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    This document is a claim form submitted by SUMOBITO health care provider to BPJS Kesehatan for reimbursement of services provided in October 2022. It includes glucose level test results for 70 patients, with a total billing amount of Rp. 700,000. Each individual test was performed by YUNI ANDRIANI, S.Kep.Ners and costs Rp. 10,000.

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    This document is a claim form submitted by SUMOBITO health care provider to BPJS Kesehatan for reimbursement of services provided in October 2022. It includes glucose level test results for 70 patients, with a total billing amount of Rp. 700,000. Each individual test was performed by YUNI ANDRIANI, S.Kep.Ners and costs Rp. 10,000.

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    3 views4 pages

    CreatePDF 28

    Uploaded by

    adelliadwi noorninenia
    This document is a claim form submitted by SUMOBITO health care provider to BPJS Kesehatan for reimbursement of services provided in October 2022. It includes glucose level test results for 70 patients, with a total billing amount of Rp. 700,000. Each individual test was performed by YUNI ANDRIANI, S.Kep.Ners and costs Rp. 10,000.

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    of 4

    BPJS Kesehatan Cab.

    MOJOKERTO
    FORMULIR PENGAJUAN KLAIM TINGKAT PERTAMA

    Nomor FPK : P2210000002008

    Provider : SUMOBITO
    Bulan Pelayanan : October 2022

    Pelayanan : Promotif

    Total Data : 70

    Total Tagihan : Rp. 700.000

    NoKunjungan NAMA TANGGAL TINDAKAN HASIL TENAGA MEDIS BIAYA

    132115011022P000478 SULASTRI 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 98.00 mgr/dl YUNI ANDRIANI, S.Kep.Ners Rp. 10.000

    132115011022P000482 JUPRI 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 87.00 mgr/dl YUNI ANDRIANI, S.Kep.Ners Rp. 10.000

    132115011022P000484 MAHMUDAH 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 89.00 mgr/dl YUNI ANDRIANI, S.Kep.Ners Rp. 10.000

    132115011022P000485 UMI SURYANTI 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 88.00 mgr/dl YUNI ANDRIANI, S.Kep.Ners Rp. 10.000

    132115011022P000486 BIDAYATI 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 95.00 mgr/dl YUNI ANDRIANI, S.Kep.Ners Rp. 10.000

    132115011022P000487 KAJATI 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 87.00 mgr/dl YUNI ANDRIANI, S.Kep.Ners Rp. 10.000

    132115011022P000489 MARDIYAH 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 93.00 mgr/dl YUNI ANDRIANI, S.Kep.Ners Rp. 10.000

    132115011022P000491 LASIYANA 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 90.00 mgr/dl YUNI ANDRIANI, S.Kep.Ners Rp. 10.000

    100.00
    132115011022P000492 SANA 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis YUNI ANDRIANI, S.Kep.Ners Rp. 10.000
    mgr/dl

    132115011022P000495 PONIMAH 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 88.00 mgr/dl YUNI ANDRIANI, S.Kep.Ners Rp. 10.000

    132115011022P000497 MGATIMAH 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 89.00 mgr/dl YUNI ANDRIANI, S.Kep.Ners Rp. 10.000

    102.00
    132115011022P000499 MAHMUDAH 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis YUNI ANDRIANI, S.Kep.Ners Rp. 10.000
    mgr/dl

    132115011022P000501 AMIANI 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 91.00 mgr/dl YUNI ANDRIANI, S.Kep.Ners Rp. 10.000

    100.00
    132115011022P000508 KUTIYAH 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis YUNI ANDRIANI, S.Kep.Ners Rp. 10.000
    mgr/dl

    132115011022P000511 MARIYATI 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 87.00 mgr/dl YUNI ANDRIANI, S.Kep.Ners Rp. 10.000
    NoKunjungan NAMA TANGGAL TINDAKAN HASIL TENAGA MEDIS BIAYA

    132115011022P000512 SUWANI 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 96.00 mgr/dl YUNI ANDRIANI, S.Kep.Ners Rp. 10.000

    132115011022P000513 HERMIN ASMANINGSIH 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 87.00 mgr/dl YUNI ANDRIANI, S.Kep.Ners Rp. 10.000

