,000
219 M AFDAL 285333592 3 L 7/9/2013 PAROTITIS 10,000 10000
220 RISWAN 285329722 37 L TV 10,000 10000
221 SRI ARINDA 285323984 27 P FARINGITIS 10,000 10,000
222 AGUSNI 285331318 19 P 7/10/2013 HEATING OFF 10,000 10000
223 AGUS 285264707 53 L LUKA 10,000 10000
TOTAL 150,000 10000 40000 50000 250,000
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

224 YONNI M 285332422 41 L 7/10/2013 ISPA 10,000 10,000


225 RIONTIKA P 285326965 20 L 7/11/2013 CC 10,000 10,000
226 ISMAWARLIS 285265179 49 P 7/13/2013 RA 10,000 10,000
227 ALI ARSYAD 285261827 62 L 7/15/2013 DERMATITIS 10,000 10,000
228 FEMILIA 285263548 8 P TONSILITIS 10,000 10,000
229 DESWITA 28588906 34 P GASTRITIS 10,000 10,000
230 FIRMAN HIDAYAT 2853344334 9 L LUKA 10,000 10000
231 BOY SANDI 285266995 19 L 7/16/2013 TINEA 10,000 10,000
232 NURANIN 285254392 51 P 7/17/2013 DERMATITIS 10,000 10,000
233 LADY 285279039 5 P FARINGITIS 10,000 10,000
234 RISWAN 285329722 42 L TV 10,000 10000
235 AFRIZAL 285279941 45 L 7/18/2013 CC 10,000 10,000
236 YASLIMAN 285274449 50 L CC 10,000 10,000
237 AGUS 285264707 53 L TV 10,000 10000
238 FIRMAN HIDAYAT 285334334 9 L 7/19/2013 TV 10,000 10000

239 MAYA MANJEL 284910557 27 P GASTRITIS 10,000 10,000

240 MAHENI 285313432 51 P 7/20/2013 CONJUNGTIVITIS 10,000 10,000

241 ELVY S 284906136 38 P HYPOTENSI 10,000 10,000

242 NINA A 285522862 30 P 7/21/2013 KB 10,000 10000

243 BIMA 28543659 4.5 L DERMATITIS 10,000 10,000

244 SISKA M 285522862 27 P DERMATITIS 10,000 10,000

245 MULYANA 285223166 37 P 7/22/2013 KB 10,000 10000

246 NURDESMERI 285510295 34 P KB 10,000 10000

247 AGUS 285365078 53 L TV 10,000 10000


248 YONNI M 285332422 41 L 7/24/2013 ISPA 10,000 10,000

TOTAL 170,000 30000 50000 250,000


NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

249 FIRMAN HIDAYAT 285334334 9.5 L 7/24/2013 TV 10,000 10000


250 YENDRAWATI 285345011 32 P 25-Jul KB 10,000 10000
251 BOY SANDI 285260995 19 L ISPA 10,000 10,000
252 NURBAYANIS 285262121 42 P GASTRITIS 10,000 10,000
253 RESTI 285531737 9 P 26-Jul FARINGITIS 10,000 10,000
254 IFRAYANTO 285341927 34 L LUKA 10,000 10000
255 YUSNIMAR 285286959 39 P GASTRITIS 10,000 10,000
256 NURSYAMSI 285282459 37 P MYALGIA 10,000 10,000
257 ROSNIARTI 285513614 37 P TINEA 10,000 10,000
258 SILVIA 285507819 30 P KB 10,000 10000
259 SARI OJI 287654987 63 P 22-Jun RA 10,000 10,000
260 ELFI 282345123 35 P 24-Jun ISPA 10,000 10,000
261 YURI 284912425 23 P 25-Jun ABSES 10,000 10,000
262 AMRILO Y 285389291 45 L FARINGITIS 10,000 10,000
263 EDI H 285645327 38 L GASTRITIS 10,000 10,000
264 JELVIN 283421235 15 L DERMATITIS 10,000 10,000
265 YANTI 2845327765 27 P 27-Jun ISK 10,000 10,000
266 ELFI 285231543 33 P ISPA 10,000 10,000
267 LEDYA 285763421 30 P ISPA 10,000 10,000
268 WASNA 285438764 35 P ISPA 10,000 10,000
269 LIDARNIS 282156433 43 P 1-Jul CARIES 10,000 10,000
270 REFAN ARYUDI 285392801 9 L FARINGITIS 10,000 10,000
271 YULFERA 285391113 35 P CARIES 10,000 10,000
272 FAISAL 285444382 7 L ISPA 10,000 10,000
273 NURBAITI 286744532 75 P HT 10,000 10,000
TOTAL 210,000 20000 20,000 250,000
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

274 ERLINA 279645996 44 P 7/1/2013 ASMA 10,000 10,000


275 LIDAR 285173573 43 P CARIES 10,000 10,000
276 SUNARSIH 279677068 60 P 2-Jul HT 10,000 10,000
277 ELVI 287997853 33 P GE 10,000 10,000
278 WIRDETI 284821367 47 P CHEPALGIA 10,000 10,000
279 DERMI YETTI 284532217 45 P 3-Jul ASMA 10,000 10,000
280 ASMUNGI 287659436 40 L 4-Jul CARIES 10,000 10,000
281 BETI 279649359 36 P CC 10,000 10,000
282 ELVI 298543721 33 P 5-Jul ISPA 10,000 10,000
283 SANDRA 2765424789 30 P 6-Jul FLOURALBUS 10,000 10,000
284 FAISAL 285444382 7 L SCABIES 10,000 10,000
285 ILHAM 279632597 13 L CC 10,000 10,000
286 SUNARSIH 279677068 60 P HT 10,000 10,000
287 SARI OJI 284921908 65 P 7/8/2013 RA 10,000 10,000
288 DELFITRI 287535631 26 P FARINGITIS 10,000 10,000
289 ADELIA 284861913 4 P ISPA 10,000 10000
290 YANTI 278342257 27 P CC 10,000 10,000
291 LEDYA 275643276 29 P HAMIL 10,000 10000
292 WIDYA 287643532 25 P HAMIL 10,000 10000
293 FAREL 284923326 3 L ILI 10,000 10,000
294 RASZEL 279615666 6,5 L FEBRIS 10,000 10,000
295 GITRA 279614981 12 P FEBRIS 10,000 10,000
296 LIDAR 276488423 43 P 7-Sep ASMA 10,000 10,000
297 SYAMSI 285434638 55 P DERMATITIS 10,000 10,000
298 ALFI 276535434 12 L 7-Nov ABSES 10,000 10,000
TOTAL 220,000 30000 250,000
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

299 DERMI 285389864 45 P 11/7/2004 ASMA 10,000 10,000


300 LIDAR 285173573 43 P ASMA 10,000 10,000
301 RAMULIS 287535877 65 P 7-Dec MYALGIA 10,000 10,000
302 SELVIA 284913382 3,5 P FEBRIS 10,000 10000
303 RIDAIYAH 28755432 55 P ASMA 10,000 10,000
304 RIVAL 285433764 13 L ISK 10,000 10,000
305 ELIDAR 284909949 56 P ISPA 10,000 10,000
306 SILVIA 284869449 15 P 13-7 CEPALGIA 10,000 10,000
307 JULIANTI 284869912 3 L ISPA 10,000 10000
308 DODI 987535934 33 L 15-7 ISPA 10,000 10,000
309 AMELYA 279641417 5 P 16-7 ULTICARIA 10,000 10,000

310 INDRAWATI 279641316 40 P CARIES 10,000 10,000

311 RINA 285419981 30 P ISPA 10,000 10,000

312 IMAM 284924564 8 L 18-7 FEBRIS 10,000 10,000

313 MELA 284863178 22 P ASMA 10,000 10,000

314 MAURA 987535866 3 P 19-7 ISPA 10,000 10000

315 RUSLI 285374147 68 L HT 10,000 10,000

316 LIDAR 276553643 43 P 20-7 ASMA 10,000 10,000

317 DERMI 276654421 45 P ASMA 10,000 10,000

318 DANI 279630538 18 L 22-7 ABSES 10,000 10,000

319 M SAFIG 284826475 2,5 L ISPA 10,000 10000


320 SANDRA 285454501 30 P MYALGIA 10,000 10,000

321 RAKIAH 987535991 90 P HT 10,000 10,000

322 NURADILA 285441636 36 P ISPA 10,000 10,000

323 SARIOJI 2874432465 67 P RA 10,000 10,000

TOTAL 210,000 40000 250,000

NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

324 SYAMSINAR 285434638 55 P 23-7 ALERGI 10,000 10,000

325 WIRNALAILI 285460468 47 P MYALGIA 10,000 10,000

326 RAKIAH 987535991 90 P MYALGIA 10,000 10,000

327 FAIZ 285462966 9 L DIARE 10,000 10,000

328 PIPIT 284828253 32 P DERMATITIS 10,000 10,000

329 ALFI 285422152 12 L 24-7 GASTRITIS 10,000 10,000

330 ARINI 284897867 8 P GASTRITIS 10,000 10,000

TOTAL 70,000 70,000

TOTAL KESELURUHAN 3,320,000

DIKETAHUI PAYAKUMBUH, AGUSTUS 2013

KEPALA PUSKESMAS TIAKAR PELAKSANA PROGRAM

dr.NETI HARTATI Desty amelia,A.Md Keb

19750316 200604 2 009 19820103 200501 2 004


RINCIAN KLAIM JAMKESMAS TAHUN 2013
PUSKESMAS TIAKAR BULAN AGUSTUS

NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

1 REFLIZAR 987534999 45 L 2-Aug HIPOTENSI 10,000 10,000


2 SRI DEWI A 284205723 19 P ALERGI 10,000 10,000
3 QOIRIAH 284212258 32 P ALERGI 10,000 10,000
4 MELGI 283766005 7 P ANXIETAS 10,000 10,000
5 MIADAHLIA 2014833811 38 P ANXIETAS 10,000 10,000
6 INDRIYANTO 285159993 23 L ISPA 10,000 10,000
7 BAYU SETIAWAN 285606731 19 L PARINGITIS 10,000 10,000
8 DELIA YULIANTI 284160936 31 P KB 10,000 10000
9 MULYANI SAFITRI 285747265 7 P CABUT GIGI SUSU 10,000 10000
10 ROSMAN L 2815397154 75 L PERIODONTITIS 10,000 10000
11 TOMI HERMASYAH 28498091 13 L 3-Aug CC 10,000 10,000
12 AHMAD 284793841 11 L PERSISTENSI 10,000 10000
13 UMI S 284861946 23 P dermatitis 10,000 10,000
14 MELDAWATI 284201212 27 P ISPA 10,000 10,000
15 SYAFRI 284808082 34 L TINEA 10,000 10,000
16 ARSYAD 284788686 9 L GE 10,000 10,000
17 MULYADI 284788462 39 L ABSES 10,000 10,000
18 SANDI ORLAND 28483573 15 L ISPA 10,000 10,000
19 RANGGA 285457555 7 L 5-Aug GE 10,000 10,000
20 LINA MANURUNG 279400162 43 P Chepalgia 10,000 10,000
21 FQULIS 285429982 35 P ISPA 10,000 10,000
22 MARDIANI 289915251 24 P 7-Aug ISPA 10,000 10,000
23 SUSANTI 284932642 17 P ISPA 10,000 10,000
TOTAL 190,000 30000 10000 0 230,000
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

24 EDIFAL CHAN 517029142 49 L 12-Aug Chepalgia 10,000 10,000


25 M.FERRY O 284932642 12 L 13-Aug Gastritis 10,000 10,000
26 LANI 2854008 47 P tambah obat 10,000 10,000
27 NURSIANA 28491958 52 P Ispa 10,000 10,000
28 FITRI HANDAYANI 284171372 17 P HAMIL 10,000 10000
29 SUDIRMAN 285094337 8 P Gastritis 10,000 10,000
30 NICO SAPUTRA 2851009587 25 L RA 10,000 10,000
31 NELSUSANTI 987535451 34 P ispa 10,000 10,000
32 SYAMSUAR 28565152 28 L ISPA 10,000 10,000
33 TRI RAHMAWATI 284897621 27 P KB 10,000 10000
34 NEFRAWATI 285854074 30 P ISPA 10,000 10,000
35 ALEYA FITRA 87535473 8 P Gastritis 10,000 10,000
36 ERMAWATI 285608772 54 P DM 10,000 10,000
37 OSNITA 285719231 35 P 14-Aug HIPOTENSI 10,000 10,000
38 DWIFANI 284204428 3 P ISPA 10,000 10000
39 DZAKI 284807668 10 L ISPA 10,000 10,000
40 LEO 284203855 9 L ABSES 10,000 10000
41 DARLISMA 284159294 59 P ISPA 10,000 10,000
42 IHSAD A 28507755 12 L TONSILITIS 10,000 10,000

