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<thead>
<tr></tr>
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<td colspan="19"><center><font size="3pt" face="arial"><b>Apotek KF -
KF.0660 Senggigi</b></td></center></font>
</tr>
<tr>
<td colspan="19"><center><font size="3pt" face="arial"><b>Jln. Senggigi Km
8, Kab. Lombok Barat, Nusa Tenggara Barat, 83355</b></td></center></font>
</tr>
<tr>
<td colspan="19"><center><font size="3pt"
face="arial"><b>081138007812</b></td></center></font>
</tr>
<tr>
<td colspan="19"><center><font size="3pt" face="arial"><b>Laporan
Pembayaran dengan Jaminan</b></td></center></font>
</tr>
<tr></tr>
<tr>
<td colspan="3"><b><font face="arial">Tanggal Pembuatan
Laporan</font></b></td>
<td><b><font face="arial">10-11-2020</font></b></td>
</tr>
</thead>
</table>
<table>
<tr>
<td colspan="5"><b>Total Pendapatan dari periode 01-09-2020 s/d 30-09-
2020:</b></td>
<td style="text-align: right;"><b>14068692.0</b></td>
</tr>
<tr>
<td colspan="5">BON KARYAWAN KFA-BON KARYAWAN KFA, MATARAM</td>
<td style="text-align: right;">226305.0</td>
</tr>
<tr>
<td colspan="5">PT. KIMIA FARMA DIAGNOSTIKA-OPEN PROVIDER KAPITASI</td>
</tr>
<tr>
<td colspan="5">PUSKESMA BANYU MULEK - LOMBOK BARAT-DEFAULT</td>
</tr>
<tr>
<td colspan="5">PUSKESMA LINGSAR - LOMBOK BARAT-DEFAULT</td>
</tr>
<tr>
<td colspan="5">PUSKESMA NARMADA - LOMBOK BARAT-DEFAULT</td>
</tr>
<tr>
<td colspan="5">PUSKESMA PERAMPUAN - LOMBOK BARAT-DEFAULT (Non Aktif)</td>
</tr>
</table>
<br>
<table border="1">
<thead>
<tr>
<th><font face="arial">No.</font></th>
<th><font face="arial">No. Transaksi</font></th>
<th><font face="arial">No. Resep</font></th>
<th><font face="arial">Tgl LIPH</font></th>
<th><font face="arial">Nama Pasien</font></th>
<th><font face="arial">Kode SAP</font></th>
<th><font face="arial">Nama Obat</font></th>
<th><font face="arial">Qty</font></th>
<th><font face="arial">HNA</font></th>
<th><font face="arial">Harga/Obat<br>(Rp.)</font></th>
<th><font face="arial">Embalase<br>(Rp.)</font></th>
<th><font face="arial">Total Harga<br>(Rp.)</font></th>
<th><font face="arial">Total Ditanggung<br>(Rp.)</font></th>
<th><font face="arial">Poli RS</font></th>
<th><font face="arial">Nama Dokter</font></th>
<th><font face="arial">Nama Penjamin</font></th>
<th><font face="arial">No. Rujukan</font></th>
<th><font face="arial">No. Keanggotaan</font></th>
<th>No. SEP</th>
</tr>
</thead>
<tbody>
<tr>
<td rowspan="15" valign=middle>1</td>
<td rowspan="15" valign=middle>T1111W1089499958P</td>
<td rowspan="15" valign=middle>32146/1/27092020/104052322</td>
<td rowspan="15" valign=middle>27-09-2020</td>
<td rowspan="15" valign=middle>Mutiara Kusuma RohmI</td>
<td >13073543</td>
<td >KIMIA FARMA HYGIO 9+ 458ML</td>
<td >1</td>
<td >5303.0</td>
<td >6417.0</td>

