Scribd Logo
Upload

Welcome to Scribd!

  • BPJS Kesehatan Cab. SINGKAWANG: Formulir Pengajuan Klaim Tingkat Pertama

    Uploaded by

    Yholanda Phoseidoncleitho
    5 views3 pages
    This document is a claim form from BPJS Kesehatan Cab. SINGKAWANG containing information about 14 antenatal care (ANC) services provided in March 2019. The total bill amount for these services is Rp 2,800,000. The form includes patient names, dates of service, medical procedures performed, health outcomes, treating medical staff, and costs for each service.

    Original Description:

    ttt

    Original Title

    Anc

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    Report this Document
    This document is a claim form from BPJS Kesehatan Cab. SINGKAWANG containing information about 14 antenatal care (ANC) services provided in March 2019. The total bill amount for these services is Rp 2,800,000. The form includes patient names, dates of service, medical procedures performed, health outcomes, treating medical staff, and costs for each service.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    5 views3 pages

    BPJS Kesehatan Cab. SINGKAWANG: Formulir Pengajuan Klaim Tingkat Pertama

    Uploaded by

    Yholanda Phoseidoncleitho
    This document is a claim form from BPJS Kesehatan Cab. SINGKAWANG containing information about 14 antenatal care (ANC) services provided in March 2019. The total bill amount for these services is Rp 2,800,000. The form includes patient names, dates of service, medical procedures performed, health outcomes, treating medical staff, and costs for each service.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 3

    BPJS Kesehatan Cab.

    SINGKAWANG
    FORMULIR PENGAJUAN KLAIM TINGKAT PERTAMA

    Nomor FPK : P1903000037119

    Provider : SELAKAU
    Bulan Pelayanan : March 2019

    Pelayanan : RJTP

    Total Data : 14

    Total Tagihan : Rp. 2.800.000

    NoKunjungan NAMA TANGGAL TINDAKAN HASIL TENAGA MEDIS BIAYA

    150311010319Y001061 SAPURA 13/03/2019 Pelayanan ANC 3 (Tiga) 30.00 SUPRIHATIN Rp. 50.000

    150311010319Y001061 SAPURA 13/03/2019 Pelayanan ANC 1 (Satu) 11.00 SUPRIHATIN Rp. 50.000

    150311010319Y001061 SAPURA 13/03/2019 Pelayanan ANC 2 (Dua) 21.00 SUPRIHATIN Rp. 50.000

    150311010319Y001061 SAPURA 13/03/2019 Pelayanan ANC 4 (Empat) 39.00 SUPRIHATIN Rp. 50.000

    150311010319Y001062 ATNAH 20/03/2019 Pelayanan ANC 4 (Empat) 37.00 Diah Supriyati Rp. 50.000

    150311010319Y001062 ATNAH 20/03/2019 Pelayanan ANC 2 (Dua) 23.00 Diah Supriyati Rp. 50.000

    150311010319Y001062 ATNAH 20/03/2019 Pelayanan ANC 1 (Satu) 10.00 Diah Supriyati Rp. 50.000

    150311010319Y001062 ATNAH 20/03/2019 Pelayanan ANC 3 (Tiga) 32.00 Diah Supriyati Rp. 50.000

    150311010319Y001063 BUN SHU PUN 12/03/2019 Pelayanan ANC 3 (Tiga) 31.00 ETIKA DAMAYANTI, S. Tr. Keb Rp. 50.000

    150311010319Y001063 BUN SHU PUN 12/03/2019 Pelayanan ANC 1 (Satu) 10.00 ETIKA DAMAYANTI, S. Tr. Keb Rp. 50.000

    150311010319Y001063 BUN SHU PUN 12/03/2019 Pelayanan ANC 2 (Dua) 25.00 ETIKA DAMAYANTI, S. Tr. Keb Rp. 50.000

