DAFTAR TAGIHAN KLAIM RAWAT JALAN PESERTA JAMKESDA ATAU NON MA

PROPINSI : JAWA TIMUR BULAN

KABUPATEN : BONDOWOSO PUSTU
Kepada YTH. :
Kepala Dinas Kesehatan Bondowoso
Di- tempat
Bersama ini kami ajuan tagihan klaim Pelayanan Kesehatan Umum Rawat Jalan Peserta Jamkesda atau Non Maskin
UMUR (TH, TANGGAL
NO NAMA PASIEN NO KTP/ NO JAMKESDA L/P
BLN(B), HARI(H)) KUNJUNGAN

1 2 4 5 6
1 Suari 351101 612630001 55 L 01 feb 2018

2 suliha 351101 6103670001 51 P 01 feb 2018

3 karyo 351101 1107550001 63 L 01 feb 2018

4 marsus 351101 4508560002 62 L 01 feb 2018

5 juriya 351101 4101590029 69 p 01 feb 2018

6 rusiani 351101 5501710001 47 p 01 feb 2018

7 sahar 351101 10501640002 54 l 01 feb 2018

8 sunarya 351101 4207260001 56 p 01 feb 2018

9 soari 351101 5110600004 57 l 01 feb 2018

10 sunat 351101 5110600004 57 p 02 feb 2018

11 baina 351101 410800063 63 p 02 feb 2018

12 suliha 351101 45061550082 48 p 02 feb 2018

13 satha 351101 6212690002 54 p 02 feb 2018

14 sari 351101 5105540001 62 p 02 feb 2018

15 rohma 351101 44101450052 56 p 02 feb 2018

16 rahmawat 351101 530354002 62 p 02 feb 2018

17 jetem 351101 5408730001 54 p 02 feb 2018

18 juhairiya 351101 4101470032 61 p 02 feb 2018

19 abdul aziz 351101 4505450001 82 l 02 feb 2018

20 fatma 351101 1904420003 55 p 02 feb 2018

21 351101 4912650001 63 l 03 feb 2018

sanidin
22 mistari 351101 0106780002 69 p 03 feb 2018

23 351101 4101490049 59 p 03 feb 2018

satk
351101 5605420002 61 p 03 feb 2018
24 riyama
25 351101 5110390001 39 l 03 feb 2018
moh tosan
26 senima 351101 1005780004 60 p 03 feb 2018
27 halil asyari 351101 602640001 64 l 06 feb 2018

28 satni 351101 7112580001 62 l 06 feb 2018

29 H abu bakar 351101 87 p 06 feb 2018

30 hasanah 351101 4101870038 31 p 07 feb 2018

31 suryat 351101 5212600009 55 p 07 feb 2018

32 mina 351101 5005600007 58 l 07 feb 2018

33 baydowi 351101 1008650003 52 p 07 feb 2018

34 erru 351101 4301350001 82 p 07 feb 2018

35 niama 351101 5801490003 69 p 07 feb 2018

36 amna 351101 4910600001 57 p 07 feb 2018

37 bunia 351101 4101450006 72 p 07 feb 2018

38 maryam 351101 4101570007 59 p 07 feb 2018

39 aliya 351101 401600163 58 p 07 feb 2018

40 salima 351101 5506500005 68 p 08 feb 2018

41 sutk 351101 4901640001 53 p 08 feb 2018

42 bia 351101 4912690002 49 p 08 feb 2018

43 bambang 351101 2609700001 47 l 08 feb 2018

44 muhammad jun 351101 1507920004 36 l 08 feb 2018

45 umar 351101 0505670002 50 l 08 feb 2018

46 genduk 351101 4101420046 76 p 08 feb 2018

47 linda 351101 5501790001 38 p 08 feb 2018

48 busadin 351101 0101410038 77 l 08 feb 2018

49 ahmad 351101 0101480009 71 p 08 feb 2018

50 djatm 351101 4101680015 49 p 08 feb 2018

51 slama 351101 4101490057 79 p 08 feb 2018

52 misran 351101 2711550001 62 l 08 feb 2018

53 nursia 351101 4102600001 46 p 09 feb 2018

54 sabiyah 351101 41016440013 45 p 09 feb 2018

55 halipa 351101 4301700002 57 p 17-Feb-18

56 naila F 351101 4304070001 11 p 17-Feb-18
57 351101

JUMLAH

Mengetahui
Kepala Puskesmas Maesan

drg. CICIK NORMA ISA

NIP. 19701225 200604 2009
AWAT JALAN PESERTA JAMKESDA ATAU NON MASKIN PELAYANAN DASAR

Februari TAHUN : 2018 KLAIM-JK-1

SUCO LOR

n Peserta Jamkesda atau Non Maskin

PELAYANAN KESEHATAN DAN BESARAN TARIF SESUAI DENGAN PERDA (RP)
DIAGNOSA TOTAL BIAYA
POLI UMUM POLI GIGI POLI KIA PEMB LAB TIN. MEDIS
7 8 9 10 11 12 13
desentri √ 10000

myalgia √ 10000

myalgia √ 10000

Ht + gastrits √ 10000

Artrits √ 10000

myalgia √ 10000

Ht √ 10000

Artrits √ 10000

myalgia √ 10000

Ht √ 10000

Ht √ 10000

Ht + ispa √ 10000

myalgia √ 10000

myalgia √ 10000

myalgia √ 10000

Ht √ 10000

hipotensi √ 10000

gastrita √ 10000

Artrits √ 10000

myalgia √ 10000

√ 10000
Ht
myalgia √ 10000

√ 10000
Artrits

√ 10000
Ht

√ 10000
gastrita
Ht √ 10000

myalgia √ 10000

myalgia √ 10000

gastrita √ 10000

gastrita √ 10000

dermatts √ 10000

Ht √ 10000
 Artrits √ 10000

Ht √ 10000

cateral + myalgia √ 10000

myalgia √ 10000

myalgia √ 10000

cepalgia √ 10000

myalgia √ 10000

cepalgia √ 10000

cepalgia √ 10000

herpes simplex √ 10000

herpes simplex √ 10000

Ks √ 10000

fatgue √ 10000

myalgia + Ht √ 10000

myalgia √ 10000

ispa √ 10000

Ht √ 10000

myalgia √ 10000

myalgia √ 10000

myalgia √ 10000

Ht √ 10000

Ht √ 10000

myalgia √ 10000

periodentts √ 10000

√
56 560000
Bondowoso 1 Maret 2018
Pelakasana Pelayanan

Ns. MIFTAHUL MUNIR, S.Kep.

NIP. 19741007 200604 1 009