<td rowspan="15" valign=middle>226305.0</td>
<td rowspan="15" valign=middle>Poly UmuM</td>
<td rowspan="15" valign=middle>Klinik Kimia Farma Senggigi </td>
<td rowspan="15" valign=middle>BON KARYAWAN KFA-BON KARYAWAN KFA,
MATARAM</td>
<td rowspan="15" valign=middle></td>
<td rowspan="15" valign=middle>Mutiara Kusuma Rohmi</td>
</tr>
<tr>
<td >13016977</td>
<td >MINUTE MAID PULPY GRAPE 350ML</td>
<td >4</td>
<td >3927.0</td>
<td >4752.0</td>
</tr>
<tr>
<td >11001721</td>
<td >SALICYL KF LOTION 60 ML</td>
<td >1</td>
<td >10000.0</td>
<td >12100.0</td>
</tr>
<tr>
<td >12005531</td>
<td >CAVIPLEX KAPLET @ 100 (ERELA)</td>
<td >20</td>
<td >640.0</td>
<td >704.0</td>
</tr>
<tr>
<td >13083545</td>
<td >NUTRIBOOST COFFEE 240ML PET</td>
<td >1</td>
<td >5606.0</td>
<td >6783.0</td>
</tr>
<tr>
<td >13016743</td>
<td >FANTA STRAWBERRY 250ML CAN</td>
<td >3</td>
<td >4148.0</td>
<td >5019.0</td>
</tr>
<tr>
<td >13016757</td>
<td >SPRITE 250ML CAN</td>
<td >2</td>
<td >4148.0</td>
<td >5019.0</td>
</tr>
<tr>
<td >13017408</td>
<td >DELFI CASHEW 65GR</td>
<td >1</td>
<td >9915.0</td>
<td >11997.0</td>
</tr>
<tr>
<td >11000152</td>
<td >ANTASIDA DOEN (DUS 100 TAB)</td>
<td >20</td>
<td >281.0</td>
<td >340.0</td>
</tr>
<tr>
<td >13016766</td>
<td >FRESTEA GREEN 500ML PET</td>
<td >2</td>
<td >4447.0</td>
<td >5381.0</td>
</tr>
<tr>
<td >13007864</td>
<td >CATAFLAM FAST 50MG SACH@9</td>
<td >2</td>
<td >7971.0</td>
<td >9645.0</td>
</tr>
<tr>
<td >13016138</td>
<td >NIVEA DEO EXT WHITE SPRAY FEMA</td>
<td >1</td>
<td >27991.0</td>
<td >33869.0</td>
</tr>
<tr>
<td >13003781</td>
<td >FLAMAR 50MG TAB@100</td>
<td >10</td>
<td >1825.0</td>
<td >2208.0</td>
</tr>
<tr>
<td >12000775</td>
<td >DEGIROL LOZ @ 20 (UN)</td>
<td >8</td>
<td >1018.0</td>
<td >1232.0</td>
</tr>
<tr>
<td >12005354</td>
<td >VOLTAREN RET 100 MG FT TAB @50</td>
<td >2</td>
<td >11640.0</td>
<td >14084.0</td>
</tr>
<tr>
<td rowspan="4" valign=middle>T1111W1089087615L</td>
<td >11000386</td>
<td >CALCIUM LACTAT 500 MG (DUS 100 TAB)</td>
<td >3000</td>
<td >74.8</td>
<td >74.8</td>

<td rowspan="4" valign=middle>PUSKESMA PERAMPUAN - LOMBOK BARAT-
DEFAULT (Non Aktif)</td>
</tr>
<tr>
<td >12005474</td>
<td >IBUPROFEN 400 MG TAB @ 100 (PEHA)</td>
<td >400</td>
<td >529.1</td>
<td >529.1</td>
</tr>
<tr>
<td >11000147</td>
<td >AMBROXOL 30 MG (DUS 100 TAB)</td>
<td >5000</td>
<td >246.4</td>
<td >246.4</td>
</tr>
<tr>
<td >13000800</td>
<td >ORPHEN 4MG TAB@200</td>
<td >10000</td>
<td >118.8</td>
<td >118.8</td>
</tr>
<tr>
<td rowspan="1" valign=middle>T1111W1089087586E</td>
<td >13000800</td>
<td >ORPHEN 4MG TAB@200</td>
<td >5000</td>
<td >118.8</td>
<td >118.8</td>

