PEMERINTAH KABUPATEN BIMA

PUSKESMAS MONTA
Jln. Lintas Tente Parado - Tangga – Monta

Status
PERINCIAN BIAYA RAWAT JALAN Umum BPJS
No.
I. IDENTITAS
Poli : Tanggal:
Nama pasien :
Jenis kelamin/umur :
Pekerjaan :
Alamat :
II. PERINCIAN BIAYA
1. Karcis : Rp.
2. Pemeriksaan dokter : ........................................................ Rp. .............................
3. Konsul dokter : ......................................................... Rp. .............................
4. Biaya tindakan (dokter/perawat/bidan)
a. ......................................................................................... Rp. .............................
b. ......................................................................................... Rp. .............................
c. ......................................................................................... Rp. .............................
5. Laboratorium
a. ......................................................................................... Rp. .............................
b. .......................................................................................... Rp. .............................
c. .......................................................................................... Rp. .............................
6. Pemeriksaan penunjang lain
a. USG Kebidanan : ........................................................... Rp. .............................
b. Gizi : ........................................................... Rp. .............................
7. Lain-lain
a. .......................................................................................... Rp. .............................
b. .......................................................................................... Rp. .............................
c. ........................................................................................... Rp. .............................
Total Biaya Rp._______________

Penyetor Kasir

............................................ .......................................

PEMERINTAH KABUPATEN BIMA

PUSKESMAS MONTA
Jln. Lintas Tente Parado - Tangga – Monta

Status
PERINCIAN BIAYA RAWAT JALAN Umum BPJS
No.
I. IDENTITAS
Poli : Tanggal:
Nama pasien :
Jenis kelamin/umur :
Pekerjaan :
Alamat :
II. PERINCIAN BIAYA
1. Karcis : Rp.
2. Pemeriksaan dokter : ......................................................... Rp. .............................
3. Konsul dokter : ......................................................... Rp. .............................
4. Biaya tindakan (dokter/perawat/bidan)
a. ......................................................................................... Rp. .............................
b. ......................................................................................... Rp. .............................
c. ......................................................................................... Rp. .............................
5. Laboratorium
a. ......................................................................................... Rp. .............................
b. .......................................................................................... Rp. .............................
c. .......................................................................................... Rp. .............................
6. Pemeriksaan penunjang lain
a. USG Kebidanan : ........................................................... Rp. .............................
b. Gizi : ........................................................... Rp. .............................
7. Lain-lain
a. .......................................................................................... Rp. .............................
b. .......................................................................................... Rp. .............................
c. ........................................................................................... Rp. .............................
Total Biaya Rp._______________

Penyetor Kasir

......................................... ...........................................