BPJS Kesehatan Cab.

BIMA
FORMULIR PENGAJUAN KLAIM

Nomor FPK : L2302000005790

Provider : RSUD Sumbawa
Bulan Pelayanan : February, 2023
Pelayanan : Rawat Jalan Tingkat Lanjut

Total Data : 18

Total Tagihan : 31,940,000

NO TRANSAKSI TANGGAL NAMA PESERTA JENIS KLAIM Biaya

2306R001L2302154329 02/02/2023 MUHRAf Ambulans 2,570,000
2306R001L2302154330 21/02/2023 GHASSAN Ambulans 2,570,000
2306R001L2302154334 18/02/2023 M. FIRDAUS Ambulans 100,000
2306R001L2302154337 28/02/2023 ISLUN Ambulans 2,570,000
2306R001L2302154339 24/02/2023 LINDASARI Ambulans 2,570,000
2306R001L2302154341 10/02/2023 ELSA SAPITRI Ambulans 2,570,000
2306R001L2302154352 22/02/2023 FAUZI DWI IBRAHIM Ambulans 2,570,000
2306R001L2302154356 04/02/2023 AMINAH Ambulans 2,570,000
2306R001L2302154360 22/02/2023 waruwati Ambulans 2,570,000
2306R001L2302154362 03/02/2023 NURAINI YANSYAH Ambulans 2,570,000
2306R001L2302154364 23/02/2023 BURHANUDDIN Ambulans 2,570,000
2306R001L2302154368 07/02/2023 SARDIYA Ambulans 2,570,000
2306R001L2302154370 28/02/2023 SOPIAN HARIADI Ambulans 100,000
2306R001L2302154375 28/02/2023 FAUZIAH Ambulans 100,000
2306R001L2302154378 22/02/2023 SABRAM HAMID Ambulans 100,000
2306R001L2302154382 01/02/2023 RAFIA Ambulans 100,000
2306R001L2302154391 18/02/2023 JON KENEDY Ambulans 100,000
2306R001L2302159151 26/02/2023 DIAN ARMINI Ambulans 3,070,000
 Tanggal,
Pengaju Klaim,

27/04/2023 12.21.58