    100.00
    132115011022P000514 DJAPARI 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis YUNI ANDRIANI, S.Kep.Ners Rp. 10.000
    mgr/dl
    102.00
    132115011022P000515 ENIK S. 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis YUNI ANDRIANI, S.Kep.Ners Rp. 10.000
    mgr/dl

    132115011022P000521 JUMAINAH 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 87.00 mgr/dl YUNI ANDRIANI, S.Kep.Ners Rp. 10.000

    132115011022P000523 PONAMI 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 87.00 mgr/dl YUNI ANDRIANI, S.Kep.Ners Rp. 10.000

    132115011022P000526 SUMARTI 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 93.00 mgr/dl YUNI ANDRIANI, S.Kep.Ners Rp. 10.000

    132115011022P000530 SHOLIKAH 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 89.00 mgr/dl YUNI ANDRIANI, S.Kep.Ners Rp. 10.000

    132115011022P000533 ZULFA KUSNING 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 88.00 mgr/dl YUNI ANDRIANI, S.Kep.Ners Rp. 10.000

    132115011022P000537 JAMILATIN 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 95.00 mgr/dl YUNI ANDRIANI, S.Kep.Ners Rp. 10.000

    132115011022P000542 SUNAMI 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 84.00 mgr/dl YUNI ANDRIANI, S.Kep.Ners Rp. 10.000

    102.00
    132115011022P000544 NGATEMI 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis YUNI ANDRIANI, S.Kep.Ners Rp. 10.000
    mgr/dl
    100.00
    132115011022P000555 MARKASIH 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis YUNI ANDRIANI, S.Kep.Ners Rp. 10.000
    mgr/dl

    132115011022P000559 SUYATI 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 95.00 mgr/dl YUNI ANDRIANI, S.Kep.Ners Rp. 10.000

    132115011022P000562 NGATEMI 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 95.00 mgr/dl YUNI ANDRIANI, S.Kep.Ners Rp. 10.000

    132115011022P000566 AMINAH 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 95.00 mgr/dl YUNI ANDRIANI, S.Kep.Ners Rp. 10.000

    132115011022P000570 PAINAH 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 89.00 mgr/dl YUNI ANDRIANI, S.Kep.Ners Rp. 10.000

    132115011022P000575 MUSLIKA 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 87.00 mgr/dl YUNI ANDRIANI, S.Kep.Ners Rp. 10.000

    132115011022P000577 MURIYATI 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 95.00 mgr/dl YUNI ANDRIANI, S.Kep.Ners Rp. 10.000

    132115011022P000578 SUWANAH 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 97.00 mgr/dl YUNI ANDRIANI, S.Kep.Ners Rp. 10.000

    132115011022P000579 SUKESI 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 95.00 mgr/dl YUNI ANDRIANI, S.Kep.Ners Rp. 10.000

    100.00
    132115011022P000580 TRIMAN 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis YUNI ANDRIANI, S.Kep.Ners Rp. 10.000
    mgr/dl

    132115011022P000581 SHOFWAN 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 87.00 mgr/dl YUNI ANDRIANI, S.Kep.Ners Rp. 10.000

    132115011022P000582 PUJI RAHAYU 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 95.00 mgr/dl YUNI ANDRIANI, S.Kep.Ners Rp. 10.000

    100.00
    132115011022P000583 WILUJENG PURWONINGSIH 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis YUNI ANDRIANI, S.Kep.Ners Rp. 10.000
    mgr/dl

    132115011022P000584 RINA DEWI FATMAWATI 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 89.00 mgr/dl YUNI ANDRIANI, S.Kep.Ners Rp. 10.000
    NoKunjungan NAMA TANGGAL TINDAKAN HASIL TENAGA MEDIS BIAYA

    132115011022P000585 KAMIDAH 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 95.00 mgr/dl YUNI ANDRIANI, S.Kep.Ners Rp. 10.000

    102.00
    132115011022P000586 MUHAMMAD MUSTAFIDZ 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis YUNI ANDRIANI, S.Kep.Ners Rp. 10.000
    mgr/dl

    132115011022P000587 SUMARNI 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 89.00 mgr/dl YUNI ANDRIANI, S.Kep.Ners Rp. 10.000

