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    of 2

    BPJS Kesehatan Cab.

    PANGKAL PINANG
    FORMULIR PENGAJUAN KLAIM TINGKAT PERTAMA

    Nomor FPK : P1905000033544

    Provider : SIMPANG PESAK

    Bulan Pelayanan : May 2019


    Pelayanan : RITP

    Total Data : 25

    Total Tagihan : Rp. 8.736.000

    NO KUNJUNGAN NAMA PESERTA TGL MASUK TGL PULANG TINDAKAN TENAGA MEDIS BIAYA

    037900000419Y000581 MASNUN (0001227733222) 30/04/2019 02/05/2019 Rawat Inap di R. Perawatan Biasa dr. RULLY SURYA DARMA Rp. 312.000

    037900000519P000450 KURYANI (0001273727136) 28/05/2019 30/05/2019 Rawat Inap di R. Perawatan Biasa dr. RULLY SURYA DARMA Rp. 312.000

    037900000519P000452 MULYANI (0002218818418) 26/05/2019 29/05/2019 Rawat Inap di R. Perawatan Biasa dr. RULLY SURYA DARMA Rp. 468.000

    037900000519P000453 ZULKIRAN (0001227789663) 25/05/2019 28/05/2019 Rawat Inap di R. Perawatan Biasa dr. RULLY SURYA DARMA Rp. 468.000

    037900000519P000454 SUKARNI (0002006814161) 25/05/2019 28/05/2019 Rawat Inap di R. Perawatan Biasa dr. DELFA SAGITA Rp. 468.000

    037900000519P000461 SARWANDI (0001303836895) 24/05/2019 25/05/2019 Rawat Inap di R. Perawatan Biasa dr. RULLY SURYA DARMA Rp. 156.000

    037900000519P000467 SUHENDRI (0002050613908) 07/05/2019 09/05/2019 Rawat Inap di R. Perawatan Biasa dr. RULLY SURYA DARMA Rp. 312.000

    037900000519P000468 JAMILAH (0002035979469) 05/05/2019 07/05/2019 Rawat Inap di R. Perawatan Biasa dr. RULLY SURYA DARMA Rp. 312.000

    037900000519P000469 ARBA'IE (0000362525016) 05/05/2019 07/05/2019 Rawat Inap di R. Perawatan Biasa dr. RULLY SURYA DARMA Rp. 312.000

    037900000519P000470 DEKA PRASETYA (0002454348227) 04/05/2019 06/05/2019 Rawat Inap di R. Perawatan Biasa dr. RULLY SURYA DARMA Rp. 312.000

    037900000519P000471 RAHNA (0000362592279) 02/05/2019 03/05/2019 Rawat Inap di R. Perawatan Biasa dr. DELFA SAGITA Rp. 156.000

    037900000519P000473 MISNI (0001383700454) 02/05/2019 04/05/2019 Rawat Inap di R. Perawatan Biasa dr. RULLY SURYA DARMA Rp. 312.000

    037900000519Y000323 TUYAMI (0000362730025) 06/05/2019 10/05/2019 Rawat Inap di R. Perawatan Biasa dr. RULLY SURYA DARMA Rp. 624.000

    037900000519Y000324 YENI (0001870885451) 18/05/2019 20/05/2019 Rawat Inap di R. Perawatan Biasa dr. RULLY SURYA DARMA Rp. 312.000

    037900000519Y000361 MASNAH (0000023387883) 19/05/2019 20/05/2019 Rawat Inap di R. Perawatan Biasa dr. RULLY SURYA DARMA Rp. 156.000

    037900000519Y000362 TARMINI (0002043315134) 20/05/2019 21/05/2019 Rawat Inap di R. Perawatan Biasa dr. DELFA SAGITA Rp. 156.000

    037900000519Y000363 SUSI BAYATI (0000028484864) 14/05/2019 17/05/2019 Rawat Inap di R. Perawatan Biasa dr. RULLY SURYA DARMA Rp. 468.000

    037900000519Y000364 HARTINI (0002474410116) 13/05/2019 14/05/2019 Rawat Inap di R. Perawatan Biasa dr. RULLY SURYA DARMA Rp. 156.000
    NO KUNJUNGAN NAMA PESERTA TGL MASUK TGL PULANG TINDAKAN TENAGA MEDIS BIAYA

    037900000519Y000365 NORBAYA (0000364131573) 11/05/2019 12/05/2019 Rawat Inap di R. Perawatan Biasa dr. RULLY SURYA DARMA Rp. 156.000

    037900000519Y000366 SUPARMAN (0000997992022) 10/05/2019 11/05/2019 Rawat Inap di R. Perawatan Biasa dr. RULLY SURYA DARMA Rp. 156.000

    037900000519Y000368 NELA NOPIANI (0001843568807) 10/05/2019 12/05/2019 Rawat Inap di R. Perawatan Biasa dr. RULLY SURYA DARMA Rp. 312.000

    037900000519Y000369 JAMILAH (0002035979469) 08/05/2019 10/05/2019 Rawat Inap di R. Perawatan Biasa dr. RULLY SURYA DARMA Rp. 312.000

    037900000519Y000370 HARINA (0001448661644) 08/05/2019 13/05/2019 Rawat Inap di R. Perawatan Biasa dr. RULLY SURYA DARMA Rp. 780.000

    037900000519Y000371 SUSI BAYATI (0000028484864) 07/05/2019 13/05/2019 Rawat Inap di R. Perawatan Biasa dr. RULLY SURYA DARMA Rp. 936.000

    037900000519Y000372 SEPAIE (0001310442568) 07/05/2019 09/05/2019 Rawat Inap di R. Perawatan Biasa dr. RULLY SURYA DARMA Rp. 312.000

    Tanggal terima FPK, Tanggal, 22/06/2019


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