3/6/2020 Provider EDC (Web Version) of Praktek Drg. Tensy A.

T [12387217]

DRG.TENSY
Tel No: 081365910510 ; 081364223894
TID: 12387217 [PRAKTEK DRG. TENSY A.]
JL. AHMAD YANI 111C ( APOTEK PANGEAN ) PEKANBARU
PEKANBARU
==============================
Patient: Kenzo ganda hamdani
Principal Name: Ferry Hamdani
Card No.: 8001001000394174
Date of Birth: Oct-05-2013
Policy No: 30000005
Member ID: 001882981
============DISCHARGE================

Reference ID : 93573579

PENGESAHAN & TAGIHAN                    
PAYOR: ADMEDIKA - BRILIFE (BANK BRI)    
PT. BANK RAKYAT INDONESIA (Persero), Tbk
001882981                               
DIAG:K04.1 IZIN SAKIT:0                 
B.OBAT            0                     
R. DASAR     307500                     
R. PENCEGAHAN     0                     
R. PERBAIKAN      0                     
R. KOMPLEKS       0                     
R. GUSI           0                     
GIGI PALSU        0                     
JUM.BIAYA :410000                       
JUM.DIBYR ASS:307500                    
DIBYR PASIEN:102500                     
75% DIJAMIN ASURANSI                    
SELISIH BIAYA BAYAR DI TEMPAT           
Scan your Reference ID
 
By: PRAKTEK DRG. TENSY A. T (PDTENSY)
June 4, 2020, 12:14 pm

https://mobile.admedika.co.id/edc/ 1/1