43 SAFNAWIR 289827285 52 P CARSINOMA 10,000 10,000

44 ALEXA FIHA 927535473 8 P ISPA 10,000 10,000

45 YUSNI 284737792 66 P DIDPEPSIA 10,000 10,000

46 USMAR 284175292 44 L OBS FEBRIS 10,000 10,000

47 SYAFRI 289932241 71 L GP 10,000 10000


48 CANDRA 285145547 36 L LUKA 10,000 10,000

TOTAL 200,000 20000 30000 0 250,000


NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

49 DESRIYETI 28538921 44 P 14-Aug ISPA 10,000 10,000

50 LUNA 285277678 7 P CABUT GIGI SUSU 10,000 10000

51 APRILA YANTI 2852775079 31 P ISPA 10,000 10000

52 MAINAR 284750627 39 P 15-Aug KB 10,000 10000

53 RAHAYA 28475879 73 P Gastritis 10,000 10,000

54 ERNI RAYA 285062218 50 P ISPA 10,000 10,000

55 RENI 285034563 31 P ISPA 10,000 10,000

56 MARLIUS 987534944 28 L CC 10,000 10,000

57 PUTRA R 279635538 11 L dermatitis 10,000 10,000

58 SUNARDI 285660797 46 L 16-Aug KB 10,000 10000

59 JEDIDES 285207546 36 L Gastritis 10,000 10,000

60 NURMALINA 284154729 42 P ISPA 10,000 10,000

61 WINDA 285507291 5 P RA 10,000 10,000

62 RATINAS 284164569 69 P HIPERTENSI 10,000 10,000

63 M IRFAN 284742775 12 L 19-Aug ISPA 10,000 10,000

64 HARDIUS 284910581 55 P ra 10,000 10,000

65 SUCI 495489194 17 P Gastritis 10,000 10,000

66 AFIF 284163783 7 L ISPA 10,000 10,000

67 DERMI YELTI 285389864 46 P 20-Aug CABUT GIGI TETAP 20,000 20000

68 LELINEL 24758406 41 L Gastritis 10,000 10,000

69 BAHTIAR NARO 285101177 77 P ra 10,000 10,000

70 WANDA 285507292 5 P Ispa 10,000 10,000


71 RABAYA 284758479 64 L 21-Aug ra 10,000 10,000

72 EKO 28419569 40 L 22-Aug Ispa 10,000 10,000

73 ADELIA 285198574 11 P Ispa 10,000 10,000

TOTAL 200,000 30000 30000 260,000


NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

74 ASRI 284711841 43 P 22-Aug PERIODONTITIS 10,000 10000

75 NUNSIARNI 284910581 5 P Stomatitis 10,000 10,000

76 YASMIN 284891645 26 P Gastritis 10,000 10,000

77 SUNARSIH 279677069 60 P 23-Aug ispa 10,000 10,000

78 GUSRIZAL 98753155 57 P Febris 10,000 10,000

79 ANDI AHMAD 285165819 18 L PERSISTENSI 10,000 10000

80 SULRA 284892474 50 P MYALGIA 10,000 10,000

81 ARI ANGGA 284894421 18 L GASTRITIS 10,000 10,000

82 DERMIYENTI 285589864 45 P 24-Aug GP 20,000 20000

83 BASRI 285134927 50 P GASTRITIS 10,000 10,000

84 YELI KAMARUDHIN 285625438 40 P GASTRITIS 10,000 10,000

85 YOGA SEPTIA 285722199 5 L 26-Aug ISPA 10,000 10,000

86 YAN HENDRI 285131889 51 P CC 10,000 10,000

87 SITI RAHANA 987535811 4 P PSIKOMATIK 10,000 10,000

88 SUBAINAH 285699925 32 P ISPA 10,000 10,000

89 OYON 287564687 45 L GASTRITIS 10,000 10,000

90 BUNGA LESTARI 284203011 11 P 27-Aug SUSP.TIPOID 10,000 10,000

91 RAHMAD HIDAYAT 28507933 10 L dermatitis 10,000 10,000

92 MILA 28984514 25 P PERSISTENSI 10,000 10000

93 NURHALIN 27387812 18 P ISPA 10,000 10,000

94 ELFI NETRI 2848201866 33 P PERIODONTITIS 10,000 10,000


95 WIDYA FITRI 287914784 25 P PULVITIS 10,000 10,000

96 RUSDI 287657989 49 L ISPA 10,000 10,000

97 ASTUL SLASIH 285458644 36 P ISPA 10,000 10000

98 BASRI 2851342923 50 L ra 10,000 10,000

TOTAL 180,000 70,000 10000 260,000


NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

99 M IRFAN 28489934 41 L 28-Aug GASTRITIS 10,000 10000

100 HAYATUS 284851168 10 P ISPA 10,000 10,000

101 NUR 28485384 11 P ISPA 10,000 10,000

102 M ARIFIN 28482996 7 L PERSISTENSI 10,000 10000

103 CHINTIA 285616416 6 P ISPA 10,000 10,000

104 NONSIARNI 284910581 52 P RA 10,000 10,000

105 NOVIANTI 284775063 11 P Febris 10,000 10,000

106 SYAMSUAR 285651551 73 L 29-Aug ra 10,000 10,000

107 CHINTIA AMELIA P 285616416 6 P ISPA 10,000 10,000

108 BASRI AMBON 285591148 60 L MYALGIA 10,000 10,000

109 DERMI YETTI 285389864 46 P ABSES 10,000 10000

110 NASRUL 285664239 52 L MYALGIA 10,000 10,000

111 WIRIANIS 285664869 50 P Chepalgia 10,000 10,000

112 NOFRI YENTI 285223232 48 P 30-Aug Gastritis 10,000 10,000

113 BASRI TANDO 285134927 50 P CABUT GIGI TETAP 20,000 20000

114 PUTRI RAMADANI 284819602 7 P PERSISTENSI 10,000 10000

115 SUNARSIH 27966008 60 P MYALGIA 10,000 10,000

116 USRINI 285719231 34 P MYALGIA 10,000 10,000

117 ONDRI P 284868146 41 L 31-Aug HIPOTENSI 10,000 10,000

118 NURDUSMETRI 285510295 34 P 1-Aug DYSMINOR 10,000 10000


119 DEA FEBRIAN 284924259 8 P 2-Aug FARINGITIS 10,000 10,000

120 JENITA AGUS 284911993 23 P 3-Aug KB 10,000 10000

121 KEYSA 285240688 2 P 6-Aug OMA 10,000 10,000

122 VIRMA SOFIA 285241421 34 P LUKA 10,000 10000

123 THIO ANGGARA 285241229 15 L 7-Aug TINEA 10,000 10,000

TOTAL 170,000 50000 30,000 10000 260,000


NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

124 AZAZ MULIA 285241229 9 L 7-Aug ISPA 10,000 10,000

125 WIWI SANTIKA 285218741 32 P 12-Aug KB 10,000 10000

126 MARHENI 285313432 49 P ISPA 10,000 10,000

127 MARTA GIA 285247405 27 P KB 10,000 10000

128 EKA SUSANTI 285164515 31 P 13-Aug KB 10,000 10000

129 FITRI YENI 285260152 27 P HAMIL 10,000 10000

130 ROSLINA 285274607 41 P GE 10,000 10,000

131 NINA A 285530848 25 P 14-Aug CC 10,000 10,000

132 RAKAMSINA 285519172 78 P HT 10,000 10,000

133 SANTI NOVITA 285317469 20 P 15-Aug LUKA 10,000 10000

134 ERWIN 28536808 46 L 16-Aug FARINGITIS 10,000 10,000

135 SYAMSINAR 285288006 66 P DECUBITUS 10,000 10,000

136 FAUZIAH 285287815 8 P LUKA 10,000 10000

137 TUSNAINI 285335291 40 P 17-Aug KB 10,000 10000

138 novit yani 285325929 27 P 19-Aug KB 10,000 10000

139 noni 28532768 11 P GASTRITIS 10,000 10,000

140 candra a 285325929 36 L 20-Aug ISPA 10,000 10,000

141 rosmiati 285513614 38 P FARINGITIS 10,000 10,000

142 marina 285321813 28 P 21-Aug KB ( IMPLANT ) 40,000 40000


143 nuranin 285254392 56 P CC 10,000 10,000

144 murni 285512949 42 P 22-Aug LUKA 10,000 10000

145 titi monika 285231846 15 P ISPA 10,000 10,000

146 SAMSURILAS 284920694 64 P 23-Aug ISPA 10,000 10,000

147 RANI RAHAYU 285329553 20 P GASTRITIS 10,000 10,000

148 PATRIA 284917959 24 P 24-Aug HAMIL 10,000 10000

TOTAL 140,000 110000 30000 280,000


NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

149 ARDA 285280874 12 L 24-Aug ISPA 10,000 10,000

150 GUSTIAN 284918141 7 L 26-Aug CC 10,000 10,000

151 BAMBANG H 285248441 15 L TONSILITIS 10,000 10,000

152 AZAHARA NABILA 285349972 8 P GASTRITIS 10,000 10,000

153 JENITA AGUS 284916404 23 P 28-Aug KB ( IMPLANT ) 40,000 40000

154 FAUZIAH 285287815 8 P LUKA 10,000 10000

155 MUNI 285645435 42 L MYALGIA 10,000 10,000

156 FITRI YENNI 285260152 27 P 29-Aug HAMIL 10,000 10000

157 ARDA 285280874 10 L 30-Aug TV 10,000 10000

158 ELDAWATI 284928884 38 P KB 10,000 10000

159 ELFI S 284906136 41 P 31-Aug HAMIL 10,000 10000

160 GUSNETI 285178318 47 P 1-Aug ANXIETAS 10,000 10,000

161 M RAUDHATUL 284758885 8 L 4-Aug DERMATITIS 10,000 10,000

162 ANWAR 285112809 37 L 7-Aug ISPA 10,000 10,000

163 ARINI MELANI 284770157 6 P DEMAM 10,000 10,000

164 HARI MULYADI 284769156 32 L ISPA 10,000 10,000

165 GUSNETI 285178318 47 P 11-Aug ANXIETAS 10,000 10,000

166 VONI 28476266 28 P 20-Aug DIARE 10,000 10,000


167 ELIDARWATI 283120303 54 P DIARE 10,000 10,000

168 GUSNETI 28578318 47 P ANXIETAS 10,000 10,000

169 SYARIAH 28764546 63 P DIARE 10,000 10,000

170 DERI 28564748 35 L GASTRITIS 10,000 10,000

171 IRA DUMA DINI 284773887 36 P 21-Aug KB 10,000 10000

172 WIWIN 285054985 29 P 13-Aug KB 10,000 10000

173 FITRIHANDAYANI 287657689 17 P GASTRITIS 10,000 10,000

TOTAL 170,000 90000 20000 280,000


NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

174 TUTI INDRIANI 284176372 26 P 13-Aug HIPOTENSI 10,000 10,000

175 AQIL RAHMAD 284821558 64 L 14-Aug ISPA 10,000 10,000

176 DARLISMA 28739862 59 P 15-Aug GASTRITIS 10,000 10,000

177 JUSMAINI 284159294 40 P 15-Aug KB 10,000 10000

178 MISRISAR 284159765 62 P 18-Aug HIPOTENSI 10,000 10,000

179 FATMAWATI 284813493 40 P 22-Aug KB 10,000 10000

180 DODI 982535934 33 L 25-Jul GE 10,000 10,000

181 M RAHLIL 279636906 5 L ISPA 10,000 10,000

182 ADRIAN 7 L LUKA 10,000 10000

183 ARIEL 279624519 7 L ISPA 10,000 10,000

184 PITRAWATI 279625678 41 P CEPALGIA 10,000 10,000

185 LIDAR 43 P ASMA 10,000 10,000

186 SALMAN 279645996 4 L SCABIES 10,000 10,000

187 ERLINA 279630933 40 P ASMA 10,000 10,000

188 NAIRA 279630909 2 P 26-Jul SCABIES 10,000 10,000

189 HERI 27963538 12 L SCABIES 10,000 10,000

190 DANI 279630538 18 L SCABIES 10,000 10,000


191 PUTRI RAMADANI 285394893 3 P ISPA 10,000 10,000

192 YULFERA 285391113 36 P ASMA 10,000 10,000

193 MADRISAH 284911964 43 P 1-Aug CEPALGIA 10,000 10,000

194 SALSABILA 284802693 10 P ALERGI 10,000 10,000

195 MEGA 284802399 30 P ISPA 10,000 10,000

196 MIFTAHUL 284896056 2 P FEBRIS 10,000 10,000

197 HELMI 274629706 45 L MYALGIA 10,000 10,000

198 RAAKIAH 987535991 90 P MYALGIA 10,000 10,000

TOTAL 220,000 0 20000 10000 250,000


NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

199 FAISALAMAT 28544382 7 L 1-Aug GE 10,000 10,000

200 M SOHIBIS 285427562 5 L FEBRIS 10,000 10,000

201 ANGGUN 285426988 11 P ABSES 10,000 10,000

202 RADIL 285406154 4 L CC 10,000 10,000

203 FAISAL 285444382 7 L GE 10,000 10,000

204 NILDAWATI 279632327 39 P CEPALGIA 10,000 10,000

205 GITIA 276914981 12 P ISPA 10,000 10,000

206 ASYLE AMINI 284897428 9 P ISPA 10,000 10,000

207 FATIMAH 279625228 75 P HT 10,000 10,000

208 REGALIA 284920986 34 P GE 10,000 10,000

209 DOVAL 284894741 13 L ISPA 10,000 10,000

210 RONI 284826374 9 L 3-Aug ISPA 10,000 10,000

211 AGUNG 8 L ASMA 10,000 10,000

212 DANI 279630538 18 L 4-Aug CEPALGIA 10,000 10,000

213 MELA 284836318 21 P ASMA 10,000 10,000

214 NURAFIMAR 284803593 44 P 5-Aug RA 10,000 10,000


215 BELA 15 P ASMA 10,000 10,000

216 IMAM 7 L CC 10,000 10,000

217 ALWIDO 279648260 4 L 6-Aug ISPA 10,000 10,000

218 WIDYA FITRI 279647829 26 P CC 10,000 10,000

219 PIPIT 32 P CC 10,000 10,000

220 SYAMSI 283434638 55 P ALERGI 10,000 10,000

221 DERMI 45 P ASMA 10,000 10,000

222 WILI 285390189 16 L SCABIES 10,000 10,000

223 ADITYA 284899825 13 L ISPA 10,000 10,000

TOTAL 250,000 250,000


NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

224 LIDAR 43 P 6-Aug ASMA 10,000 10,000

225 M NASIR 285444922 70 L LUKA 10,000 10,000

226 FATIMAH 279625228 80 P HT 10,000 10,000

227 BERMAWI 285399213 52 L 12-Aug GE 10,000 10,000

228 M NASIR 285444922 70 L LUKA 10,000 10,000

229 ROSNIA 285435178 87 P GE 10,000 10,000

230 RIFI 15 P CC 10,000 10,000

231 GUSMAYERTI 284913178 28 P 13-Aug CEPALGIA 10,000 10,000

232 LIDAR 43 P 14-Aug ASMA 10,000 10,000

233 PIPIT 30 P 15-Aug DIARE 10,000 10,000

234 DERMI 45 P ASMA 10,000 10,000

235 AQIL RAHMAD 284899948 10 L DIARE 10,000 10,000

236 M JUSMAN 285385915 12 L ABSES 10,000 10,000

237 WIDYA FITRI 25 P HAMIL 10,000 10000

238 NIRDAWATI 98753855 24 P KONSTIPASI 10,000 10,000


239 RAMULIS 987535877 70 P HT 10,000 10,000

240 PUTRI 285394893 3 P 16-Aug H 10,000 10,000

241 YULFERA 285391113 35 P ABSES 10,000 10,000

242 HAIKAL 285449501 7 L ISPA 10,000 10,000

243 PENI 284910067 32 P GE 10,000 10,000

244 RAFQI 284912325 3 L CEPALGIA 10,000 10,000

245 MUTIARA 285384464 6 P ABSES 10,000 10,000

246 LIDAR 43 P 17-Aug GE 10,000 10,000

247 WINTA 284905811 19 P 18-Aug ASMA 10,000 10,000

248 DEFIANO 34 L TINEA 10,000 10,000

TOTAL 240,000 10000 250,000

NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

249 MELI 284836318 22 P 8/19/2013 ASMA 10,000 10,000

250 SYAMSI 285434638 28 P ALERGI 10,000 10,000

251 SARIOJI 284421908 65 P 20-Aug RA 10,000 10,000

252 M JAUHARI 284897384 13 L ISPA 10,000 10,000

253 WINA 279103971 27 P ISPA 10,000 10,000

254 SUNARSIH 279677068 60 P 21-Aug HT 10,000 10,000


255 DESWIKA 284897867 26 P HAMIL 10,000 10,000

TOTAL 60,000 10000 70,000

TOTAL KESELURUHAN 2,640,000

DIKETAHUI PAYAKUMBUH, SEPTEMBER 2013


KEPALA PUSKESMAS TIAKAR PELAKSANA PROGRAM

dr.NETI HARTATI Desty amelia,A.Md Keb


19750316 200604 2 009 19820103 200501 2 004
RINCIAN KLAIM JAMKESMAS TAHUN 2013
PUSKESMAS TIAKAR BULAN SEPTEMBER
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

1 ARUM DANI 285496334 9 L 2-Sep Gastritis 10,000 10,000

2 MAIYARLIS 987534617 41 P 3-Sep KB 10,000 10,000

3 GENTA MASIESNAL 987534639 9 L 7-Sep OBS FEBRIS 10,000 10,000

4 LATIFAH ARISTA 284769966 6.5 P 7-Sep ISPA 10,000 10,000

5 LAILA OKTAVIANI 285095676 5 P 16-Sep ISPA 10,000 10,000

6 FITRIANIS 284195755 21 P 17-Sep ISPA 10,000 10,000

7 AGUSTINI 284863421 47 P 17-Sep HIPERTENSI 10,000 10,000

8 KURAINI 285095788 41 P 17-Sep KB 10,000 10000

9 ZAITUL ASNI 284901906 24 P 20-Sep KB 10,000 10000

10 RABIATUL HUSNA 284774141 15 P 3-Sep Gastritis 10,000 10000

11 ORIZA SYATIFA 284774174 3 P 3-Aug dermatitis 10,000 10,000

12 FAUZIAH 284793841 8 P 4-Sep ISPA 10,000 10000

13 HAVIZAH 284861946 1 P SUSP.CAMPAK 10,000 10,000

14 EVA KHAIDIR 285112868 38 P FLUOR ALBUS 10,000 10,000

15 HARMAINI INCEK 517024394 78 L DISENTRI 10,000 10,000


16 DEWI KARMILA 285178318 27 P FLUOR ALBUS 10,000 10,000
17 IPIT FEBRINA 285127481 27 P 5-Sep ISPA 10,000 10,000
18 GUSNETI 285178318 47 P ANXIETAS 10,000 10,000
19 BUJANG 285457555 36 L ALERGI 10,000 10,000
20 ROSMAILI 285155526 45 P 9-Sep ALERGI 10,000 10,000

