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  • BPJS Ok

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    Parid Kasdiantoro
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    This document is a claim form from BPJS Kesehatan in Tulungagung, Indonesia. It includes details of 13 medical transport/ambulance services provided in December 2022, with a total billing amount of Rp. 1,300,000. Each transport service lists the patient's name, date of service, attending medical professional and individual cost of Rp. 100,000.

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    This document is a claim form from BPJS Kesehatan in Tulungagung, Indonesia. It includes details of 13 medical transport/ambulance services provided in December 2022, with a total billing amount of Rp. 1,300,000. Each transport service lists the patient's name, date of service, attending medical professional and individual cost of Rp. 100,000.

    Copyright:

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

    BPJS Ok

    Uploaded by

    Parid Kasdiantoro
    This document is a claim form from BPJS Kesehatan in Tulungagung, Indonesia. It includes details of 13 medical transport/ambulance services provided in December 2022, with a total billing amount of Rp. 1,300,000. Each transport service lists the patient's name, date of service, attending medical professional and individual cost of Rp. 100,000.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 2

    BPJS Kesehatan Cab.

    TULUNGAGUNG
    FORMULIR PENGAJUAN KLAIM TINGKAT PERTAMA

    Nomor FPK : P2212000021368

    Provider : Tugu
    Bulan Pelayanan : December 2022

    Pelayanan : RJTP

    Total Data : 13

    Total Tagihan : Rp. 1.300.000

    NoKunjungan NAMA TANGGAL TINDAKAN HASIL TENAGA MEDIS BIAYA

    131506011222P000049 FARENDRA TYO SAPUTRA 02/12/2022 Evakuasi medis / Ambulans Darat 0.00 dr. Reza Suzana Rp. 100.000

    131506011222P000527 SAINO 10/12/2022 Evakuasi medis / Ambulans Darat 0.00 dr. Nonong Puspowicahyo Rp. 100.000

    131506011222P000633 GIMIN 13/12/2022 Evakuasi medis / Ambulans Darat 0.00 dr. Nonong Puspowicahyo Rp. 100.000

    131506011222P000855 MUDAYAT 16/12/2022 Evakuasi medis / Ambulans Darat 0.00 dr. Nonong Puspowicahyo Rp. 100.000

    131506011222P000906 MUDANI 15/12/2022 Evakuasi medis / Ambulans Darat 0.00 dr. Nonong Puspowicahyo Rp. 100.000

    131506011222P001185 KAMALI 22/12/2022 Evakuasi medis / Ambulans Darat 0.00 dr. Nonong Puspowicahyo Rp. 100.000

    131506011222P001213 BOIMIN 21/12/2022 Evakuasi medis / Ambulans Darat 0.00 dr. Reza Suzana Rp. 100.000

    131506011222P001225 PRAYITNO 22/12/2022 Evakuasi medis / Ambulans Darat 0.00 dr. MUHAMMAD RIDWAN FAUZI Rp. 100.000

    131506011222P001285 YULI EKOWATI 16/12/2022 Evakuasi medis / Ambulans Darat 0.00 Istirohmawati,S.S.T. Rp. 100.000

    131506011222P001404 SUBATIN . 10/12/2022 Evakuasi medis / Ambulans Darat 0.00 Istirohmawati,S.S.T. Rp. 100.000

    131506011222P001411 YANIS WAHYU RAMADHANI 26/12/2022 Evakuasi medis / Ambulans Darat 0.00 Istirohmawati,S.S.T. Rp. 100.000

    131506011222P001413 DEWI AMIATI 26/12/2022 Evakuasi medis / Ambulans Darat 0.00 Istirohmawati,S.S.T. Rp. 100.000

    131506011222P001668 SUBADI 28/12/2022 Evakuasi medis / Ambulans Darat 0.00 dr. MUHAMMAD RIDWAN FAUZI Rp. 100.000

    Tanggal terima FPK, Tanggal, 05/01/2023


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