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    of 2

    BPJS Kesehatan Cab.

    BANYUWANGI
    FORMULIR PENGAJUAN KLAIM TINGKAT PERTAMA

    Nomor FPK : P2104000021950

    Provider : PUSKESMAS TLOGOSARI


    Bulan Pelayanan : April 2021

    Pelayanan : RJTP

    Total Data : 15

    Total Tagihan : Rp. 3.075.000

    NoKunjungan NAMA TANGGAL TINDAKAN HASIL TENAGA MEDIS BIAYA

    133210010421P000756 MUHAMMAD ROFIKI 26/04/2021 Evakuasi medis / Ambulans Darat 0.00 dr. DIANA MASFUFAH Rp. 205.000

    133210010421P000757 MASRAN 27/04/2021 Evakuasi medis / Ambulans Darat 0.00 dr. DIANA MASFUFAH Rp. 205.000

    133210010421P000758 MUHAMMAD ANAS 12/04/2021 Evakuasi medis / Ambulans Darat 0.00 dr. DIANA MASFUFAH Rp. 205.000

    133210010421P000759 MISDARI 02/04/2021 Evakuasi medis / Ambulans Darat 0.00 dr. DIANA MASFUFAH Rp. 205.000

    133210010421P000760 NIMO 05/04/2021 Evakuasi medis / Ambulans Darat 0.00 dr. DIANA MASFUFAH Rp. 205.000

    133210010421P000761 HASAN 08/04/2021 Evakuasi medis / Ambulans Darat 0.00 dr. DIANA MASFUFAH Rp. 205.000

    133210010421P000762 ISHAK 06/04/2021 Evakuasi medis / Ambulans Darat 0.00 dr. DIANA MASFUFAH Rp. 205.000

    133210010421P000795 KELVIN AVALIYA 10/04/2021 Evakuasi medis / Ambulans Darat 0.00 dr. DIANA MASFUFAH Rp. 205.000

    133210010421P000796 ANITA 24/04/2021 Evakuasi medis / Ambulans Darat 0.00 dr. DIANA MASFUFAH Rp. 205.000

    133210010421P000797 SUTILAH 02/04/2021 Evakuasi medis / Ambulans Darat 0.00 dr. DIANA MASFUFAH Rp. 205.000

    133210010421P000798 USWATUN HASANAH 07/04/2021 Evakuasi medis / Ambulans Darat 0.00 dr. DIANA MASFUFAH Rp. 205.000

    133210010421P000799 SLAMAH 27/04/2021 Evakuasi medis / Ambulans Darat 0.00 dr. DIANA MASFUFAH Rp. 205.000

    133210010421P000800 NINGSIH SUSILOWATI 28/04/2021 Evakuasi medis / Ambulans Darat 0.00 dr. DIANA MASFUFAH Rp. 205.000

    133210010421P000801 MARDEWI 27/04/2021 Evakuasi medis / Ambulans Darat 0.00 dr. DIANA MASFUFAH Rp. 205.000

    133210010421P000802 KIMYATUL JANNAH 29/04/2021 Evakuasi medis / Ambulans Darat 0.00 dr. DIANA MASFUFAH Rp. 205.000

    Tanggal terima FPK, Tanggal, 06/05/2021


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