BPJS Kesehatan Cab.

PALOPO
FORMULIR PENGAJUAN KLAIM
Nomor FPK : L1809000002345
Provider : ANGKONA
Bulan Pelayanan : September, 2018
Pelayanan : Promotif

Total Data : 19
Total Tagihan : 475,000

NO TRANSAKSI TANGGAL NAMA PESERTA JENIS KLAIM Biaya

18280202L1809142513 20/09/2018 WAYAN NIK IVA 25,000
18280202L1809142536 20/09/2018 PUTU SURIASIH IVA 25,000
18280202L1809142541 20/09/2018 EPI PAKASI IVA 25,000
18280202L1809142543 20/09/2018 NATA MALUMU' IVA 25,000
18280202L1809142571 20/09/2018 Damaris Timba Tasik IVA 25,000
18280202L1809142577 20/09/2018 KETUT SUNARTI IVA 25,000
18280202L1809142581 20/09/2018 AGUSTINA PATOMBA IVA 25,000
18280202L1809142586 20/09/2018 NI MADE SUARMI IVA 25,000
18280202L1809142599 20/09/2018 DESAK PUTU RAKA IVA 25,000
18280202L1809142632 20/09/2018 KADEK SUDARNI IVA 25,000
18280202L1809142641 20/09/2018 KETUT NURMILI IVA 25,000
18280202L1809142651 20/09/2018 HASNA IVA 25,000
18280202L1809142664 20/09/2018 ELVI TAYUNGGI IVA 25,000
18280202L1809142681 20/09/2018 MARTINA IVA 25,000
18280202L1809142700 17/09/2018 KADEK PUTRI IVA 25,000
18280202L1809142737 20/09/2018 DESI IVA 25,000
18280202L1809142758 20/09/2018 DESAK MADE SUKRI IVA 25,000
18280202L1809142772 20/09/2018 WAYAN WIRAWATI IVA 25,000
18280202L1809142786 20/09/2018 NI KETUT RUMINTI IVA 25,000
 Tanggal,
Pengaju Klaim,

09/10/2018 11.08.22