    132115011022P000588 KASWAJI 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 95.00 mgr/dl YUNI ANDRIANI, S.Kep.Ners Rp. 10.000

    102.00
    132115011022P000589 MARINI 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis YUNI ANDRIANI, S.Kep.Ners Rp. 10.000
    mgr/dl
    100.00
    132115011022P000590 AMAROH 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis YUNI ANDRIANI, S.Kep.Ners Rp. 10.000
    mgr/dl

    132115011022P000591 YULIANI 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 89.00 mgr/dl YUNI ANDRIANI, S.Kep.Ners Rp. 10.000

    132115011022P000592 RAMINING 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 89.00 mgr/dl YUNI ANDRIANI, S.Kep.Ners Rp. 10.000

    100.00
    132115011022P000593 ASMA'UL KHUSNAH 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis YUNI ANDRIANI, S.Kep.Ners Rp. 10.000
    mgr/dl

    132115011022P000594 SUMI 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 95.00 mgr/dl YUNI ANDRIANI, S.Kep.Ners Rp. 10.000

    132115011022P000595 SUPARDI 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 87.00 mgr/dl YUNI ANDRIANI, S.Kep.Ners Rp. 10.000

    102.00
    132115011022P000596 NUR THOLIB 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis YUNI ANDRIANI, S.Kep.Ners Rp. 10.000
    mgr/dl
    100.00
    132115011022P000597 DJAMILAH 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis YUNI ANDRIANI, S.Kep.Ners Rp. 10.000
    mgr/dl

    132115011022P000598 NGATENI 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 87.00 mgr/dl YUNI ANDRIANI, S.Kep.Ners Rp. 10.000

    132115011022P000599 NUR KHOIRIYAH 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 90.00 mgr/dl YUNI ANDRIANI, S.Kep.Ners Rp. 10.000

    132115011022P000600 DARNITI 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 88.00 mgr/dl YUNI ANDRIANI, S.Kep.Ners Rp. 10.000

    101.00
    132115011022P000601 JUMROH 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis YUNI ANDRIANI, S.Kep.Ners Rp. 10.000
    mgr/dl

    132115011022P000602 ATMININ 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 87.00 mgr/dl YUNI ANDRIANI, S.Kep.Ners Rp. 10.000

    105.00
    132115011022P000603 MUSLIKHAH 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis YUNI ANDRIANI, S.Kep.Ners Rp. 10.000
    mgr/dl

    132115011022P000604 SAHABAT HUSEN 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 80.00 mgr/dl YUNI ANDRIANI, S.Kep.Ners Rp. 10.000

    132115011022P000605 CHUROTIN 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 90.00 mgr/dl YUNI ANDRIANI, S.Kep.Ners Rp. 10.000

    132115011022P000606 SULASTRI 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 99.00 mgr/dl YUNI ANDRIANI, S.Kep.Ners Rp. 10.000

    110.00
    132115011022P000607 SITI AMINAH 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis YUNI ANDRIANI, S.Kep.Ners Rp. 10.000
    mgr/dl
    105.00
    132115011022P000608 MUSLICH 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis YUNI ANDRIANI, S.Kep.Ners Rp. 10.000
    mgr/dl
    NoKunjungan NAMA TANGGAL TINDAKAN HASIL TENAGA MEDIS BIAYA

    100.00
    132115011022P000609 SUMANAH 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis YUNI ANDRIANI, S.Kep.Ners Rp. 10.000
    mgr/dl
    115.00
    132115011022P000610 NURSAADAH 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis YUNI ANDRIANI, S.Kep.Ners Rp. 10.000
    mgr/dl
    100.00
    132115011022P000611 SUPARTINI 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis YUNI ANDRIANI, S.Kep.Ners Rp. 10.000
    mgr/dl
    110.00
    132115011022P000612 NUNIK ROHWULYANI 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr.Dewi Rachmawati Rp. 10.000
    mgr/dl
    100.00
    132115011022P002360 MULIATI 05/10/2022 Gula Darah Puasa (GDP) - PRB/Prolanis YUNI ANDRIANI, S.Kep.Ners Rp. 10.000
    mgr/dl

    Tanggal terima FPK, Tanggal, 22/10/2022


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