21 ALIF 285168014 18 L ALERGI 10,000 10,000

22 M,RAMADHAN 987535058 8 L 10-Sep ISPA 10,000 10,000

23 ROBI 285202809 56 P 13-Sep HIPOTENSI 10,000 10,000


TOTAL 200,000 0 30000 0 230,000

NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

24 HENGKI MERE 284758727 37 L 15-Sep DEMAM 10,000 10,000

25 LASTRI BR HOMBING 285123791 28 P 18-Sep KB 10,000 10,000

26 NABILA FITRI 285113812 8 P 20-Sep ISPA 10,000 10,000

27 GINA RAMANDA 285143725 13 P GIGI 10,000 10,000

28 DEWI MAYASARI 285122643 21 P HAMIL 10,000 10000

29 MIRAWATI 285185182 33 P 23-Sep KB 10,000 10,000

30 SUCI 285214329 18 P ISPA 10,000 10,000

31 SUSANTI 28512986 24 P 24-Sep HAMIL 10,000 10,000

32 SYAMSIDAR 285154413 75 P ARTRITIS 10,000 10,000

33 RINI AFRIANTI 285333399 21 P 2-Sep KB 10,000 10000

34 FITRI YENI 285260152 28 P Gastritis 10,000 10,000

35 MAYA MENJEL 284910551 28 P HYPOTENSI 10,000 10,000

36 DARUS LAINI 284309999 55 P GE 10,000 10,000

37 IFRAYANTO 285341927 35 L KB 10,000 10,000

38 BIMA PUTRA 285343659 4 L ISPA 10,000 10000

39 SARIFA 987528385 17 P TINEA 10,000 10,000

40 RANI RAHAYU P 285329553 20 P HYPOTENSI 10,000 10000


41 FATRIA 284917959 28 P HYPOTENSI 10,000 10,000
42 RISNAWATI 285491801 36 P KB 10,000 10,000
43 PUTRI AISYAH 285268836 6 P Gastritis 10,000 10,000
44 BAIRUS 2855202285 77 P TINEA 10,000 10,000
45 SRI ARINDA 285323984 27 P ISPA 10,000 10,000

46 FITRI YENI 285260152 28 P CC 10,000 10,000

47 MASWATI 285527654 33 P KB 10,000 10000


48 HAIDIL PITRA 285326504 9 L LUKA 10,000 10,000

TOTAL 150,000 10000 80000 0 250,000

NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

49 ELFI SUSDANTI 284906136 38 P HYPOTENSI 10,000 10,000

50 AFRIZAL 285279941 40 L CARIES 10,000 10,000

51 ELFI NAIMAR 285259869 50 P Gastritis 10,000 10,000

52 FATRIA 284917959 28 P Gastritis 10,000 10,000

53 RANI RAHAYU 285329553 20 P ISPA 10,000 10,000

54 RATNA JUWITA 285227875 36 P KB 10,000 10,000

55 HARDI 285261221 17 L CC 10,000 10,000

56 M HAFIZ 285343266 9 L dermatitis 10,000 10,000

57 IFRAYANTO 285341927 35 L TV 10,000 10,000

58 ALICIA 285927275 3.5 P ASMA 10,000 10,000

59 FITRI YENI 285260152 27 P HYPOTENSI 10,000 10,000

60 MAYA MENJEL 284910557 28 P HYPOTENSI 10,000 10,000

61 SRI ARINDA 285323984 27 P CARIES 10,000 10,000

62 MISRAWATI 285441041 33 P 23-Aug MYALGIA 10,000 10,000

63 SYAFRIADI 285441759 37 L ISPA 10,000 10,000

64 DONA 2845058111 12 P ABSES 10,000 10,000

65 WINTA 987536092 19 P ALERGI 10,000 10,000


66 NORA 279633265 33 P KB 10,000 10,000
67 SYNTIA 279633265 9 P ASMA 10,000 10,000
68 DAMBRA 289445787 70 L 24-Aug DIARE 10,000 10,000
69 FATIMAH 279625228 80 P HT 10,000 10,000

70 LIDAR 285507292 43 P ASMA 10,000 10,000

71 DAFA 987536103 5 L ISPA 10,000 10,000


72 NILDAWATI 279632327 40 P ABSES 10,000 10,000

73 RASZEL 279615666 7 L ISPA 10,000 10,000

TOTAL 170,000 40000 30000 10,000 250,000

NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

74 SUNARSIH 279877068 60 P 30-Aug HT 10,000 10000

75 JELVIN 285360546 15 L TINEA 10,000 10,000

76 DERMI Y 285389864 15 P 1-Sep ASMA 10,000 10,000

77 DENI 284719364 5 L ISPA 10,000 10,000

78 LIDAR 98753155 43 P 2-Sep ASMA 10,000 10,000

79 MILAWATI 285420936 31 P CC 10,000 10000

80 ALDI 285423513 6 L ISPA 10,000 10,000

81 NENG 289851091 38 P Gastritis 10,000 10,000

82 RAKA 284877944 5 L ISPA 10,000 10000

83 NURAIN 284837804 14 P ISPA 10,000 10,000

84 MELA 284836318 22 P ASMA 10,000 10,000

85 WITY 2853901889 16 L CARIES 10,000 10,000

86 DERMI Y 285131889 45 P ABSES 10,000 10,000

87 DESWIKA 279677913 27 P Gastritis 10,000 10,000

88 ROSMAN 285397154 80 L ASMA 10,000 10,000

89 DENI 284719364 5 L CC 10,000 10,000

90 YULHADI 285378696 52 L 3-Sep ISPA 10,000 10,000

91 WIDYA 279657854 26 P CARIES 10,000 10,000

92 WILY 2853901885 18 L GE 10,000 10000

93 DINDA 279633576 7 P DEMAM 10,000 10,000

94 MILDAWATI 279632327 41 P ABSES 10,000 10,000

95 NAIRA 279630933 2 P ISPA 10,000 10,000


96 RATIH 284908162 27 P CC 10,000 10,000

97 SYAMSI 285434638 55 P 4-Sep ALERGI 10,000 10000

98 YURI 284912425 24 P MASTITIS 10,000 10,000

TOTAL 210,000 40,000 0 250,000

NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

99 RIVALDO 28486982 11 L TONSILITIS 10,000 10,000

100 JULIAN 284869912 3 L FEBRIS 10,000 10000

101 YUNITA 284861316 27 P GRAVID 10,000 10000

102 MAIDELVA 284750627 35 P 5-Sep CC 10,000 10000

103 DENI 28475879 5 L LUKA 10,000 10,000

104 DERI 285062218 37 P ISPA 10,000 10,000

105 TIO 285034563 10 L 6-Sep ISPA 10,000 10,000

106 ARIEL 987534944 7 L ISPA 10,000 10,000

107 RIVAL 279635538 11 L CC 10,000 10,000

108 LIDAR 285660797 43 P CC 10,000 10000

109 DESWIKA 285207546 26 P CC 10,000 10,000

110 SARIOJI 284154729 63 P RA 10,000 10,000

111 SALMAN 285507291 5 L 7-Sep CC 10,000 10,000

112 YENDRI 284164569 37 P CEPALGIA 10,000 10,000

113 NURHAYANI 284742775 38 P MYALGIA 10,000 10,000

114 ERLINA 284910581 45 P ISPA 10,000 10,000

115 HENDRA 495489194 37 L 9-Sep CARIES 10,000 10,000


116 NURADILA 284163783 33 P CC 10,000 10,000
117 DERMI 285389864 45 P ASMA 10,000 10000
118 VITA 24758406 45 P ABSES 10,000 10,000
119 M NASIR 285101177 75 L ALERGI 10,000 10,000
120 RANDA 285507292 15 L 11-Sep ISPA 10,000 10,000

121 HERMAN 284758479 49 L LUKA 10,000 10,000

122 APRI 284802906 5 L ISPA 10,000 10,000

123 DERMI 285389865 45 P 12-Sep Ispa 10,000 10,000

TOTAL 210,000 20000 20000 250,000

NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

124 YULIAR 517010859 46 P 12-Sep ISPA 10,000 10,000

125 WIDO 285277678 4 L CABUT GIGI SUSU 10,000 10000

126 SRILER 279680826 29 P ISPA 10,000 10000

127 ARFI 285390639 13 L ISPA 10,000 10000

128 DONA 285441759 12 P Gastritis 10,000 10,000

129 ZAINAL 285062218 47 L ISPA 10,000 10,000

130 PUTRI 285394893 3 P 13-Sep ISPA 10,000 10,000

131 YULFERA 285391113 36 P CC 10,000 10,000

132 NURSEHA 284888531 40 P dermatitis 10,000 10,000

133 PARIMI 285660797 73 L KB 10,000 10000

134 TITIN 285207546 46 P Gastritis 10,000 10,000

135 RADIL 285406145 4 L ISPA 10,000 10,000

136 MELA 284836318 22 P RA 10,000 10,000

137 RANTI 28414535 16 P HIPERTENSI 10,000 10,000

138 NURHAYANI 285412342 38 P ISPA 10,000 10,000

139 LIDAR 284910581 43 P ra 10,000 10,000

140 NIRDAWATI 287535855 24 P 14-Sep Gastritis 10,000 10,000


141 NAURA 987535866 3 P ISPA 10,000 10,000
142 MIFTA 279658416 6 L CABUT GIGI TETAP 20,000 20000
143 M.NASIR 285444922 75 L Gastritis 10,000 10,000
144 ZAINAL 279626556 45 L 16-Sep ra 10,000 10,000

145 AREK 279624579 7 L Ispa 10,000 10,000

146 HAFIZAH 284901895 3 P ra 10,000 10,000

147 SYAFRIZAL 279681107 32 L Ispa 10,000 10,000

148 PUTRA 279650538 17 L Ispa 10,000 10,000

TOTAL 210,000 30000 20000 260,000

NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

149 SYAMSI 285434464 55 P ISPA 10,000 10,000

150 AZIZ 285434638 6 L CABUT GIGI SUSU 10,000 10000

151 DERMI 285289864 49 P ISPA 10,000 10000

152 TANIA 285372538 13 L LUKA 10,000 10000

153 PIPSY 284828253 32 P CC 10,000 10,000

154 JELVIA 285360546 15 L 17-Sep TINEA 10,000 10,000

155 DERA 987536158 5 P ISPA 10,000 10,000

156 LIDAR 987534944 43 L ASMA 10,000 10,000

157 AZIZ 285434469 6 L VARISELA 10,000 10,000

158 RAKIAS 285660797 75 P RA 10,000 10000

159 DENI 284719364 5.5 L ISPA 10,000 10,000

160 DENA 284928545 28 P dermatitis 10,000 10,000

161 SELVITA 285507291 4 P 18-Sep CC 10,000 10,000

162 MELA 284164569 24 P ASMA 10,000 10,000

163 HELDA 284862399 31 P CARIES 10,000 10,000

164 M.SAFOQ 284826475 3 L 19-Sep ISPA 10,000 10,000

165 ZAINAL 279626556 45 L LUKA 10,000 10,000


166 YUSRO 284908599 32 L TONSILITIS 10,000 10,000
167 NUR AFIMAR 284803543 49 P DIARE 10,000 10000
168 DINDA 279633576 8 P CEPALGIA 10,000 10,000
169 DELFITRI 987535631 28 P dermatitis 10,000 10,000

170 RANGGA 279643048 8 L ISPA 10,000 10,000

171 NELDAWATI 279632327 39 P 20-Sep ANEMIA 10,000 10,000

172 RUSLI 285374147 68 L Ispa 10,000 10,000

173 WASNA 284827285 38 P KB 10,000 10,000

TOTAL 210,000 10000 20000 10,000 250,000

NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

174 SAFNAWEPI 284827285 53 L 21-Sep ALERGI 10,000 10,000

175 SARIOJI 284921908 65 P RA 10,000 10000

176 DERMI 285389869 45 P ASMA 10,000 10000

177 ZULKKIFLI 284863299 55 L ISPA 10,000 10000

178 RENI 285425548 37 P 23-Sep ISPA 10,000 10,000

179 ERLINDA 285062218 37 P FLOURALBUS 10,000 10,000

180 RUSLI 285374147 68 L HT 10,000 10,000

181 APRI 284802986 6 L DIARE 10,000 10,000

182 RIDWAN 285192646 13 L ABSES 10,000 10,000

183 LIDAR 285660797 42 P ASMA 10,000 10000

184 MUTIARA 285384467 6 P ALERGI 10,000 10,000

185 AMELYA 279641417 5 P 24-Sep TONSILITIS 10,000 10,000

186 NAIMAR 285416019 70 P 25-Sep MYALGIA 10,000 10,000

187 AIRA 487536158 5 P Ispa 10,000 10,000

188 NURLEHA 284888531 38 P Ispa 10,000 10,000

189 HELDA 284802399 31 P ra 10,000 10,000

190 YULIA D 2851351921 21 L 2-Sep hamil 10,000 10,000


191 NIRDAWATI 987533855 2 P ISPA 10,000 10,000
192 ERUMAWATI 2794969 41 P CABUT GIGI TETAP 20,000 20000
193 EGGA D 284099078 3 L Gastritis 10,000 10,000
194 MISRAWATI 285680098 38 L ra 10,000 10,000

195 ZULKIFLI 284822765 37 L Ispa 10,000 10,000

196 RESTI 285679192 18 P ra 10,000 10,000

197 BASRI 285139927 50 L periodontitis 10,000 10,000

198 METRI 284414769 51 P Ispa 10,000 10,000

TOTAL 210,000 40000 10000 260,000

NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

200 ELIDAR 284139729 42 P ISPA 10,000 10,000

201 KASRI 284715575 31 P CABUT GIGI SUSU 10,000 10000

202 AFRIZAL 285341311 34 L ISPA 10,000 10000

203 FITRIA NINGSIH 28484595 16 P 3-Sep KB 10,000 10000

204 ETI ROHANA 987535811 41 P Gastritis 10,000 10,000

205 DERMI YENTI 285389864 46 P cabut gigi permanent 20,000 20,000

206 NUR ASNI 285125253 46 P 4-Sep ISPA 10,000 10,000

207 RITA WATI 284838131 45 P CC 10,000 10,000

208 NUR ELMA 285469525 56 L dermatitis 10,000 10,000

209 MUTIA AULIA 987534988 7 P KB 10,000 10000

210 REYNALDI 987534977 11 L Gastritis 10,000 10,000

211 RINI MARLINA 285283697 38 P ISPA 10,000 10,000

212 M JALIL 285145749 5 L cabut gigi susu 10,000 10,000

213 CANDRA 285145547 69 L abses 10,000 10,000

214 INTAN 284772486 8 P ISPA 10,000 10,000

215 KEYSA 284772666 5 P ra 10,000 10,000

216 EMA 284804921 49 P Gastritis 10,000 10,000


217 EMLIA 285054107 5.5 P ISPA 10,000 10,000
218 NOVIYANTI 285054039 25 P CABUT GIGI TETAP 20,000 20000
219 RATIH ANGGI 284932445 27 P 5-Sep 10,000 10,000
220 SAFNI 285641166 47 P ra 10,000 10,000

