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  • Rekap Pengajuan Klem Ambulance

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    This document is a recapitulation of ambulance transportation claims from Garum Health Center. It includes 8 patients transported to Waluyo Hospital in Ndudi from November 2nd to 16th, 2020. The document lists each patient's name, BPJS card number, diagnosis, reason for referral, referring doctor, date of admission and discharge, mileage, and ambulance tariff. It requests a triplicate claim form, copies of patient IDs, referral letters, medical certificates, signed service receipts, and original invoices with stamp duty to process the claims.

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    NOVEMBER 1

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    This document is a recapitulation of ambulance transportation claims from Garum Health Center. It includes 8 patients transported to Waluyo Hospital in Ndudi from November 2nd to 16th, 2020. The document lists each patient's name, BPJS card number, diagnosis, reason for referral, referring doctor, date of admission and discharge, mileage, and ambulance tariff. It requests a triplicate claim form, copies of patient IDs, referral letters, medical certificates, signed service receipts, and original invoices with stamp duty to process the claims.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    6 views2 pages

    Rekap Pengajuan Klem Ambulance

    Uploaded by

    ugd garum
    This document is a recapitulation of ambulance transportation claims from Garum Health Center. It includes 8 patients transported to Waluyo Hospital in Ndudi from November 2nd to 16th, 2020. The document lists each patient's name, BPJS card number, diagnosis, reason for referral, referring doctor, date of admission and discharge, mileage, and ambulance tariff. It requests a triplicate claim form, copies of patient IDs, referral letters, medical certificates, signed service receipts, and original invoices with stamp duty to process the claims.

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    © All Rights Reserved
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    of 2

    REKAP PENGAJUAN KLEM AMBULANCE

    JUML TARIF
    NAMA NOMOR KARTU DIAGNOSA ALASAN DOKTER FASKES TANGGAL TANGGAL NO.Pol
    NO ALAMAT NO.TELP /HP AH DRIVER AMBUL
    PENDERITA BPJS PENYAKIT DIRUJUK PERUJUK TUJUAN MRS DIRUJUK Ambulance
    KM ANCE
    Dsn G1P0A0 uk 34
    Kemloko inpartu kala
    2/7 mg inpartu
    UCI 2/2 Desa 1 fase laten dr. Arne Putri RSU AN-
    1 0000671632514 081555339523 kala 1 fase laten 2/11/2020 2/11/2020 AG.1048 LP ,000
    MARITA dengan Mahargiani NISA
    Sidodadi dengan
    premature
    Kec. Garum premature
    Dsn G2P1A0 uk 38
    Sumberjo 4/7 mg dengan inpartu kala
    NUR 3/17 Desa dr. Arne Putri RSU AN-
    2 0002466682435 08873621049 inpartu kala 1 1 fase laten 2/11/2020 2/11/2020 AG.1048 LP ,000
    RIZQIYATI Mahargiani NISA
    Karangrejo fase laten memanjang
    Kec.Garum memanjang
    Dsn
    Sumberjo G1P0A0 uk RSUD
    3/17 Desa G1P0A0 uk 39 dr. Arne Putri
    3 KRISTIANA 0000671864804 085806109611 39 mg NGUDI 2/11/2020 2/11/2020 13 AG.1048 LP 205,000
    mg dengan PE Mahargiani
    Karangrejo dengan PE WALUYO
    Kec.Garum
    Dsn G2P1A0 uk 40 Inpartu kala
    Ringinrejo mg inpartu kala 1 fase aktif RSUD
    LILIN 2/12 Desa dr.Arne Putri
    4 0002047891116 085755886829 1 fase aktif dengn NGUDI 7/11/2020 7/11/2020 13 AG.1048 LP 205,000
    NOVITA Mahargiani
    Karangrejo dengn ketuban ketuban WALUYO
    Kec Garum mekoneal mekoneal
    Lk Bence II G1P0A0 uk 34 inpartu kala
    1/3 Desa 5/7 mg inpartu 1 fase laten RSUD
    ANISATUL dr.Arne Putri
    5 0001037534668 Bence Kec. 085332893559 kala 1 fase laten dengan NGUDI 8/11/2020 8/11/2020 13 AG.1048 LP 205,000
    FITRIA Mahargiani
    garum dengan KPD + KPD + WALUYO
    premature premature
    Dsn G2P1A0 uk 39-
    Sumberjo Inpartu kala RSUD
    40 mg inpartu
    1/17 Desa 1 fase laten dr.Arne Putri NGUDI
    6 SUSIANI 0000732875905 - kala 1 fase laten 9/11/2020 9/11/2020 13 AG.1048 LP 205,000
    memanjang Mahargiani WALUYO
    Karangrejo memanjang dan
    dan febris WLINGI
    Kec.Garum febris
    G1P0A0 uk 37 Kala 1 fase
    Lk 2/7 mg inpartu laten
    RSUD
    tanggung kala 1 fase laten dengan
    HARTINI dr.Arne Putri NGUDI
    7 0001037619336 3/1 Desa 0895364929363 dengan letak letak 12/11/2020 12/11/2020 13 AG.1048 LP 205,000
    SEFTIANI Mahargiani WALUYO
    Bence Kec. lintang dan lintang dan
    WLINGI
    Garum ketuban ketuban
    mekoneal mekoneal
    Dsn Sumber G2P1A0 uk RSUD
    TINTRIM
    3/1 Desa G2P1A0 uk 22 22 mg dr.Arne Putri NGUDI
    8 SULASIYAT 0001185583959 085735072790 16/11/2020 16/11/2020 13 AG.1048 LP 205,000
    Slorok mg dengan PEB dengan Mahargiani WALUYO
    I
    Kec.Garum PEB WLINGI

    Surat pengajuan klaim (FPK) rangkap 3 (tiga) Yang Mengajukan


    Fotocopy kartu BPJS kesehatan/ kartu identitas lain sesuai PKS (askes/jamsostek/jamkesmas/KTA) Kepala Puskesmas Garum
    Surat rujukan
    Surat keterangan medis dokter (kondisi pasien saat dirujuk)
    Bukti pelayanan yang sudah ditandatangani pasien dr.ARNE PUTRI MAHARGIANI
    Kwitansi asli rangkap 3 diatas materai 6.000 NIP.19830305 201101 2 015

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