<td rowspan="1" valign=middle>PUSKESMA LINGSAR - LOMBOK BARAT-
DEFAULT</td>
</tr>
<tr>
<td rowspan="4" valign=middle>T1111W10888331078</td>
<td rowspan="4" valign=middle>Janne Anne Muldoon</td>
<td >11000025</td>
<td >CETIRIZINE 10 MG (DUS 30 TAB)</td>
<td >6</td>
<td >367.0</td>
<td >444.0</td>

<td rowspan="4" valign=middle>Poly UmuM</td>
<td rowspan="4" valign=middle>Dr Maylia</td>
<td rowspan="4" valign=middle>PT. KIMIA FARMA DIAGNOSTIKA-OPEN
PROVIDER KAPITASI</td>
</tr>
<tr>
<td >12005551</td>
<td >CEFADROXIL 500 MG @ 100 KAPS</td>
<td >10</td>
<td >764.0</td>
<td >924.0</td>
</tr>
<tr>
<td >12005474</td>
<td >IBUPROFEN 400 MG TAB @ 100 (PEHA)</td>
<td >6</td>
<td >250.0</td>
<td >466.0</td>
</tr>
<tr>
<td >12000938</td>
<td >ERLAMYCETIN EAR DROPS 1%</td>
<td >1</td>
<td >7800.0</td>
<td >9438.0</td>
</tr>
<tr>
<td >13003289</td>
<td >DEPAKOTE 250MG TAB@100</td>
<td >600</td>
<td >8520.6</td>
<td >8520.6</td>

<td rowspan="1" valign=middle>PUSKESMA NARMADA - LOMBOK BARAT-
DEFAULT</td>
</tr>
<tr>
<td rowspan="1" valign=middle>T1111W1087742170H</td>
<td >13003289</td>
<td >DEPAKOTE 250MG TAB@100</td>
<td >600</td>
<td >8520.6</td>
<td >8520.6</td>

<td rowspan="1" valign=middle>PUSKESMA NARMADA - LOMBOK BARAT-
DEFAULT</td>
</tr>
<tr>
<td >12002626</td>
<td >DEXTROSE 40% INFUS 25 ML</td>
<td >10</td>
<td >12512.5</td>
<td >12512.5</td>

<td rowspan="1" valign=middle>PUSKESMA BANYU MULEK - LOMBOK BARAT-
DEFAULT</td>
</tr>
<tr>
<td rowspan="3" valign=middle>T1111W1087692721R</td>
<td rowspan="3" valign=middle>Jonas Malanguna (0000136668565)
Mataram</td>
<td >11000397</td>
<td >PARACETAMOL 500 MG (DUS 100 TAB)</td>
<td >10</td>
<td >262.0</td>
<td >303.0</td>

<td rowspan="3" valign=middle>Penyakit Dalam </td>
<td rowspan="3" valign=middle>Dr. MayliA</td>
</tr>
<tr>
<td >11000025</td>
<td >CETIRIZINE 10 MG (DUS 30 TAB)</td>
<td >10</td>
<td >367.0</td>
<td >444.0</td>
</tr>
<tr>
<td >11000183</td>
<td >DEXAMETHASONE 0.5 MG (BTL 100 TAB)</td>
<td >10</td>
<td >109.0</td>
<td >132.0</td>
</tr>
<tr>
<td rowspan="3" valign=middle>SamareL</td>
<td >11000394</td>
<td >HYDROCORTISONE 2,5%CR(DUS 24TUBE@ 5GRAM)</td>
<td >1</td>
<td >3458.0</td>
<td >4184.0</td>

<td rowspan="3" valign=middle>Penyakit Dalam </td>
<td rowspan="3" valign=middle>Dr. MayliA</td>
</tr>
<tr>
<td >11000011</td>
<td >AMOXICILLIN 500 MG (DUS 100 TAB)</td>
<td >10</td>
<td >378.0</td>
<td >407.0</td>
</tr>
<tr>
<td >11000183</td>
<td >DEXAMETHASONE 0.5 MG (BTL 100 TAB)</td>
<td >10</td>
<td >109.0</td>
<td >132.0</td>
</tr>
</tbody>
</table>
</div>

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