    150311010319Y001063 BUN SHU PUN 12/03/2019 Pelayanan ANC 4 (Empat) 38.00 ETIKA DAMAYANTI, S. Tr. Keb Rp. 50.000

    150311010319Y001064 FATMAWATI 04/03/2019 Pelayanan ANC 4 (Empat) 37.00 Diah Supriyati Rp. 50.000

    150311010319Y001064 FATMAWATI 04/03/2019 Pelayanan ANC 2 (Dua) 20.00 Diah Supriyati Rp. 50.000

    150311010319Y001064 FATMAWATI 04/03/2019 Pelayanan ANC 1 (Satu) 12.00 Diah Supriyati Rp. 50.000

    150311010319Y001064 FATMAWATI 04/03/2019 Pelayanan ANC 3 (Tiga) 34.00 Diah Supriyati Rp. 50.000
    NoKunjungan NAMA TANGGAL TINDAKAN HASIL TENAGA MEDIS BIAYA

    150311010319Y001065 SUSI 14/03/2019 Pelayanan ANC 3 (Tiga) 34.00 Diah Supriyati Rp. 50.000

    150311010319Y001065 SUSI 14/03/2019 Pelayanan ANC 1 (Satu) 12.00 Diah Supriyati Rp. 50.000

    150311010319Y001065 SUSI 14/03/2019 Pelayanan ANC 2 (Dua) 21.00 Diah Supriyati Rp. 50.000

    150311010319Y001065 SUSI 14/03/2019 Pelayanan ANC 4 (Empat) 38.00 Diah Supriyati Rp. 50.000

    150311010319Y001066 KURAISA 14/03/2019 Pelayanan ANC 4 (Empat) 35.00 Diah Supriyati Rp. 50.000

    150311010319Y001066 KURAISA 14/03/2019 Pelayanan ANC 2 (Dua) 20.00 Diah Supriyati Rp. 50.000

    150311010319Y001066 KURAISA 14/03/2019 Pelayanan ANC 1 (Satu) 12.00 Diah Supriyati Rp. 50.000

    150311010319Y001066 KURAISA 14/03/2019 Pelayanan ANC 3 (Tiga) 30.00 Diah Supriyati Rp. 50.000

    150311010319Y001067 YULIArNA 11/03/2019 Pelayanan ANC 3 (Tiga) 34.00 SUPRIHATIN Rp. 50.000

    150311010319Y001067 YULIArNA 11/03/2019 Pelayanan ANC 1 (Satu) 11.00 SUPRIHATIN Rp. 50.000

    150311010319Y001067 YULIArNA 11/03/2019 Pelayanan ANC 2 (Dua) 20.00 SUPRIHATIN Rp. 50.000

    150311010319Y001067 YULIArNA 11/03/2019 Pelayanan ANC 4 (Empat) 38.00 SUPRIHATIN Rp. 50.000

    150311010319Y001068 TRI WAHYUNI ARA 18/03/2019 Pelayanan ANC 4 (Empat) 38.00 SUPRIHATIN Rp. 50.000

    150311010319Y001068 TRI WAHYUNI ARA 18/03/2019 Pelayanan ANC 2 (Dua) 20.00 SUPRIHATIN Rp. 50.000

    150311010319Y001068 TRI WAHYUNI ARA 18/03/2019 Pelayanan ANC 1 (Satu) 10.00 SUPRIHATIN Rp. 50.000

    150311010319Y001068 TRI WAHYUNI ARA 18/03/2019 Pelayanan ANC 3 (Tiga) 34.00 SUPRIHATIN Rp. 50.000

    150311010319Y001069 ANNA 04/03/2019 Pelayanan ANC 3 (Tiga) 34.00 SUPRIHATIN Rp. 50.000

    150311010319Y001069 ANNA 04/03/2019 Pelayanan ANC 1 (Satu) 7.00 SUPRIHATIN Rp. 50.000

    150311010319Y001069 ANNA 04/03/2019 Pelayanan ANC 2 (Dua) 16.00 SUPRIHATIN Rp. 50.000