221 OSNITA 285319231 35 P Ispa 10,000 10,000

222 DARLISMA 284159274 60 P ra 10,000 10,000

223 M.FADLAN 286907969 2.5 L Ispa 10,000 10,000

224 MAGRITIS 285277645 10 P Ispa 10,000 10,000

TOTAL 180,000 70000 20000 270,000

NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

225 LEDY TRI 285279039 4.5 P 5-Sep ISPA 10,000 10,000

226 APRILIA YANTI 285277599 32 P CABUT GIGI SUSU 10,000 10000

227 REHAN 284816362 6 L ISPA 10,000 10000

228 ERMAWATI 517023448 42 P 7-Sep KB 10,000 10000

229 DERMI YELTI 285389864 46 P Gastritis 10,000 10,000

230 GADIS 285626496 87 P ISPA 10,000 10,000

231 LEO HARDIKA 284203855 10 L 9-Sep ISPA 10,000 10,000

232 RIDHO PRASETYO 285629253 5 L CC 10,000 10,000

233 FANI FADILLA 283766308 11 P dermatitis 10,000 10,000

234 DESWITA 279677913 26 P KB 10,000 10000

235 NOVI MUCHTAR 28481974 19 P Gastritis 10,000 10,000

236 KAFI R 284913534 24 L ISPA 10,000 10,000

237 ZULHAEDAR 28565998 41 P RA 10,000 10,000

238 HAFIS DINDA 285736173 11 L HIPERTENSI 10,000 10,000

239 EGI 285731584 9 L ISPA 10,000 10,000

240 PRIHATI 285637397 26 P ra 10,000 10,000


241 NABIL BELASNI 285151037 3 L Gastritis 10,000 10,000
242 EMRITA 289353323 17 P ISPA 10,000 10,000
243 ROZINURNALINA 284371978 42 P CABUT GIGI TETAP 20,000 20000
244 FATIAH 284141305 10 P Gastritis 10,000 10,000
245 SALMAN 28934526 4 P ra 10,000 10,000

246 RENO SYAH PUTRA 284781565 11 P Ispa 10,000 10,000

247 AGIM 284861147 5 L ra 10,000 10,000

248 LAUREN 285465227 12 P 10-Sep Ispa 10,000 10,000

249 BUJANG SAID 285120101 56 L Ispa 10,000 10,000

TOTAL 210,000 30000 20000 260,000

NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

250 ROSMINI 284745952 62 P ISPA 10,000 10,000

251 REGIA RAHADINI 285685211 3 P CABUT GIGI SUSU 10,000 10000

252 GUSNETI 285178318 48 P ISPA 10,000 10000

253 SALMA N 284927466 6 P KB 10,000 10000

254 M EDIZ MIKAR 284927657 4 L Gastritis 10,000 10,000

256 RAHAYU 285139251 45 P 11-Sep ISPA 10,000 10,000

257 SYAMSI 285221952 20 P ISPA 10,000 10,000

258 UNIANG 28559351 65 P CC 10,000 10,000

259 SISMERI 284710709 38 P dermatitis 10,000 10,000

260 EGI MONANDA 285736386 10 P KB 10,000 10000

261 EPI SUSANTI 289859184 13 P Gastritis 10,000 10,000

262 BUNGA 300557416 34 P abses 10,000 10,000

263 RUSTAM 28517491 75 L RA 10,000 10,000

264 USMAN 284141957 69 P HIPERTENSI 10,000 10,000

265 RAMAYUNIS 284210256 67 P ISPA 10,000 10,000


266 NOVIA H 2848260003 5.5 P ra 10,000 10,000

267 MONSIARNI 284910581 17 P Gastritis 10,000 10,000


268 SAMI 284841911 40 P ISPA 10,000 10,000
269 DAWEIN 244844537 2 L CABUT GIGI TETAP 20,000 20000
270 TITIN 284845524 45 P Gastritis 10,000 10,000
271 LARA SAVIRA 284768381 13 P 13-Sep ra 10,000 10,000

272 EGI MONANDA 285736386 9 L pulvitis 10,000 10,000

273 HARIS DIANDRA 285736173 24 L ra 10,000 10,000

274 EDO SEPTRIO 285746679 11 L Ispa 10,000 10,000

275 ASRIL 284899159 55 L Ispa 10,000 10,000

TOTAL 190,000 50000 20000 260,000

NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

276 IRWAN 228472243 17 L 13-Sep ISPA 10,000 10,000

277 DENI 285463468 21 P CABUT GIGI SUSU 10,000 10000

278 M HAVIS 2857023457 10 P ISPA 10,000 10000

279 HAIKAL 285417891 3 L 14-Sep KB 10,000 10000

280 RUSTAM 285671589 60 P Gastritis 10,000 10,000

281 DIANA EKA 285094337 9 P ISPA 10,000 10,000

282 SALMA N 284927466 9 P ISPA 10,000 10,000

283 M EDIZ MIKAR 284927657 6 L CC 10,000 10,000

284 KHAIRUL 285683884 4 L dermatitis 10,000 10,000

285 USRI 284721210 49 L KB 10,000 10000

286 REHAN FADLAN 284709887 16 L Gastritis 10,000 10,000

287 DAFA 4875343265 9 L ISPA 10,000 10,000

288 SYAFNI 285641160 5 P RA 10,000 10,000

289 M. SYUKRI 2848207034 69 L HIPERTENSI 10,000 10,000


290 RAHMAT FAISAL 284725498 10 L ISPA 10,000 10,000

291 MIRDARATI 2975357645 8 P ra 10,000 10,000

292 SALMA 285212129 14 P 16-Sep Gastritis 10,000 10,000


293 AFISTEN 284833653 3 L ISPA 10,000 10,000
294 DARLISMA 284159290 20 P CABUT GIGI TETAP 20,000 20000
295 NURJASI 285467479 41 P Gastritis 10,000 10,000
296 MARSA 284813358 70 P ra 10,000 10,000

297 SRI 285507292 3 P Ispa 10,000 10,000

298 ADI CANDRA 284758479 29 L CABUT GIGI TETAP 20,000 20,000

299 ARI 28419569 43 L Ispa 10,000 10,000

300 LAYLA 285198574 6 P 17-Sep Ispa 10,000 10,000

TOTAL 200,000 50000 20000 270,000

NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

301 QISKA 285741456 24 P 17-Sep ISPA 10,000 10,000

302 YULIA 2857390101 26 P CABUT GIGI SUSU 10,000 10000

303 NAKESYA 285791781 4 P ISPA 10,000 10000

304 RAKA 284144747 6 L KB 10,000 10000

305 ASRIL 284849109 73 P 18-Sep Gastritis 10,000 10,000

306 MULDAYENI 2842011234 35 P ISPA 10,000 10,000

307 ELONIA 284860629 27 P ISPA 10,000 10,000

308 RUSTAM 987534944 50 L CC 10,000 10,000

309 zuraida 284205849 11 P 19-Sep dermatitis 10,000 10,000

310 muharia 279650158 6 P KB 10,000 10000

311 m iqbal 284750728 45 L 20-Sep CABUT GIGI TETAP 20,000 20,000

312 edo septio 28574497 11 L ISPA 10,000 10,000

313 SITI ROHANA 285746679 31 P RA 10,000 10,000


314 AURA NINGSIH 987535811 1 P HIPERTENSI 10,000 10,000

315 DASRISOL 274769404 57 L ISPA 10,000 10,000

316 M FIKRI ISWANDI 987535102 14 L ra 10,000 10,000

317 MUNIR 284054645 12 L Gastritis 10,000 10,000


318 ROSMAN 284855848 79 L ISPA 10,000 10,000
319 ASTRI M 285397154 11 P 23-Sep CABUT GIGI TETAP 20,000 20000
320 ASWANDI 285526719 46 L Gastritis 10,000 10,000
321 YOGA 285722199 6 L ra 10,000 10,000

322 MERI 987534584 31 P Ispa 10,000 10,000

323 M.ABDUL 987534595 7 L ra 10,000 10,000

324 DERMA YELTI 285389864 46 P CABUT GIGI TETAP 20,000 20,000

325 MAULUSI 284887664 9 P Ispa 10,000 10,000

TOTAL 180,000 70000 30000 280,000

NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

326 ILMA 285659302 9 P 23-Sep ISPA 10,000 10,000

327 DHEA 284703207 8 P CABUT GIGI SUSU 10,000 10000

328 AZPA S 278934726 2 P ISPA 10,000 10000

329 IRANETI 284727519 56 P 24-Sep KB 10,000 10000

330 RENO SYAH PUTRA 284781565 20 L cabut gigi tetap 20,000 20,000

331 RIZAL 284145609 5 L ISPA 10,000 10,000

332 MISLAWATI 284760437 45 P ISPA 10,000 10,000

333 INDRA YETI 284856941 50 P CC 10,000 10,000

334 HAIKAL 285457893 3.5 L 26-Sep dermatitis 10,000 10,000

335 USMAN 289776532 35 L KB 10,000 10000

336 NILDAWATI 279032127 36 P Gastritis 10,000 10,000

337 SUDIRMAN 285133426 58 L ISPA 10,000 10,000


338 FEBBY I 285481767 45 P RA 10,000 10,000

339 MAIRIZAL 285164175 21 L HIPERTENSI 10,000 10,000

340 KIKI 289818229 12 L ISPA 10,000 10,000

341 HAFID 285677799 23 P 27-Sep ra 10,000 10,000

342 MITRA DEWI 28482267 29 P Gastritis 10,000 10,000


343 MARSA 284526789 3.5 P ISPA 10,000 10,000
344 YASRIL 285723786 49 L CABUT GIGI TETAP 20,000 20000
345 ICHA 284877659 35 P Gastritis 10,000 10,000
346 HENDRA 285429435 34 L ra 10,000 10,000

347 YULIZA 285748593 36 P Ispa 10,000 10,000

348 HENGKI 284165414 26 L ra 10,000 10,000

349 RUSTIAN 285614967 71 L 28-Sep Ispa 10,000 10,000

350 TATI WARNI 284723436 42 P Ispa 10,000 10,000

TOTAL 190,000 50000 30000 270,000

NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

351 YUSNI 284737792 67 P 28-Sep ISPA 10,000 10,000

352 ZURAIDA 284036353 68 P cabut gigi tetap 20,000 20000

353 WAHID 284191280 9 L ISPA 10,000 10000

354 NASIPA PUTRI 284199281 7 P KB 10,000 10000

355 HENDRI 285628197 21 L Gastritis 10,000 10,000

356 MURNIATI 284825081 32 P ISPA 10,000 10,000

357 NATI A 28476956 37 P 30-Sep ISPA 10,000 10,000

358 SUHARNA 987534579 35 P CC 10,000 10,000

259 NORIZA MELA 284836318 27 P dermatitis 10,000 10,000

360 M. EBAR DAVID 284899678 3 L KB 10,000 10000

361 RATNA KASIA 285089123 70 P Gastritis 10,000 10,000


362 WIDIA ASTUTI 285423456 25 P ISPA 10,000 10,000

363 IRMA IRAWATI 2857205876 18 P RA 10,000 10,000

364 ALDO 285367791 5 L HIPERTENSI 10,000 10,000

365 ALDI 2853682346 5 L ISPA 10,000 10,000

366 SULASTRI 285379235 23 P ra 10,000 10,000

367 SYAFNI 285141776 47 P Gastritis 10,000 10,000


368 YETI 284757346 36 P ISPA 10,000 10,000
369 BETARAS 285149563 42 P CABUT GIGI TETAP 20,000 20000

TOTAL 210,000

TOTAL KESELURUHAN 3,820,000

DIKETAHUI PAYAKUMBUH, OKTOBER 2013


KEPALA PUSKESMAS TIAKAR PELAKSANA PROGRAM

dr.NETI HARTATI Desty amelia,A.Md Keb


19750316 200604 2 009 19820103 200501 2 004
RINCIAN KLAIM JAMKESMAS TAHUN 2013
PUSKESMAS TIAKAR BULAN OKTOBER

NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

1 SILVIA HADI 987538961 22 P 1-Oct HAMIL 10,000 10,000

2 ROSNETI 285168341 38 P Gastritis 10,000 10,000

3 MAYA 987534639 2 P 4-Oct ISPA 10,000 10,000

4 DERI 284769966 28 L 5-Oct Gastritis 10,000 10,000

5 SILVIA HADI 987538961 22 P 6-Oct HAMIL 10,000 10,000

6 GUSNETI 285178318 47 P 7-Oct ANXIETAS 10,000 10,000

7 PONI 285178318 17 P ALERGI 10,000 10,000

8 DWI PUJI LESTARI 285095788 26 P 11-Oct HAMIL 10,000 10000

9 SUSANTI 285120786 24 P 14-Oct HAMIL 10,000 10000

10 YUSLINAR 987535179 57 P 14-Oct S KEPALA 10,000 10000

11 RUMZI 284774174 37 L ALERGI 10,000 10,000

12 RESMA NELWITA 285143275 44 P 17-Oct ISPA 10,000 10000


13 CANDRA ASMARA 285325929 36 L ISPA 10,000 10,000
14 PANI 285178318 17 P ALERGI 10,000 10,000
15 YULITA 285287815 45 P 18-Oct LUKA INF 10,000 10,000
16 FAUZIAH 285156369 8 P 21-Oct ISPA 10,000 10,000
17 SAMSURILAS 284920694 69 P 22-Oct ISPA 10,000 10,000
18 LIDYA NOFA 285118997 30 P 24-Oct HIPOTENSI 10,000 10,000
19 RUBAYAH 285457555 75 P DIARE 10,000 10,000
20 DEWI MAYASARI 285122643 21 P Gastritis 10,000 10,000
21 SYAMSI 285168014 55 P 25-Sep ALERGI 10,000 10,000
22 RATIH 284908162 31 P ISPA 10,000 10,000
23 ZACKY 284810141 5.5 L OMA 10,000 10,000
TOTAL 180,000 0 50000 0 230,000

NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

24 YUNDRITA 284815034 48 P dermatitis 10,000 10,000

25 DERMI 285389864 45 P ASMA 10,000 10,000

26 LIDAR 285113812 43 P ASMA 10,000 10,000

27 JASRI 987536114 69 L RA 10,000 10,000

28 JASRI 987536114 69 L 27-Sep RA 10,000 10000

29 LIDAR 285185182 43 P ASMA 10,000 10,000

30 DONA 285441759 12 P Gastritis 10,000 10,000

31 M HAIKAL 285449501 8 L PAROTITIS 10,000 10,000

32 FIKA 285382721 29 P LUKA 10,000 10,000

33 WASNA 285333399 40 P LUKA 10,000 10000

34 RIFAN 285392801 9 L 1-Oct ABSES 10,000 10,000

35 FATIMAH 279625228 75 P HT 10,000 10,000

36 YENDRI 284825171 37 P HYPOTENSI 10,000 10,000

37 RAHUL 278094453 10 L LUKA 10,000 10,000

38 M ALIF 285383575 9 L TONSILITIS 10,000 10000

39 FIKA 285382721 29 P TV 10,000 10,000

40 BETTY 279649359 37 P ISK 10,000 10000

41 BAGIO 284802349 40 P Gastritis 10,000 10,000

42 ROSTI 285428979 63 L 2-Oct CARIES 10,000 10,000

43 RAHMA YULI 284895922 28 P HAMIL 10,000 10,000

44 SAFNAWEPI 284827285 52 L ISPA 10,000 10,000

45 AGUSMA 284809195 72 P HT 10,000 10,000

46 SARI OJI 284921908 65 P 3-Oct ISPA 10,000 10,000

47 ERLINA 279645996 45 P ISPA 10,000 10000


48 NURBAITI 284854421 13 P HT 10,000 10,000

TOTAL 180,000 20000 10000 40000 250,000

NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

49 DERMI 285289864 27 P 3-Oct ISK 10,000 10,000

50 DONA 285441759 45 P GE 10,000 10,000

51 DINA 284922595 2.5 P ISPA 10,000 10,000

52 LIDAR 284917959 55 P ASMA 10,000 10,000

53 NAIRA 279630923 45 P 4-Oct ISPA 10,000 10,000

54 RIDDAIYAH 279680005 18 P ASMA 10,000 10,000

55 DERMI 285261221 5.5 P ASMA 10,000 10,000

56 IRFAN 279610806 10 L FEBRIS 10,000 10,000

57 RANGGA 278095408 41 L 5-Oct ISPA 10,000 10,000

58 RAHUL 278094453 27 L FARINGITIS 10,000 10,000

59 PITRAWATI 279625678 51 P 7-Oct ISPA 10,000 10,000

60 YUNITA 284821316 44 P HAMIL 10,000 10,000

61 SUMARNI 987535732 4.5 P CARIES 10,000 10,000

62 ZAHRIAL 285390977 8 L ISPA 10,000 10,000

63 ARINI 279671948 55 P ABSES 10,000 10,000

64 AGUNG 2845058111 25 L ISPA 10,000 10,000

65 SYAMSI 285439638 45 P 8-Oct ALERGI 10,000 10,000

66 VIVI 284810061 16 P FLOURALBUS 10,000 10,000


67 DERMI 279633265 27 P ASMA 10,000 10,000
68 WILY 289445787 53 L ISPA 10,000 10,000
69 RATIH 279625228 27 P FARINGITIS 10,000 10,000
70 RIDAIYAH 279680005 53 P RA 10,000 10,000
71 ZULKIFLI 284803299 55 L 9-Oct LUKA 10,000 10,000
72 MISWARNI 279632327 72 P RA 10,000 10,000
73 AZURA 279670274 22 P 10-Oct ISPA 10,000 10,000

