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

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    Risal Buabes
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    This document is a claim form from BPJS Kesehatan Cab. Ternante containing details of 31 medical treatments provided in November 2020 with a total cost of Rp. 6,630,000. It includes treatments such as emergency medical evacuation, prenatal care, postnatal care, family planning services and more. The services were provided by BANEMO clinic and its staff led by Asmina Ali.

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    This document is a claim form from BPJS Kesehatan Cab. Ternante containing details of 31 medical treatments provided in November 2020 with a total cost of Rp. 6,630,000. It includes treatments such as emergency medical evacuation, prenatal care, postnatal care, family planning services and more. The services were provided by BANEMO clinic and its staff led by Asmina Ali.

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    © All Rights Reserved
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    25 views2 pages

    BPJS Kesehatan Cab. TERNATE: Formulir Pengajuan Klaim Tingkat Pertama

    Uploaded by

    Risal Buabes
    This document is a claim form from BPJS Kesehatan Cab. Ternante containing details of 31 medical treatments provided in November 2020 with a total cost of Rp. 6,630,000. It includes treatments such as emergency medical evacuation, prenatal care, postnatal care, family planning services and more. The services were provided by BANEMO clinic and its staff led by Asmina Ali.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    of 2

    BPJS Kesehatan Cab.

    TERNATE
    FORMULIR PENGAJUAN KLAIM TINGKAT PERTAMA

    Nomor FPK : P2011000023432

    Provider : BANEMO
    Bulan Pelayanan : November 2020

    Pelayanan : RJTP

    Total Data : 31

    Total Tagihan : Rp. 6.630.000

    NoKunjungan NAMA TANGGAL TINDAKAN HASIL TENAGA MEDIS BIAYA

    031210001120P000112 MASITA HABIBU 19/11/2020 Evakuasi medis / Ambulans Air 0.00 CYNTHIA DONARTA TARIGAN Rp. 5.525.000

    031210001120P000113 GUSMAWANI IKSAN 09/11/2020 Pelayanan KB : Pemasangan IUD / Implant ASMINA ALI, Amd.Keb Rp. 100.000

    031210001120P000114 NURLELA SALASA 25/11/2020 Pelayanan KB : Suntik ASMINA ALI, Amd.Keb Rp. 15.000

    031210001120P000115 JUNAEDA LACANDU 12/11/2020 Pelayanan KB : Suntik ASMINA ALI, Amd.Keb Rp. 15.000

    031210001120P000116 NURWATI AMIN 23/11/2020 Pelayanan KB : Suntik ASMINA ALI, Amd.Keb Rp. 15.000

    031210001120P000117 AJIDA BARHAM 25/11/2020 Pelayanan KB : Suntik ASMINA ALI, Amd.Keb Rp. 15.000

    031210001120P000118 RISKA MASRI 02/11/2020 Pelayanan KB : Suntik ASMINA ALI, Amd.Keb Rp. 15.000

    031210001120P000119 RATMI HAKIM 23/11/2020 Pelayanan KB : Suntik ASMINA ALI, Amd.Keb Rp. 15.000

    031210001120P000120 RABILA GANI 13/11/2020 Pelayanan PNC 1 (Satu) ASMINA ALI, Amd.Keb Rp. 25.000

    031210001120P000121 RABILA GANI 18/11/2020 Pelayanan PNC 2 (Dua) ASMINA ALI, Amd.Keb Rp. 25.000

    031210001120P000123 RABILA GANI 03/11/2020 Pelayanan ANC 3 (Tiga) ASMINA ALI, Amd.Keb Rp. 50.000

    031210001120P000124 NURSAN KASIM 03/11/2020 Pelayanan ANC 3 (Tiga) ASMINA ALI, Amd.Keb Rp. 50.000

    031210001120P000125 HIDAYATI ISHAK 03/11/2020 Pelayanan ANC 3 (Tiga) ASMINA ALI, Amd.Keb Rp. 50.000

    031210001120P000126 HAMIMA HAFEL 03/11/2020 Pelayanan ANC 2 (Dua) ASMINA ALI, Amd.Keb Rp. 50.000

    031210001120P000127 DINIYAWATI RAHMAN 03/11/2020 Pelayanan ANC 2 (Dua) ASMINA ALI, Amd.Keb Rp. 50.000

    031210001120P000128 FITRIANI ASHAD 03/11/2020 Pelayanan ANC 3 (Tiga) ASMINA ALI, Amd.Keb Rp. 50.000
    NoKunjungan NAMA TANGGAL TINDAKAN HASIL TENAGA MEDIS BIAYA

    031210001120P000129 NURHIJJA SOFYAN 03/11/2020 Pelayanan ANC 3 (Tiga) ASMINA ALI, Amd.Keb Rp. 50.000

    031210001120P000130 NURLAELA SADEK 05/11/2020 Pelayanan PNC 1 (Satu) ASMINA ALI, Amd.Keb Rp. 25.000

    031210001120P000131 NURLAELA SADEK 03/11/2020 Pelayanan ANC 3 (Tiga) ASMINA ALI, Amd.Keb Rp. 50.000

    031210001120P000132 NURSAN KASIM 25/11/2020 Pelayanan PNC 1 (Satu) ASMINA ALI, Amd.Keb Rp. 25.000

    031210001120P000133 NURSAN KASIM 20/11/2020 Pelayanan PNC 2 (Dua) ASMINA ALI, Amd.Keb Rp. 25.000

    031210001120P000134 NURLAELA SADEK 09/11/2020 Pelayanan PNC 2 (Dua) ASMINA ALI, Amd.Keb Rp. 25.000

    031210001120P000136 ASRINI HAERUDDIN 03/11/2020 Pelayanan ANC 3 (Tiga) ASMINA ALI, Amd.Keb Rp. 50.000

    031210001120P000137 NURSIFA IBRAHIM 03/11/2020 Pelayanan ANC 2 (Dua) ASMINA ALI, Amd.Keb Rp. 50.000

    031210001120P000138 WAHYUNI SAINUDIN 09/11/2020 Pelayanan PNC 1 (Satu) ASMINA ALI, Amd.Keb Rp. 25.000

    031210001120P000139 WAHYUNI SAINUDIN 13/11/2020 Pelayanan PNC 2 (Dua) ASMINA ALI, Amd.Keb Rp. 25.000

    031210001120P000141 WAHYUNI SAINUDIN 03/11/2020 Pelayanan ANC 3 (Tiga) ASMINA ALI, Amd.Keb Rp. 50.000

    031210001120P000142 SITISIA ABDURAHMAN 03/11/2020 Pelayanan ANC 1 (Satu) ASMINA ALI, Amd.Keb Rp. 50.000

    031210001120P000143 ASMI SUKUR 12/11/2020 Pelayanan KB : Suntik ASMINA ALI, Amd.Keb Rp. 15.000

    031210001120P000145 ASTUTI AMRIN 04/11/2020 Pelayanan ANC 3 (Tiga) ASMINA ALI, Amd.Keb Rp. 50.000

    031210001120P000146 SANDRA M SAFAR 04/11/2020 Pelayanan ANC 3 (Tiga) ASMINA ALI, Amd.Keb Rp. 50.000

    Tanggal terima FPK, Tanggal, 06/12/2020


    Verifikator Pengaju Klaim

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