    150311010319Y001069 ANNA 04/03/2019 Pelayanan ANC 4 (Empat) 41.00 SUPRIHATIN Rp. 50.000

    150311010319Y001070 SYARIFAH RAMLAH 01/03/2019 Pelayanan ANC 4 (Empat) 37.00 Nurhajizah Amd, Keb Rp. 50.000

    150311010319Y001070 SYARIFAH RAMLAH 01/03/2019 Pelayanan ANC 2 (Dua) 21.00 Nurhajizah Amd, Keb Rp. 50.000

    150311010319Y001070 SYARIFAH RAMLAH 01/03/2019 Pelayanan ANC 1 (Satu) 8.00 Nurhajizah Amd, Keb Rp. 50.000

    150311010319Y001070 SYARIFAH RAMLAH 01/03/2019 Pelayanan ANC 3 (Tiga) 29.00 Nurhajizah Amd, Keb Rp. 50.000

    150311010319Y001071 AGUSTINA 04/03/2019 Pelayanan ANC 3 (Tiga) 36.00 MAUHIDA Rp. 50.000

    150311010319Y001071 AGUSTINA 04/03/2019 Pelayanan ANC 1 (Satu) 12.00 MAUHIDA Rp. 50.000

    150311010319Y001071 AGUSTINA 04/03/2019 Pelayanan ANC 2 (Dua) 27.00 MAUHIDA Rp. 50.000

    150311010319Y001071 AGUSTINA 04/03/2019 Pelayanan ANC 4 (Empat) 38.00 MAUHIDA Rp. 50.000
    NoKunjungan NAMA TANGGAL TINDAKAN HASIL TENAGA MEDIS BIAYA

    150311010319Y001072 LIZA 12/03/2019 Pelayanan ANC 4 (Empat) 37.00 Nurhajizah Amd, Keb Rp. 50.000

    150311010319Y001072 LIZA 12/03/2019 Pelayanan ANC 2 (Dua) 24.00 Nurhajizah Amd, Keb Rp. 50.000

    150311010319Y001072 LIZA 12/03/2019 Pelayanan ANC 1 (Satu) 11.00 Nurhajizah Amd, Keb Rp. 50.000

    150311010319Y001072 LIZA 12/03/2019 Pelayanan ANC 3 (Tiga) 33.00 Nurhajizah Amd, Keb Rp. 50.000

    150311010319Y001073 DEBIANA 12/03/2019 Pelayanan ANC 3 (Tiga) 32.00 Nurhajizah Amd, Keb Rp. 50.000

    150311010319Y001073 DEBIANA 12/03/2019 Pelayanan ANC 1 (Satu) 10.00 Nurhajizah Amd, Keb Rp. 50.000

    150311010319Y001073 DEBIANA 12/03/2019 Pelayanan ANC 2 (Dua) 23.00 Nurhajizah Amd, Keb Rp. 50.000

    150311010319Y001073 DEBIANA 12/03/2019 Pelayanan ANC 4 (Empat) 36.00 Nurhajizah Amd, Keb Rp. 50.000

    150311010319Y001074 MELI 19/03/2019 Pelayanan ANC 4 (Empat) 40.00 Nurhajizah Amd, Keb Rp. 50.000

    150311010319Y001074 MELI 19/03/2019 Pelayanan ANC 2 (Dua) 20.00 Nurhajizah Amd, Keb Rp. 50.000

    150311010319Y001074 MELI 19/03/2019 Pelayanan ANC 1 (Satu) 12.00 Nurhajizah Amd, Keb Rp. 50.000

    150311010319Y001074 MELI 19/03/2019 Pelayanan ANC 3 (Tiga) 36.00 Nurhajizah Amd, Keb Rp. 50.000

    Tanggal terima FPK, Tanggal, 27/09/2019


    Verifikator Pengaju Klaim

    You might also like