TOTAL 200,000 20000 20000 10,000 250,000

NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

74 ERNA YULITA 279877068 45 P 10-Oct dermatitis 10,000 10000

75 ARINI 279671984 4.5 P ABSES 10,000 10,000

76 PIT 285389864 19 P HAMIL 10,000 10,000

77 YUNITA 284719364 19 P HAMIL 10,000 10,000

78 ASRI 98753155 20 P HAMIL 10,000 10,000

79 DESWIKA 285420936 20 P ASMA 10,000 10000

80 NURBAITI 285423513 65 P 11-Oct RA 10,000 10,000

81 SARIOJI 284921908 68 P RA 10,000 10,000

82 LIDAR 284877944 43 P ASMA 10,000 10000

83 DERMI 284837804 45 P 12-Oct ASMA 10,000 10,000

84 ERLINA 279645996 45 P DESMINORE 10,000 10,000

85 ELIDAR 284904959 51 P 14-Oct CEPALGIA 10,000 10,000

86 RIVAL 284804379 16 L LUKA 10,000 10,000

87 LIDAR 279677913 43 P 16-Oct ASMA 10,000 10,000

88 RIVAL 284804375 16 L LUKA 10,000 10,000

89 YULI 284719364 36 P 17-Oct HAMIL 10,000 10,000

90 LIDAR 285378696 43 P CC 10,000 10,000

91 AIRA 987536158 5 P ISPA 10,000 10,000

92 DERMI 2853901885 45 P 18-Oct ASMA 10,000 10000

93 M IRFAN 285389864 5 L 19-Oct ISPA 10,000 10,000


94 AGUNG 284899048 8 L HERPES 10,000 10,000
95 WIRNA LAILI 279630933 48 P CEPALGIA 10,000 10,000
96 APRIADI 289460468 5 L ALERGI 10,000 10,000
97 RINA 284802906 38 P HAEMOROID 10,000 10000
98 PENI 284199817 34 P ABSES 10,000 10,000

TOTAL 170,000 20,000 40000 20000 250,000

NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

99 YOGA 28486982 16 L 19-Oct ABSES 10,000 10,000

100 SARIOJI 284921908 63 P RA 10,000 10000

101 SITI AISYAH 517006113 66 P 21-Oct Gastritis 10,000 10000

102 AGUNG 284750627 8 L HERPES 10,000 10000

103 ROSMAULETO 28475879 80 L CC 10,000 10,000

104 RONI 284826374 9 L 22-Oct ISPA 10,000 10,000

105 YULFERA 285391113 35 P HYPOTENSI 10,000 10,000

106 PUTRI 285394893 3.5 P CC 10,000 10,000

107 SHARUL 285432941 10 L FARICELA 10,000 10,000

108 ERMI 285660797 54 P Gastritis 10,000 10000

109 MADRISAH 284911964 44 P FLOURALBUS 10,000 10,000

110 NASRIAL 285475162 47 L 23-Oct MYALGIA 10,000 10,000

111 AULIA SAFITRI 279681491 4 P ISPA 10,000 10,000

112 SRILEC 279680826 29 P ISPA 10,000 10,000

113 Fatma 285424031 13 P VARICELA 10,000 10,000


114 DERMI 284910581 45 P 24-Oct ISPA 10,000 10,000
115 WILY 285390189 16 L DIARE 10,000 10,000
116 Fatma 285424031 13 P VARICELA 10,000 10,000
117 AFDAL 284851269 14 L FEBRIS 10,000 10000
118 INDRA 2854545518 22 L ISPA 10,000 10,000
119 AGUNG 285101177 8 L HERPES 10,000 10,000
120 MUSTIKA WATI 987536046 27 P 1-Oct ISPA 10,000 10,000
121 YANDI AKMAL 284819815 38 L LUKA 10,000 10,000
122 NELMA 284802906 72 P ISPA 10,000 10,000
123 DONA SAFITRI 285441759 12 P Ispa 10,000 10,000

TOTAL 230,000 10000 0 10000 250,000

NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

124 QURATUL AINI 285644035 22 P 1-Oct ISPA 10,000 10,000

125 LUTFI 286207630 17 L CABUT GIGI SUSU 10,000 10000

126 AKAZURA 285579077 4.5 P PULVITIS 10,000 10000

127 TOMI PRATAMA 284750651 13 L ISPA 10,000 10000

128 KASMINA 285505345 54 L Gastritis 10,000 10,000

129 MULHADI 284839133 43 L 2-Oct ISPA 10,000 10,000

130 GISKI DWI 2815741415 24 P ISPA 10,000 10,000

131 ABDUL H 284767751 32 L CC 10,000 10,000

132 PUTRI AULIA 287538882 10 P dermatitis 10,000 10,000

133 AYLALEO 284816518 7 P KB 10,000 10000

134 GUSMIANA 285718689 59 P 3-Oct Gastritis 10,000 10,000

135 MULHADI 284839232 43 L ISPA 10,000 10,000

136 DARA SUSANTI 284758942 16 P RA 10,000 10,000

137 MAHYUNI 2847501953 60 L HIPERTENSI 10,000 10,000

138 JASRIL 285412342 38 L ISPA 10,000 10,000

139 PILIAN 285460365 24 L ra 10,000 10,000

140 SYAMSUAR 285652551 75 L Gastritis 10,000 10,000


141 ZULHAIDAH 285654418 41 P ISPA 10,000 10,000
142 ADEK TANJUNG 287531899 32 P CABUT GIGI TETAP 20,000 20000
143 EPI SOPIANTO 284897976 27 L 4-Oct Gastritis 10,000 10,000
144 SITI ROHANA 287535811 41 P ra 10,000 10,000
145 PATMONO 284767719 48 L Ispa 10,000 10,000
146 M DIPA 284857953 13 L ra 10,000 10,000
147 AMELIA 279641417 5 P Ispa 10,000 10,000
148 SYAMSURIZAL 285646724 53 L Ispa 10,000 10,000

TOTAL 210,000 40000 10000 260,000

NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

149 AFRIZAL 285324311 35 L 4-Oct ISPA 10,000 10,000

150 OKTA MARINA 284432437 27 P TMJ 10,000 10000

151 RUSTIAN 285671496 71 P ISPA 10,000 10000

152 DONA SAFITRI 287667899 12 P 5-Oct LUKA 10,000 10000

153 MITRA LINA 284828253 40 P CC 10,000 10,000

154 ZURAIDA 284830353 68 P TINEA 10,000 10,000

155 ROSMAN 2853077154 45 L 7-Oct ISPA 10,000 10,000

156 VIRA ELMI 284176989 43 P ASMA 10,000 10,000

157 LAILA S 2796011311 9 P VARISELA 10,000 10,000

158 YUMITA 284172759 29 P 8-Oct RA 10,000 10000

159 KURNIA FAJRI 285200526 5.5 P ISPA 10,000 10,000

160 SUDIRMAN 285130146 58 L dermatitis 10,000 10,000

161 ANISAR 284219049 78 P CC 10,000 10,000

162 TRI VAHYEKA 284827317 12 L ASMA 10,000 10,000

163 FEHRA YENI 285072164 31 P CARIES 10,000 10,000

164 GUSMIANA 285718689 55 P 9-Oct ISPA 10,000 10,000

165 MULIADI 284834232 43 L LUKA 10,000 10,000


166 RANGGA NANDA 28549149 19 L TONSILITIS 10,000 10,000
167 RUSTAM 285071498 49 L DIARE 10,000 10000
168 JUMA 285134949 11 L CEPALGIA 10,000 10,000
169 PRAMUDIA 285134174 13 L dermatitis 10,000 10,000
170 AFRIZAL 987538735 38 L ISPA 10,000 10,000
171 SYAFNI 285641166 48 P ANEMIA 10,000 10,000
172 M RIDHO 284742999 7 L Ispa 10,000 10,000
173 KHAIRUL 285603884 49 L KB 10,000 10,000
TOTAL 210,000 10000 20000 10,000 250,000

NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

174 USMAN 284141957 82 L 10-Oct ALERGI 10,000 10,000

175 ERMITA 284353323 51 P RA 10,000 10000

176 ROZI 284355718 17 L ASMA 10,000 10000

177 SUSILAWATI 2847167009 35 P TAMBAL TETAP 20,000 20000

178 TAMI WAMI 284732436 37 P ISPA 10,000 10,000

179 ZULMA 284892434 50 P 11-Oct ISPA 10,000 10,000

180 ENIDA 285603934 47 P HT 10,000 10,000

181 MONSIARNI 284910381 52 P DIARE 10,000 10,000

182 QURATUL AINI 285644045 25 P 12-Oct ABSES 10,000 10,000

183 SALMA 284892434 42 P CABUT GIGI TETAP 20,000 20000

184 ANGGI 284894706 14 P ALERGI 10,000 10,000

185 NOVILA DEWI 284094179 19 P TONSILITIS 10,000 10,000

186 YASNI 284737792 46 P 16-Oct MYALGIA 10,000 10,000

187 TIO 285338136 11 L Ispa 10,000 10,000

188 ERLILA 285336832 40 P Ispa 10,000 10,000

189 MUHAINI 284951081 43 P ra 10,000 10,000

190 ISNET 2851351921 51 P Ispa 10,000 10,000


191 SHINTA 2841548498 17 P ISPA 10,000 10,000
192 AFRIZAL 2853243187 41 L Ispa 10,000 10000
193 SUDIRMAN 2851231469 3 L Gastritis 10,000 10,000
194 YUYLIA 2849055347 50 P ra 10,000 10,000
195 WINDI 289915811 28 P Ispa 10,000 10,000
196 HUSNUL K 2854015703 13 P ra 10,000 10,000
197 KHAIRUL 285603884 49 L 17-Oct periodontitis 10,000 10,000
198 RUSDI 284736374 43 L Ispa 10,000 10,000
TOTAL 210,000 60000 0 270,000

NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

200 MUSTIKA WATI 287556546 27 P 17-Oct ISPA 10,000 10,000

201 YUNALDI 287484656 29 L CABUT GIGI SUSU 10,000 10000

202 ERNAWATI 387296754 34 P ISPA 10,000 10000

203 SYAHRIL 285641186 16 L KB 10,000 10000

204 INDRI R 987535811 43 P Gastritis 10,000 10,000

205 ROSTIAN 285671496 46 P ISPA 10,000 10,000

206 OSNITA 285719231 36 P 18-Oct ISPA 10,000 10,000

207 EPI SUSANTI 284854184 45 P CC 10,000 10,000

208 FAJRI MANDALA 284175022 11 L dermatitis 10,000 10,000

209 DELFINA RAHMI 285097364 26 P KB 10,000 10000

210 IRNA IRAWATI 285726587 18 P ISPA 10,000

211 REGIA RAHADINI 285685211 38 P ISPA 10,000 10,000

212 ROSMANETI 285683949 36 P cabut gigi susu 10,000 10,000

213 SYAMSIDAR 285744183 69 P abses 10,000 10,000

214 SITI ROHANA 987535817 35 P 19-Oct ISPA 10,000 10,000

215 ELVI 284175358 40 P ra 10,000 10,000

216 FITRI HANDAYANI 284176372 17 P Gastritis 10,000 10,000


217 MURDIAN 285054107 75 L 21-Oct ISPA 10,000 10,000
218 ROSTIAN 285671996 25 L ISPA 10,000 10000
219 RAFI 285019866 20 L Gastritis 10,000 10,000
220 NURELNA 285489512 47 P ra 10,000 10,000
221 RAYO 284883219 37 P Ispa 10,000 10,000
222 MULDAYENI 284201212 31 P ra 10,000 10,000
223 YURLIDARAT 287151267 47 P Ispa 10,000 10,000
224 SUCI A 285708199 14 P Ispa 10,000 10,000
TOTAL 200,000 30000 20000 250,000

NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

225 ISMILAIYUN 284818241 20 P 21-Oct ISPA 10,000 10,000

226 RESTI 285670192 18 P CABUT GIGI SUSU 10,000 10000

227 RIZKI E 284770701 8 L ISPA 10,000 10000

228 KHAIRUL 285603884 49 L 22-Oct KB 10,000 10000

229 FINO RANADA 281985049 13 L Gastritis 10,000 10,000

230 RINI 284886189 24 P ISPA 10,000 10,000

231 MEIYUNI 284888798 2 P ISPA 10,000 10,000

232 NOZULNI SYAM 285651573 32 P 23-Oct CC 10,000 10,000

233 MITRAVAL 284739812 15 L dermatitis 10,000 10,000

234 ANTING GUSTI 284844077 42 P KB 10,000 10000

235 USMATI 284819806 27 P Gastritis 10,000 10,000

236 DAMITUN 28489615 69 L ISPA 10,000 10,000

237 BAYU SHAVAR 28566731 17 L RA 10,000 10,000

238 INDRI R 98752827 19 P HIPERTENSI 10,000 10,000

239 SUNARTI 28512899 54 L ISPA 10,000 10,000

240 EKO 284190693 41 P 24-Oct Gastritis 10,000 10,000


241 GUSNI 285729534 52 P Gastritis 10,000 10,000
242 NURHELNI 285469525 50 P ISPA 10,000 10,000
243 RESTI S 28507912 18 P CABUT GIGI TETAP 20,000 20000
244 YOGA 285722199 6 L Gastritis 10,000 10,000
245 NOVIA H 285503624 24 L ra 10,000 10,000
246 AHMAD 28568808 15 L Ispa 10,000 10,000
247 SYASNI 28504166 48 L ra 10,000 10,000
248 SITI ROHANA 987535811 35 P 25-Oct Ispa 10,000 10,000
249 INDRI R 987528835 44 P Ispa 10,000 10,000

