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  • LampiranKlaim-20151223123109-1302R0011215C02 (1302R001)

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    Anonymous 0eVs2Olj
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    This 3 sentence summary provides the key details from the document: The document is an application form for a claim (COB) submitted by PT. ASURANSI JIWA INHEALTH INDONESIA to RSUD IBNU SINA for November 2015, listing two patients - Ricky Dharma and Jahja Bin Umar - with a total billing amount of 60,000 Indonesian Rupiah.

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    BPJS KESEHATAN

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    LampiranKlaim-20151223123109-1302R0011215C02 [1302R001]

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    This 3 sentence summary provides the key details from the document: The document is an application form for a claim (COB) submitted by PT. ASURANSI JIWA INHEALTH INDONESIA to RSUD IBNU SINA for November 2015, listing two patients - Ricky Dharma and Jahja Bin Umar - with a total billing amount of 60,000 Indonesian Rupiah.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    8 views1 page

    LampiranKlaim-20151223123109-1302R0011215C02 (1302R001)

    Uploaded by

    Anonymous 0eVs2Olj
    This 3 sentence summary provides the key details from the document: The document is an application form for a claim (COB) submitted by PT. ASURANSI JIWA INHEALTH INDONESIA to RSUD IBNU SINA for November 2015, listing two patients - Ricky Dharma and Jahja Bin Umar - with a total billing amount of 60,000 Indonesian Rupiah.

    Copyright:

    © All Rights Reserved
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    Flag for inappropriate content
    of 1

    PT.

    ASURANSI JIWA INHEALTH INDONESIA


    LAMPIRAN FORMULIR PENGAJUAN KLAIM (COB)

    NAMA PROVIDER : RSUD IBNU SINA

    BULAN PELAYANAN : November 2015

    TINGKAT PELAYANAN : RJTL

    NO FPK : 1302R0011215C02

    No No SJP Tgl SJP Noka InHealth Nama Peserta PISA Biaya Tagihan

    1 1302R0011115X000007 11-Nov-2015 1001430729088 RICKY DHARMA P 30,000

    2 1302R0011115X000014 23-Nov-2015 1001010684881 JAHJA BIN UMAR P 30,000

    Total 60,000

    Lampiran FPK; page 1 of 1; printed 12/23/2015 12:31:09 PM

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