FORMAT PELAPORAN PESERTA PRB AKTIF

Bulan : Desember 2019

DAFTAR PESERTA PRB AKTIF BERKUNJUNG

NO TANGGAL NAMA PESERTA NO NO HP DIAGNOSA ALAMAT KETERANGAN

BERKUNJUNG KIS/BPJS PENGAMBILAN OBAT
23 HR 30 HR
1 2-12-2019 JEJEN AHMAD JAELANI 0000482113596 Human Sukamulya Rt 19/06 RUJUK
immunodeficiency
virus [HIV] disease
resulting in infectious
and parasitic diseases
2 2-12-2019 KOSWARA 0000482449959 0821 2238 6822 Atherosclerotic Gintungsalam Rt 23/06 RUJUK
cardiovascular
disease, so described
3 2-12-2019 ENER NERSIH 0001010354635 Congestive heart Krajan II V
failure
4 2-12-2019 DEDY FREDY 0001010358819 0821 2234 0949 Congestive heart Krajan I RUJUK
failure
5 4-12-2019 TITI ROHAETI 0000064072157 Congestive heart Karawang Jaya V
failure
6 9-12-2019 UDI 0000481621048 0896 9971 5713 Congestive heart Sukajaya RUJUK
failure
7 9-12-2019 SAPTA 0000482912537 0821 2556 5832 Non-insulin- Gintungsalam RUJUK
dependent diabetes
mellitus with other
specified
complications
8 9-12-2019 SUMIRAH 0002283748075 0812 9454 5735 Congestive heart Krajan II V
failure
9 12-12-2019 OMAN ROHMAN 0002271276505 Congestive heart RUJUK
failure
10 13-12-2019 KOSWARA 0000482449959 0821 2234 6822 Congestive heart Gintungsalam V
failure
11 13-12-2019 DIAN NURJANAH 0001294442684 Congestive heart Sukaresmi Rt 12/05 V
failure
12 16-12-2019 JUWARTI 0000482277791 HNP CIBALADO V
13 16-12-2019 RASTA SUNARTA 0000063665605 Congestive heart V
failure
14 16-12-2019 Simon Johanes Harun 0001475162289 O812 1068 865 CHF Warungbambu RUJUK

Karawang, 23 Desember 2019

Memet Komarudin, SKM, MM.Kes

NIP. 19630512 198703 1 011