TOTAL 210,000 30000 20000 260,000

NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

250 RIRI 987588979 23 P 25-Oct ISPA 10,000 10,000

251 STEFI Y 287535692 9 P CABUT GIGI SUSU 10,000 10000

252 DESRITA R 987125457 28 P ISPA 10,000 10000

253 MURNI 289888749 34 P KB 10,000 10000

254 RIRI M 289880189 23 P Gastritis 10,000 10,000

256 QODIN 285474756 7 P ISPA 10,000 10,000

257 AFRIYANTI 28489178 36 P INSISI ABSES 40,000 40,000

258 HARUN 284816215 65 P CC 10,000 10,000

259 YUSNI 284757792 38 P 26-Oct dermatitis 10,000 10,000

260 RUSTIAN 285671492 65 P KB 10,000 10000

261 YUSRIZUL 284817475 42 L Gastritis 10,000 10,000

262 NOLISYAM 28551575 34 P abses 10,000 10,000

263 SYAMSUAR 285051515 75 L RA 10,000 10,000

264 DAHRI 284853879 69 P HIPERTENSI 10,000 10,000

265 NURASNI 285125153 56 P 28-Oct ISPA 10,000 10,000


266 RAHI 284918167 26 L ra 10,000 10,000

267 M FADLI 285584881 12 P Gastritis 10,000 10,000


268 SRI RAMADINI 284355567 16 L ISPA 10,000 10,000
269 YOSI M 285328564 18 L ISPA 10,000 10000
270 SYAFNI 285641166 17 L Gastritis 10,000 10,000
271 M FIKRI ISWANDI 284854123 13 P ra 10,000 10,000
272 USMAN 284141957 80 L 29-Oct ISPA 10,000 10,000
273 YUSHANELDI 285309935 44 P ra 10,000 10,000
274 ANNAR 28558434 49 L Ispa 10,000 10,000
275 MUSDAVANI 284766467 47 P Ispa 10,000 10,000

TOTAL 200,000 60000 20000 280,000

NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

276 USNAR 228472243 44 L 29-Oct ISPA 10,000 10,000

277 SISGI 285463468 86 P CABUT GIGI SUSU 10,000 10000

278 RIDO P 2857023457 18 L ISPA 10,000 10000

279 DZAKI 284807065 10 L KB 10,000 10000

280 SYINTIA 279633205 11 L 30-Oct Gastritis 10,000 10,000

281 GISKA 285741415 24 P ISPA 10,000 10,000

282 ABDUL H 285428297 15 L ISPA 10,000 10,000

283 NURJASNI 285656962 76 P CC 10,000 10,000

284 INDRA 285669864 45 P dermatitis 10,000 10,000

285 MUCHTAR 289895265 49 L KB 10,000 10000

286 REYARTI 987599787 11 L Gastritis 10,000 10,000

287 ROZI S 28435578 17 L ISPA 10,000 10,000

288 ERNITA 284355847 51 P RA 10,000 10,000

289 YUSNITA 284932607 40 P 1-Oct KB 10,000 10,000


290 SURYUNI MARSOKA 278093981 31 L 2-Oct HIPOTENSI 10,000 10,000

291 RESTI 285280716 17 P CC 10,000 10,000

292 ETI YULIA 285280694 36 P 3-Oct HIPOTENSI 10,000 10,000


293 ELFI HAIMAR 28529869 48 P Gastritis 10,000 10,000
294 IFRAYANTO 2853419214 34 P 4-Oct KB 10,000 10000
295 NURMAWATI 285343209 35 P 5-Oct CC 10,000 10,000
296 BIMA PUTRA 285343659 5 P 7-Oct CARIES 10,000 10,000
297 BAMBANG HADI 285248441 16 L ISPA 10,000 10,000
298 SUSILAWATI 24758237 24 P RA 10,000 10,000
299 M YUSUF AGUSTINA 285238103 13 L 8-Oct ISPA 10,000 10,000
300 ILHAM M 285338147 8 L Ispa 10,000 10,000
TOTAL 190,000 20000 40000 250,000

NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

301 BUNGA 284926803 6 P 9-Oct TONSILITIS 10,000 10,000

302 FATRIA 284917959 29 P 10-Oct HIPOTENSI 10,000 10000

303 GUSTIANA 284918141 7 P ISPA 10,000 10000

304 NINA A 285530848 25 P 11-Oct KB 10,000 10000

305 AZZAM 285530848 6 BLN L 18-Sep ISPA 10,000 10,000

306 ABDL ROZAK 284934352 5 L 12-Oct LUKA 10,000 10,000

307 RINI 285333399 20 P 13-Oct KB 10,000 10,000

308 MAIDARLIS 284910333 49 P 16-Oct ISPA 10,000 10,000

309 YURMITATI 285291685 50 P 19-Sep Gastritis 10,000 10,000

310 ETI YULIA 285280694 36 P 17-Oct HERPES 10,000 10000

311 FATRIA 284917959 29 P 18-Oct HIPOTENSI 10,000 10,000

312 THIO ANGGARA 285241421 15 L ISPA 10,000 10,000

313 ROBI CANDRA 285551886 18 L 19-Oct ISPA 10,000 10,000


314 DANUN 285347395 72 L 21-Oct URTICARIA 10,000 10,000

315 ROSMAWATI 285273821 55 P 22-Oct HT 10,000 10,000

316 FANYA 284926803 6 P TONSILITIS 10,000 10,000

317 RINI 28533399 20 P 23-Oct FARINGITIS 10,000 10,000


318 MARTA GIA 285247405 27 P 24-Oct KB 10,000 10,000
319 SILVIA 285507819 30 P KB 10,000 10000
320 DENDI LASWARDI 276880698 37 L 25-Oct ISPA 10,000 10,000
321 HABIBULLAH 276889724 4.5 L 26-Oct ISPA 10,000 10,000
322 BAIRAS 285520228 70 P SERUMEN PROP 10,000 10,000
323 ELFI HUSNA 28494379 53 P 28-Oct ra 10,000 10,000
324 MARDIANIS 285517967 47 P 29-Oct HEATING OFF 10,000 10,000
325 SAMSURILAS 284920694 68 P 30-Oct ISPA 10,000 10,000
TOTAL 200,000 0 40000 10000 250,000

NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

326 SRI RAMADINI 28533445 17 P 31-Oct ISPA 10,000 10,000

327 HILDA LINI 285329349 40 P KB 10,000 10000

328 MULYANA 285231666 37 P KB 10,000 10000

TOTAL 30,000

TOTAL KESELURUHAN 3,330,000

DIKETAHUI PAYAKUMBUH, NOVEMBER 2013


KEPALA PUSKESMAS TIAKAR PELAKSANA PROGRAM

dr.NETI HARTATI Desty amelia,A.Md Keb


19750316 200604 2 009 19820103 200501 2 004
RINCIAN KLAIM JAMKESMAS TAHUN 2013
PUSKESMAS TIAKAR BULAN NOVEMBER

NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

1 SUCI ANISA 285626002 3.5 P 1-Nov HAMIL 10,000 10,000

2 DHIVA MAUZANE 285671496 5 P Gastritis 10,000 10,000

3 TRI RAHMAWATI 284897924 26 P ISPA 10,000 10,000

4 AMILIUS 284897621 69 L Gastritis 10,000 10,000

5 HANSTANDO 284890082 11 L HAMIL 10,000 10,000

6 EGI MONANDA 285736183 45 P ANXIETAS 10,000 10,000

7 REGINA 285736386 3.5 P ALERGI 10,000 10,000

8 DASRISOL 987535102 57 L HAMIL 10,000 10000

9 ASNUR 284836656 24 L HAMIL 10,000 10000

10 ROSTIANTI 285671496 75 P S KEPALA 10,000 10000

11 DASNI TANDO 285134927 48 L ALERGI 10,000 10,000

12 RENI MARLINA 285283697 38 P 2-Nov ISPA 10,000 10000


13 M.ARIFHIDAYAT 284821209 8 L ISPA 10,000 10,000
14 HAFIZ ARIF F 284891545 2.5 L ALERGI 10,000 10,000
15 HANS DIANDA 285736173 5 P 4-Nov LUKA INF 10,000 10,000
16 ESI YANTI 284873837 42 P ISPA 10,000 10,000
17 GUSNELI 285178318 48 P ISPA 10,000 10,000
18 SYAFRI 28443243 71 L HIPOTENSI 10,000 10,000
19 SYAFNI 985641166 49 L DIARE 10,000 10,000
20 PONI 285179567 17 P Gastritis 10,000 10,000
21 NURELMA 285460525 56 P ALERGI 10,000 10,000
22 SYAMSUAR 285651551 77 L ISPA 10,000 10,000
23 ABIBAH AISYAH 285590676 7 P OMA 10,000 10,000
TOTAL 180,000 0 50000 0 230,000

NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

24 RATIH DWI ASTUTI 285584501 48 P 4-Nov dermatitis 10,000 10,000

25 USMAN 284141957 75 L ASMA 10,000 10,000

26 EMA R 284854921 49 P ASMA 10,000 10,000

27 ROSTIAN 285671496 69 L 6-Nov RA 10,000 10,000

28 ZULBAINI 285109746 42 P RA 10,000 10000

29 YURDALITA 284831943 45 P ASMA 10,000 10,000

30 YULISMAR 285440433 62 P Gastritis 10,000 10,000

31 AQIL RAHMAT MUFTI 284739862 6 L PAROTITIS 10,000 10,000

32 YULIZA 285748593 36 P LUKA 10,000 10,000

33 M.RIDO 284742999 7 L LUKA 10,000 10000

34 IEAN BINTANG 987534483 15 L ABSES 10,000 10,000

35 RINI MUKTAR 284886189 33 P HT 10,000 10,000

36 MAYA 27404780 20 P HYPOTENSI 10,000 10,000

37 RIDO E 285629753 5 L LUKA 10,000 10,000

38 HENDRI 285282979 21 L TONSILITIS 10,000 10000

39 RIVO 285710758 14 L 7-Nov TV 10,000 10,000

40 ERNITA 279681830 40 P ISK 10,000 10000

41 MULIA A 28545717 31 P Gastritis 10,000 10,000

42 ROHANA 284770695 36 P CARIES 10,000 10,000

43 EDO S 285790679 11 L HAMIL 10,000 10,000

44 NURAHILA 285506711 7 P ISPA 10,000 10,000

45 MAINAR 284750027 39 P HT 10,000 10,000

46 SITI ROHANA 987535811 41 P 8-Nov ISPA 10,000 10,000

47 ADRIZAL 285607919 46 P ISPA 10,000 10000

48 BASRI TANDO 285139921 50 L HT 10,000 10,000


TOTAL 180,000 20000 10000 40000 250,000

NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

49 M NASIR 289814412 48 L 8-Nov ISK 10,000 10,000

50 IKHSAN 284747999 8 L GE 10,000 10,000

51 RANGGA S 285457550 7.5 P 9-Nov ISPA 10,000 10,000

52 M JUSMAN 285385915 12 L ASMA 10,000 10,000

53 FAZIAH 284141305 10 P ISPA 10,000 10,000

54 NENI 285094561 31 P 11-Nov ASMA 10,000 10,000

55 M EGA DAVIT 289899078 5.5 P ASMA 10,000 10,000

56 YANTI 284899072 10 L FEBRIS 10,000 10,000

57 MURADILA 284750998 75 P ISPA 10,000 10,000

58 RUSTAN 285071990 70 P FARINGITIS 10,000 10,000

59 DAKZER 28568175 67 P ISPA 10,000 10,000

60 FIFI 28417637 17 P HAMIL 10,000 10,000

61 RAFI 284050534 28 L CARIES 10,000 10,000

62 NOVILA DEWI 284894721 20 P ISPA 10,000 10,000

63 DELMIYENTI 285319647 39 P ABSES 10,000 10,000

64 YUSNITA 284717112 40 P ISPA 10,000 10,000

65 RAHMAD 285202091 9 L ALERGI 10,000 10,000

66 WINDA 285507292 16 P FLOURALBUS 10,000 10,000


67 IRNA IRAWATI 286726587 15 P ASMA 10,000 10,000
68 MARDISON 289445787 36 L 12-Nov ISPA 10,000 10,000
69 EVANIL WATI 279625228 42 P FARINGITIS 10,000 10,000
70 ANIZAR 279680005 47 L RA 10,000 10,000
71 RATIH DWI ASTUTI 284803299 17 P LUKA 10,000 10,000
72 ROBBI RAMADANI 279632327 23 L RA 10,000 10,000
73 MUKLIS 279670274 62 L ISPA 10,000 10,000

TOTAL 200,000 20000 20000 10,000 250,000

NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

74 WIDYA F 279877068 26 P 12-Nov dermatitis 10,000 10000

75 YULIA FERA 279671984 16 P ABSES 10,000 10,000

76 SYAFNI 285389864 49 L HAMIL 10,000 10,000

77 OLIVIA 284719364 15 P HAMIL 10,000 10,000

78 M RIDHO 98753155 7 L HAMIL 10,000 10,000

79 IRDRA D 285420936 20 L ASMA 10,000 10000

80 M RISKI 285423513 5 P 13-Nov RA 10,000 10,000

81 NEFI E 284921908 29 P RA 10,000 10,000

82 AURA R 284877944 4 P ASMA 10,000 10000

83 ILMA 284837804 6 P ASMA 10,000 10,000

84 RAHIL 279645996 3 L DESMINORE 10,000 10,000

85 BASRI RINDO 284904959 50 L 14-Nov CEPALGIA 10,000 10,000

86 NUR EFENDI 284804379 22 L LUKA 10,000 10,000

87 BOY S 279677913 29 L ASMA 10,000 10,000

88 IWAN B S 284804375 15 L LUKA 10,000 10,000


89 GUNSIARNI 284719364 60 P HAMIL 10,000 10,000
90 BUHARI C 285378696 36 L CC 10,000 10,000
91 RAFI A 987536158 22 L ISPA 10,000 10,000
92 NOVITA DEWI 2853901885 20 P ASMA 10,000 10000
93 M EGA DAVIT 284899078 6 L ISPA 10,000 10,000
94 M ANFI 28489071 24 L HERPES 10,000 10,000
95 SYINTA B 279633205 11 P CEPALGIA 10,000 10,000
96 DINDA 27963352 7 P ALERGI 10,000 10,000
97 ZULKARNIA 284899291 59 L HAEMOROID 10,000 10000
98 KHAIRUL 28564556 49 L 15-Nov ABSES 10,000 10,000

TOTAL 170,000 20,000 40000 20000 250,000

NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

99 AFNI 285280950 19 L 15-Nov ABSES 10,000 10,000

100 ASRI 289701051 20 L RA 10,000 10000

101 DHIVA MAUZANE 28489724 4 P Gastritis 10,000 10000

102 DEDI RUPI 284158157 6 P HERPES 10,000 10000

103 SYAFNI 284829221 41 L CC 10,000 10,000

104 YESI YULITA 285503411 31 P ISPA 10,000 10,000

105 YESSI 285391113 20 P 16-Nov HYPOTENSI 10,000 10,000

106 RAHMI 285394893 15 P 18-Nov CC 10,000 10,000

107 MELDA 285432941 7 L FARICELA 10,000 10,000

108 RINI MUKTAR 285660797 32 P Gastritis 10,000 10000

109 PRIHATI 284911964 26 P FLOURALBUS 10,000 10,000

110 RUSTAM 285475162 63 P MYALGIA 10,000 10,000

111 HANIFA P 279681491 4 P ISPA 10,000 10,000

112 AZIMATUL ZAHRA 279680826 1.5 P ISPA 10,000 10,000

113 FIFI YANTI 285424031 28 P VARICELA 10,000 10,000


114 REVANO 284910581 5 L ISPA 10,000 10,000
115 HENA YULITA 285390189 30 P DIARE 10,000 10,000
116 REGI 285424031 7 L VARICELA 10,000 10,000
117 WISNA 284851269 35 L FEBRIS 10,000 10000
118 NURIA HABIBULLAH 2854545518 3.5 P ISPA 10,000 10,000
119 DINO 285101177 55 P HERPES 10,000 10,000
120 EPI 284554565 4 L ISPA 10,000 10,000
121 ANGGA 284819815 3 L LUKA 10,000 10,000
122 NURMALA 279431114 15 P ISPA 10,000 10,000
123 MIS ALENA 289193345 59 P Ispa 10,000 10,000

TOTAL 230,000 10000 0 10000 250,000

NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

124 ARDIANSYAH 284761912 18 L 18-Nov ISPA 10,000 10,000

125 MAIYENI 284223323 54 P CABUT GIGI SUSU 10,000 10000

126 BASRI AMBAR 285591148 59 L PULVITIS 10,000 10000

127 ERNAWATI 284181491 29 P ISPA 10,000 10000

128 HENGKI 284165414 36 L Gastritis 10,000 10,000

129 SYAFNI 285641166 43 P ISPA 10,000 10,000

130 DINI P 2815741415 24 P 19-Nov ISPA 10,000 10,000

131 RATIUS 284767751 32 L CC 10,000 10,000

132 MURDIANA 287538882 10 P dermatitis 10,000 10,000

133 LAILATUL K 284816518 7 P KB 10,000 10000

134 ADITYA 285718689 59 P 20-Nov Gastritis 10,000 10,000

135 REYNALDI 284839232 43 L ISPA 10,000 10,000

136 NURHAIDAH 284758942 16 P RA 10,000 10,000

137 YULIA 2847501953 60 L HIPERTENSI 10,000 10,000

138 DAWANG 285412342 38 L ISPA 10,000 10,000

139 ZULHAIDA 285460365 24 L ra 10,000 10,000

140 RAHMAT F 285652551 75 L Gastritis 10,000 10,000


141 WARNETI 285654418 41 P ISPA 10,000 10,000
142 FIKA MAYASARI 287531899 32 P CABUT GIGI TETAP 20,000 20000
143 BACHTIAr 284897976 27 L Gastritis 10,000 10,000
144 SYAMSIDAR 287535811 41 P ra 10,000 10,000
145 ALIF 284767719 48 L Ispa 10,000 10,000
146 ASNITA 284857953 13 L ra 10,000 10,000
147 REHAN 279641417 5 P Ispa 10,000 10,000
148 RANDI P 285646724 53 L Ispa 10,000 10,000

TOTAL 210,000 40000 10000 260,000

NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

149 KHAIRUL 285324311 35 L 4-Oct ISPA 10,000 10,000

150 CHINTIA A 284432437 27 P TMJ 10,000 10000

151 DERMI YANTI 285671496 71 P ISPA 10,000 10000

152 SUGIANTO 287667899 12 P 5-Oct LUKA 10,000 10000

153 M ILYAD 284828253 40 P CC 10,000 10,000

154 QAINA 284830353 68 P TINEA 10,000 10,000

155 SHEN 2853077154 45 L 7-Oct ISPA 10,000 10,000

156 STESI 284176989 43 P ASMA 10,000 10,000

157 AFNA N 2796011311 9 P VARISELA 10,000 10,000

158 FITRI HANDAYANI 284172759 29 P 8-Oct RA 10,000 10000

159 BEMBI 285200526 5.5 P ISPA 10,000 10,000

160 JIHAN FADILA 285130146 58 L dermatitis 10,000 10,000

161 ASEP S 284219049 78 P CC 10,000 10,000

162 SYAMSIDAR 284827317 12 L ASMA 10,000 10,000

163 FEHRA YENI 285072164 31 P CARIES 10,000 10,000

164 NURHAYATI 285718689 55 P 9-Oct ISPA 10,000 10,000

165 DIPA 284834232 43 L LUKA 10,000 10,000


166 RUSTIAR 28549149 19 L TONSILITIS 10,000 10,000
167 MUCHTAR 285071498 49 L DIARE 10,000 10000
168 YUSNIZAR 285134949 11 L CEPALGIA 10,000 10,000
169 YUNI 285134174 13 L dermatitis 10,000 10,000
170 LINA A 987538735 38 L ISPA 10,000 10,000
171 NUR ASNA 285641166 48 P ANEMIA 10,000 10,000
172 SYARI 284742999 7 L Ispa 10,000 10,000
173 MUTIARA 285603884 49 L KB 10,000 10,000

TOTAL 210,000 10000 20000 10,000 250,000

NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

174 SUSILAWATI 284141957 82 L 10-Oct ALERGI 10,000 10,000

175 SITI ROHANA 284353323 51 P RA 10,000 10000

176 KARTINI 284355718 17 L ASMA 10,000 10000

177 SALMA 2847167009 35 P TAMBAL TETAP 20,000 20000

178 ILHASM 284732436 37 P ISPA 10,000 10,000

179 REGIA RAHADINI 284892434 50 P 11-Oct ISPA 10,000 10,000

180 YULIZAR 285603934 47 P HT 10,000 10,000

181 M RIDHO 284910381 52 P DIARE 10,000 10,000

182 MURDIANA 285644045 25 P 12-Oct ABSES 10,000 10,000

183 MARIANA 284892434 42 P CABUT GIGI TETAP 20,000 20000

184 MALA 284894706 14 P ALERGI 10,000 10,000

185 USMAN 284094179 19 P TONSILITIS 10,000 10,000

186 YASNI 284737792 46 P 16-Oct MYALGIA 10,000 10,000

187 TIO 285338136 11 L Ispa 10,000 10,000

188 ERLILA 285336832 40 P Ispa 10,000 10,000

189 MUHAINI 284951081 43 P ra 10,000 10,000

190 ISNET 2851351921 51 P Ispa 10,000 10,000


191 SHINTA 2841548498 17 P ISPA 10,000 10,000
192 AFRIZAL 2853243187 41 L Ispa 10,000 10000
193 SUDIRMAN 2851231469 3 L Gastritis 10,000 10,000
194 YUYLIA 2849055347 50 P ra 10,000 10,000
195 WINDI 289915811 28 P Ispa 10,000 10,000
196 HUSNUL K 2854015703 13 P ra 10,000 10,000
197 KHAIRUL 285603884 49 L 17-Oct periodontitis 10,000 10,000
198 RUSDI 284736374 43 L Ispa 10,000 10,000
TOTAL 210,000 60000 0 270,000

NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

200 MUSTIKA WATI 287556546 27 P 17-Oct ISPA 10,000 10,000

201 YUNALDI 287484656 29 L CABUT GIGI SUSU 10,000 10000

202 ERNAWATI 387296754 34 P ISPA 10,000 10000

203 SYAHRIL 285641186 16 L KB 10,000 10000

204 INDRI R 987535811 43 P Gastritis 10,000 10,000

205 ROSTIAN 285671496 46 P ISPA 10,000 10,000

206 OSNITA 285719231 36 P 18-Oct ISPA 10,000 10,000

207 EPI SUSANTI 284854184 45 P CC 10,000 10,000

208 FAJRI MANDALA 284175022 11 L dermatitis 10,000 10,000

209 DELFINA RAHMI 285097364 26 P KB 10,000 10000

210 IRNA IRAWATI 285726587 18 P ISPA 10,000

211 REGIA RAHADINI 285685211 38 P ISPA 10,000 10,000

212 ROSMANETI 285683949 36 P cabut gigi susu 10,000 10,000

213 SYAMSIDAR 285744183 69 P abses 10,000 10,000

214 SITI ROHANA 987535817 35 P 19-Oct ISPA 10,000 10,000

215 ELVI 284175358 40 P ra 10,000 10,000

216 FITRI HANDAYANI 284176372 17 P Gastritis 10,000 10,000


217 MURDIAN 285054107 75 L 21-Oct ISPA 10,000 10,000
218 ROSTIAN 285671996 25 L ISPA 10,000 10000
219 RAFI 285019866 20 L Gastritis 10,000 10,000
220 NURELNA 285489512 47 P ra 10,000 10,000
221 RAYO 284883219 37 P Ispa 10,000 10,000
222 MULDAYENI 284201212 31 P ra 10,000 10,000
223 YURLIDARAT 287151267 47 P Ispa 10,000 10,000
224 SUCI A 285708199 14 P Ispa 10,000 10,000

TOTAL 200,000 30000 20000 250,000

NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

225 ISMILAIYUN 284818241 20 P 21-Oct ISPA 10,000 10,000

226 RESTI 285670192 18 P CABUT GIGI SUSU 10,000 10000

227 RIZKI E 284770701 8 L ISPA 10,000 10000

228 KHAIRUL 285603884 49 L 22-Oct KB 10,000 10000

229 FINO RANADA 281985049 13 L Gastritis 10,000 10,000

230 RINI 284886189 24 P ISPA 10,000 10,000

231 MEIYUNI 284888798 2 P ISPA 10,000 10,000

232 NOZULNI SYAM 285651573 32 P 23-Oct CC 10,000 10,000

233 MITRAVAL 284739812 15 L dermatitis 10,000 10,000

234 ANTING GUSTI 284844077 42 P KB 10,000 10000

235 USMATI 284819806 27 P Gastritis 10,000 10,000

236 DAMITUN 28489615 69 L ISPA 10,000 10,000

237 BAYU SHAVAR 28566731 17 L RA 10,000 10,000

238 INDRI R 98752827 19 P HIPERTENSI 10,000 10,000

239 SUNARTI 28512899 54 L ISPA 10,000 10,000

240 EKO 284190693 41 P 24-Oct Gastritis 10,000 10,000

241 GUSNI 285729534 52 P Gastritis 10,000 10,000


242 NURHELNI 285469525 50 P ISPA 10,000 10,000
243 RESTI S 28507912 18 P CABUT GIGI TETAP 20,000 20000
244 YOGA 285722199 6 L Gastritis 10,000 10,000
245 NOVIA H 285503624 24 L ra 10,000 10,000
246 AHMAD 28568808 15 L Ispa 10,000 10,000
247 SYASNI 28504166 48 L ra 10,000 10,000
248 SITI ROHANA 987535811 35 P 25-Oct Ispa 10,000 10,000
249 INDRI R 987528835 44 P Ispa 10,000 10,000

TOTAL 210,000 30000 20000 260,000

NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

250 RIRI 987588979 23 P 25-Oct ISPA 10,000 10,000

251 STEFI Y 287535692 9 P CABUT GIGI SUSU 10,000 10000

252 DESRITA R 987125457 28 P ISPA 10,000 10000

253 MURNI 289888749 34 P KB 10,000 10000

254 RIRI M 289880189 23 P Gastritis 10,000 10,000

256 QODIN 285474756 7 P ISPA 10,000 10,000

257 AFRIYANTI 28489178 36 P INSISI ABSES 40,000 40,000

258 HARUN 284816215 65 P CC 10,000 10,000

259 YUSNI 284757792 38 P 26-Oct dermatitis 10,000 10,000

260 RUSTIAN 285671492 65 P KB 10,000 10000

261 YUSRIZUL 284817475 42 L Gastritis 10,000 10,000

262 NOLISYAM 28551575 34 P abses 10,000 10,000

263 SYAMSUAR 285051515 75 L RA 10,000 10,000

264 DAHRI 284853879 69 P HIPERTENSI 10,000 10,000

265 NURASNI 285125153 56 P 28-Oct ISPA 10,000 10,000

266 RAHI 284918167 26 L ra 10,000 10,000

267 M FADLI 285584881 12 P Gastritis 10,000 10,000


268 SRI RAMADINI 284355567 16 L ISPA 10,000 10,000
269 YOSI M 285328564 18 L ISPA 10,000 10000
270 SYAFNI 285641166 17 L Gastritis 10,000 10,000
271 M FIKRI ISWANDI 284854123 13 P ra 10,000 10,000
272 USMAN 284141957 80 L 29-Oct ISPA 10,000 10,000
273 YUSHANELDI 285309935 44 P ra 10,000 10,000
274 ANNAR 28558434 49 L Ispa 10,000 10,000
275 MUSDAVANI 284766467 47 P Ispa 10,000 10,000

TOTAL 200,000 60000 20000 280,000

NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN
276 USNAR 228472243 44 L 29-Oct ISPA 10,000 10,000
277 SISGI 285463468 86 P CABUT GIGI SUSU 10,000 10000
278 RIDO P 2857023457 18 L ISPA 10,000 10000
279 DZAKI 284807065 10 L KB 10,000 10000
280 SYINTIA 279633205 11 L 30-Oct Gastritis 10,000 10,000
281 GISKA 285741415 24 P ISPA 10,000 10,000
282 ABDUL H 285428297 15 L ISPA 10,000 10,000
283 NURJASNI 285656962 76 P CC 10,000 10,000
284 INDRA 285669864 45 P dermatitis 10,000 10,000
285 MUCHTAR 289895265 49 L KB 10,000 10000
286 REYARTI 987599787 11 L Gastritis 10,000 10,000
287 ROZI S 28435578 17 L ISPA 10,000 10,000
288 ERNITA 284355847 51 P RA 10,000 10,000
289 YUSNITA 284932607 40 P 1-Oct KB 10,000 10,000
290 SURYUNI MARSOKA 278093981 31 L 2-Oct HIPOTENSI 10,000 10,000
291 RESTI 285280716 17 P CC 10,000 10,000
292 ETI YULIA 285280694 36 P 3-Oct HIPOTENSI 10,000 10,000
293 ELFI HAIMAR 28529869 48 P Gastritis 10,000 10,000
294 IFRAYANTO 2853419214 34 P 4-Oct KB 10,000 10000
295 NURMAWATI 285343209 35 P 5-Oct CC 10,000 10,000
296 BIMA PUTRA 285343659 5 P 7-Oct CARIES 10,000 10,000
297 BAMBANG HADI 285248441 16 L ISPA 10,000 10,000
298 SUSILAWATI 24758237 24 P RA 10,000 10,000
299 M YUSUF AGUSTINA 285238103 13 L 8-Oct ISPA 10,000 10,000
300 ILHAM M 285338147 8 L Ispa 10,000 10,000
TOTAL 190,000 20000 40000 250,000
TOTAL KESELURUHAN 3,100,000

DIKETAHUI PAYAKUMBUH, NOVEMBER 2013


KEPALA PUSKESMAS TIAKAR PELAKSANA PROGRAM

dr.NETI HARTATI Desty amelia,A.Md Keb


19750316 200604 2 009 19820103 200501 2 004
RINCIAN KLAIM JAMKESMAS TAHUN 2
PUSKESMAS TIAKAR BULAN DESEMB
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN
1 ERLINA 279645996 44 P 6/1/2013 DESMINORE
2 SITI HANA 279646176 9 P ISPA
3 YAZID 279664277 13 L ABSES
4 M ILHAM 285449139 9 L ISPA
5 LIDAR 2849498191 43 P ASMA
6 DANI 284133014 18 L INFS.KULIT
7 HERI 284816812 12 L ISPA
8 YOLA 981535956 5 P ISPA

9 YULIANIS 278093531 34 P MASTITIS


10 PUTRI 2815394893 3 P 6/3/2013 ISPA
11 YULTERA 285391113 35 P ISPA
12 SYAMSI 285434638 55 P dermatitis
13 SELVIA YENTI 284913382 4 P ISPA
14 REZA 285403206 16 P 6/4/2013 ISPA
15 M FARUL 279621966 4.5 L CC

16 NORIZA MELA 284836318 22 P ASMA


17 YULIANIS 278093531 30 P MASTITIS
18 ZULKIFLI 284803295 55 L INFS.KULIT
19 RATNA 987535743 19 P FARINGITIS
20 M SAFIQ 284826475 2.5 L ISPA
21 M ALIF 285383575 9 L ILI
22 YOPI 284807935 10 P ISPA
23 HERI 2796130909 13 L 6/5/2013 TONSILITIS
24 RAFQI 284912335 2.5 L CC
TOTAL
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN
25 ZAHRIAL 285340977 44 L 6/5/2013 ISPA
26 PUTRA 279630538 18 L 6/8/2013 ABSES
27 DERMI 285720333 45 P 6/10/2013 ISPA
28 WINA 278103921 25 P DYSPEPSIA
29 DESWITA 284830582 38 P ISPA
30 ANUGRAH 284833091 5 L ISPA
31 SENANG 284832404 7 P ISPA
32 RAFQI 284912335 2.5 L TONSILITIS
33 KHALID 517040059 3 L URTIKARIA
34 KHAILA 285459658 4 P ISPA
35 DELFITRI 987535631 28 P TINEA
36 FIRMAN 987535653 7 L ISPA
37 NENG 28548510991 38 P 6/11/2013 DYSPEPSIA
38 ZULKIFLI 284803299 55 L ISPA
39 ERLINDA 284900923 36 P ISK
40 DELFITRI 987535631 28 P FARINGITIS
41 HANI 284640291 12 P OMA
42 LIDAR 285797960 43 P FARINGITIS
43 RANGGA 278095400 5 L 6/12/2013 ABSES
44 KARIMA 284813493 16 P Gastritis
45 YULFERA 285391113 36 P ISPA
46 YEN 284739096 37 P FARINGITIS
47 YULIANIS 278093531 35 P Chepalgia
48 NAYRA 279030931 2 P 6/13/2013 CC
49 DANI 285178816 18 P TONSILITIS
50 HANI 285406154 12 L TONSILITIS
TOTAL
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN
51 RANGGA 284901039 14 P 5/13/2013 dermatitis
52 SAYDUL 15 L INFKS KULIT
53 SAMSIDAR 987535203 85 P CC
54 NURAINI 987535596 60 P RA
55 VIONI 2848540048 11 P dermatitis
56 UFACRA 284824708 3 P ISPA
57 ERNA 284855005 44 P TINEA
58 SARUL 285432941 9 L GE
59 M SAFIQ 284826475 2 L 14-May ABSES
60 ELFI 287456788 33 P ISPA
61 M.WAZIR 284841292 54 L GE
62 Junaidi 285715290 69 L Chepalgia
63 Enida 285603906 44 P anemia
64 Mardiana 517022030 35 P HT
65 Muryadi 289205890 56 L Gastritis
66 Afrizal 517007750 32 L 5/15/2013 Febris
67 Lutfia 517009086 6 P Febris
68 Mona Diana 285160599 17 P Gastritis
69 Hamzah Fansuri 284926116 13 L Ispa

70 Yeli kamaruddin 517029941 38 P Ispa


71 Misailis 284204621 42 P CC
72 Zulnaida 284205249 49 P CC
73 Betti 279649359 35 P 5/16/2013 CC
74 Rianza Andra 279649798 16 L Ispa
75 Marlius 517029322 28 L Ispa
76 Reynaldi 987534977 11 L Ispa
TOTAL
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN
77 Khairul 284745530 45 L 17-May RA
78 M.Saga 285190896 7 L CC
79 M.Defrant 285191990 4 L ispa
80 Lelinar 517024754 52 P RA
81 Hani Febrian 285790044 15 P 18-May Stomatitis
82 Erna 285090009 45 P Gastritis
83 Laila 285095070 5 P ispa
84 Arini 286770052 6 P Febris
85 Itraval 517023022 45 L 5/20/2013 ispa
86 Wahyu 284215583 4 L Febris
87 Bunga lestari 284201001 10 P Febris
88 Warneli 517006861 62 P Gastritis

89 Ermiyal 285514349 57 P Chepalgia


90 Riri Karlina 284373390 17 P Stomatitis
91 Nuna Khatih 284112003 5 P vulnus
92 Muslim 284900299 76 L asma
93 Shifa Virenza 284151846 16 P Ispa
94 Ermita 284353328 45 P 21-May RA
95 Wis dewita 284771294 30 P GE akut

96 Hengki 517004482 28 L Skizofrenia


97 Betti 279649359 35 P INFEKSI GUSI
98 Rianza Andra 279649798 16 L INFEKSI GUSI
99 Marlius 517029322 28 L 22-May Mialgia
100 Asniwati 517030885 47 P Gastritis
101 Mariana Putri 284317108 6 P Tambal
102 Kartini 284715595 32 P Gastritis
TOTAL
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL DIAGNOSA
JAMKESMAS ( THN ) KELAMIN KUNJUNGAN
103 SUSANTI 285120786 24 P 5/23/2013 MYALGIA
104 AFRIZAL 285120706 25 P GASTRITIS
105 USLINAR 286579044 44 P KB
106 VONI 284762766 27 P 24-May S,KEPALA
107 CITRA VANHESTI 284763240 9 P VARICELA
108 VICKI SANDRA 2874762766 32 L 5/25/2013 VARICELA
109 SOFI 2876324212 8 P VARICELA
110 DESI SAPUTRI 284758762 33 P ISPA
111 SYIFA 2484763249 2 P VARICELA
112 VONI 285123791 37 P 27-May HIPOTENSI
113 LASTRI 285335291 33 P ALERGI
114 SYTUSRAINI 285335291 50 P ALERGI
115 GUSNETI 285178318 47 P ANXIETAS
116 Deni sagita 517000724 29 P Psokosomatis
117 Samsunidar 517030582 64 P Psokosomatis
118 Laylatul Rahmi 5170237754 16 P asma
119 Ayumi 285194891 19 P Ispa
120 alvian perdana zega 285506842 2 L 5/28/2013 Febris
121 Jefri tanjung 285655869 16 L OA
122 Harun 285285857 2 L askariasis
123 Agung Rizaldi 285285497 8 L Ispa

124 Desi Isrami 517031043 16 P Ispa


125 Rahmat Hidayat 285074142 9 L 29-May Ispa
126 Lioni Suherman 284820018 16 P Gastritis
127 Dwitami 284024428 2 P Dermatitis
128 Isnandi 284080274 27 L SAKIT GIGI
TOTAL
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN
129 Dwi Fani Adinda 284204428 2 P 5/30/2013 Obs. Febris
130 Usma 517006901 75 P Chest pain
131 Yulfitri 284747084 37 P GE akut
132 Agusfi bujang 28718471 65 L 31-May OA
133 Alif 517019916 14 L Chepalgia
134 Ridho 585029251 5 L Ispa
135 Nursani 51719449 60 P RA
136 Muhazifa 284748726 5 P 4/27/2013 Febris
137 Novi 284357079 12 P Ispa
138 Rozi 284155718 17 L 4/29/2013 Gastritis
139 Nurma 517024471 58 P Gastritis
140 Yulia vera 285117039 60 L 4/30/2013 asma
141 Yosna olivia 284958599 31 P Mialgia
142 M.Nabil 279017141 6 L Alergi
143 Mainar 284750627 38 P 5/1/2013 Gastritis
144 Fatimah 285625754 6 P cabut
145 Fani fadillah 2837663308 2 P ILI
146 Ismawati 284855141 43 P 3-May Hamil
147 Tuti Indriani 2848211158 25 P 4-May Ispa
148 Fatmawati 28418344493 40 P 6-May Dermatitis
149 Murlizza 285070331 39 P Gastritis
150 Aqil Rahmat 284739862 5 L Ispa
151 Darlisma 284159294 57 P 7-May Gastritis
152 Rubama 284778696 37 P Gastritis
153 Wiwin 285055367 28 P 13-May Gastritis
154 Aini 284909466 28 P Ispa
TOTAL
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN
155 Ramadanil 284185765 25 L 15-May Febris
156 Voni pertiwi 517002928 20 P Febris
157 Nindi Oktantia 284583115 19 P 5/18/2013 Ispa
158 Fitri dewi 2844821168 29 P Ispa
159 Nurhadina 285662801 15 P Chepalgia
160 Zulmita adewi 5170227836 45 P herpes zoozter
161 Dea apriani 284481314 8 P 5/20/2013 Ispa
162 Yusron Fahroiri 284481178 15 L Ispa
163 Rawinas 284839907 43 P RA
164 Naila Maldina 285077531 2 P 24-May Obs. Febris
165 Risnawati 285077261 33 P Gastritis
166 Dea Ifanka 285077406 9 P sscabies
167 Ezi 517030391 14 L 29-Apr Ispa
168 Deni sagita 517000724 29 P Psokosomatis
169 Samsunidar 517030582 64 P 4/30/2013 Psokosomatis
170 Laylatul Rahmi 5170237754 16 P asma
171 Ayumi 285194891 19 P 3-May Ispa
172 Nazwa Athira 285517743 6 P Dermatitis
173 Putri Aisyah 285268836 6 P 7-May Gastritis
174 Mislimin 284920209 74 L Scabies
175 Kamaruddin 285517844 54 L 11-May Scabies
176 Mardianis 285517844 44 P Scabies
177 Raka Gustivono 285518318 16 L 5/14/2013 Abses
178 Dira dwi candra 285327549 8 P 5/16/2013 Abses
179 Risnawati 285517743 35 P KB
180 Gusneti 51702368 47 P 5/20/2013 Anxietas
TOTAL
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN
181 RAHMAD H 517021154 20 L 13-4-2013 ISPA
182 WARNETI 517004486 62 P ISPA
183 DINDA 517269041 12 P Scabies
184 ISNA 517023696 58 P Febris
185 MITRA DEWI 517219323 28 P 16-4-2013 Febris
186 USMAN 517006901 80 L ISPA
187 YASMAWATI 51008306 32 P ISPA
188 LAILA 517228738 7 P CABUT GIGI SUSU

189 SAFNIJA 517028758 48 L ISPA


190 MURLIZA 517004201 47 P ASMA
191 MUSNAR 33173548 50 P 17-4-2013 DYSPEPSIA
192 MARTALIZA 517028207 30 P ABSES
193 SUGIMIN 517004638 48 L ASMA
194 HARADI 517021176 44 L 18-4-2013 TMBL TETAP

195 NINGSIH ERIKA 517007702 38 P ISPA


196 ROSTIA 517031447 70 P Faringitis
197 NASRIAL 517032123 43 L Ispa
198 MURLIZA 517004210 48 P Inf. Kulit
199 SWARNI 517027803 63 P 19-4-2013 ISPA
200 ABDUL HINDI 517005905 15 L ISPA
201 RENI SARTIKA 5149552346 22 P 20-4-2013 GASTRITIS
202 MARUSMAR 5170255518 44 P CABUT GIGI TETAP

203 DIKA PRATAMA 517219626 11 L 21-4-2013 FEBRIS


204 BUYUNG NARO 517219604 46 P ISPA
205 SAMSUNIDAR 517030583 54 P GASTRITIS
206 JUMADI 517013717 53 L MYALGIA
TOTAL
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN
207 YASPITA LINI 517028905 35 P 21-4-2013
208 NEVIERAMAN 517028769 45 P ISPA
209 ROKO RAMA 517028815 13 L ISPA
210 JUMADI 517013717 53 L 23-4-2013 GASTRITIS
211 AFDIL R 517219672 13 L GASTRITIS
212 FRAN FEBRIANUR 517029410 7 L FEBRIS
213 YARNELI 517028591 72 P ISPA
214 TITIS MISRAWATI 123373760 17 P ISPA
215 LAILATUL KHAIR 517030738 12 P FEBRIS
216 RENO S 517018376 19 L 24-4-2013 GASTRITIS
217 YOLI S 517007968 18 L ISPA
218 JELVIN F 51700779 14 L ISPA
219 PONI P 517032019 18 P dermatitis
220 MELANISA 517024462 22 P ISPA
221 LIDARNIS 517005819 40 P 25-4-2013 ISPA
222 RAHMAT 517021154 13 L CHEPALGIA
223 AMILIANTI 517001556 11 P GASTRITIS
224 ASWANDI 517001859 46 L KANKER
225 ENAWATI 517003751 37 P ISPA
226 NOVIA 517000702 87 L MYALGIA
227 USMAN 5170061701 38 P 28-4-2013 ISPA
228 YELLY K 517029941 48 P dermatitis
229 SOSMANIRA 517004572 31 P Inf. kulit
230 ELINAR 517030773 28 L GASTRITIS
231 DENI S 517000724 8 P ISPA
232 MELDA 517030964 9 P GASTRITIS
TOTAL
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN

233 LIDAR 43 P 6-Aug ASMA

234 M NASIR 285444922 70 L LUKA

235 FATIMAH 279625228 80 P HT

236 BERMAWI 285399213 52 L 12-Aug GE

237 M NASIR 285444922 70 L LUKA

238 ROSNIA 285435178 87 P GE

239 RIFI 15 P CC

240 GUSMAYERTI 284913178 28 P 13-Aug CEPALGIA

241 LIDAR 43 P 14-Aug ASMA

242 PIPIT 30 P 15-Aug DIARE

243 DERMI 45 P ASMA

244 AQIL RAHMAD 284899948 10 L DIARE

245 M JUSMAN 285385915 12 L ABSES

246 WIDYA FITRI 25 P HAMIL

247 NIRDAWATI 98753855 24 P KONSTIPASI

248 RAMULIS 987535877 70 P HT

249 PUTRI 285394893 3 P 16-Aug H

250 YULFERA 285391113 35 P ABSES

251 HAIKAL 285449501 7 L ISPA

252 PENI 284910067 32 P GE

253 RAFQI 284912325 3 L CEPALGIA

254 MUTIARA 285384464 6 P ABSES

255 LIDAR 43 P 17-Aug GE

256 WINTA 284905811 19 P 18-Aug ASMA

257 DEFIANO 34 L TINEA

TOTAL
NO NAMA PASIEN NO KARTU UMUR JENIS TANGGAL
DIAGNOSA
JAMKESMAS (THN) KELAMIN KUNJUNGAN

258 MELI 284836318 22 P 8/19/2013 ASMA

259 SYAMSI 285434638 28 P ALERGI

260 SARIOJI 284421908 65 P 20-Aug RA

261 M JAUHARI 284897384 13 L ISPA

262 WINA 279103971 27 P ISPA

263 SUNARSIH 279677068 60 P 21-Aug HT


264 DESWIKA 284897867 26 P HAMIL
265 RAHMAD H 517021154 20 L 13-4-2013 ISPA
266 WARNETI 517004486 62 P ISPA
267 DINDA 517269041 12 P Scabies
268 ISNA 517023696 58 P Febris
269 MITRA DEWI 517219323 28 P 16-4-2013 Febris

TOTAL

TOTAL KESELURUHAN

DIKETAHUI
KEPALA PUSKESMAS TIAKAR

dr.NETI HARTATI
19750316 200604 2 009
AMKESMAS TAHUN 2013
KAR BULAN DESEMBER
PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
180,000 0 60000 0 0 240,000
PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10000 10,000
10,000 10,000
10000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10000 10,000
10,000 10,000
10,000 10,000
220,000 0 40000 0 260,000
PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD

POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
240,000 0 20000 0 260,000
PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD

POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

10,000 10,000
10,000 10,000
10000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
25,000 25,000
10,000 10,000
210,000 45000 20000 0 275,000
PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD

POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
210,000 10000 40000 10000 260,000
PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD

POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
20,000 20,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
240,000 20000 10000 270,000
PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD

POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
240,000 0 20000 0 260,000
PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD

POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
UT GIGI SUSU 10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
25,000 25,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
T GIGI TETAP 20,000 20,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
220,000 55000 10000 285,000
PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD

POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
250,000 0 10000 0 260,000
PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD
POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

10,000 10,000

10,000 10,000

10,000 10,000

10,000 10,000

10,000 10,000

10,000 10,000

10,000 10,000

10,000 10,000

10,000 10,000

10,000 10,000

10,000 10,000

10,000 10,000

10,000 10,000

10,000 10000

10,000 10,000

10,000 10,000

10,000 10,000

10,000 10,000

10,000 10,000

10,000 10,000

10,000 10,000

10,000 10,000

10,000 10,000

10,000 10,000

10,000 10,000

240,000 10000 250,000


PELAYANAN KES DAN BESARAN TARIF SESUAI PERDA (Rp) TOTAL TTD

POLI UMUM POLI GIGI POLI KIA LABOR P.SEPESIALISTIK BIAYA PASIEN

10,000 10,000

10,000 10,000

10,000 10,000

10,000 10,000

10,000 10,000

10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000
10,000 10,000

120,000 10000 130,000

2,710,000

PAYAKUMBUH, DESEMBER 2013


PELAKSANA PROGRAM

Desty amelia,A.Md Keb


19820103 200501 2 004

You might also like