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    This document is a claim form submitted to BPJS Kesehatan for reimbursement. It details two childbirth services provided in August 2022 by SAJA'AH,AM.Keb totaling Rp. 1,400,000. The first service was for ROHANA from August 1-2, 2022 and the second was for RUSMAINI on August 24, 2022. Both services included normal vaginal birth packages performed by a midwife. The total claim amount is Rp. 1,400,000.

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    This document is a claim form submitted to BPJS Kesehatan for reimbursement. It details two childbirth services provided in August 2022 by SAJA'AH,AM.Keb totaling Rp. 1,400,000. The first service was for ROHANA from August 1-2, 2022 and the second was for RUSMAINI on August 24, 2022. Both services included normal vaginal birth packages performed by a midwife. The total claim amount is Rp. 1,400,000.

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    © All Rights Reserved
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    4 views1 page

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    Uploaded by

    Lia Harnati27
    This document is a claim form submitted to BPJS Kesehatan for reimbursement. It details two childbirth services provided in August 2022 by SAJA'AH,AM.Keb totaling Rp. 1,400,000. The first service was for ROHANA from August 1-2, 2022 and the second was for RUSMAINI on August 24, 2022. Both services included normal vaginal birth packages performed by a midwife. The total claim amount is Rp. 1,400,000.

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    BPJS Kesehatan Cab.

    LUBUKLINGGAU
    FORMULIR PENGAJUAN KLAIM TINGKAT PERTAMA

    Nomor FPK : P2208000035375

    Provider : SAJA'AH,AM.Keb

    Bulan Pelayanan : August 2022


    Pelayanan : RITP

    Total Data : 2

    Total Tagihan : Rp. 1.400.000

    NO KUNJUNGAN NAMA PESERTA TGL MASUK TGL PULANG TINDAKAN TENAGA MEDIS BIAYA

    B00138680822P000001 ROHANA (0002674166005) 01/08/2022 02/08/2022 Paket Persalinan per Vaginam normal (oleh Bidan) SAJA'AH,AM.Keb Rp. 700.000

    B00138680822P000007 RUSMAINI (0001505599817) 24/08/2022 24/08/2022 Paket Persalinan per Vaginam normal (oleh Bidan) SAJA'AH,AM.Keb Rp. 700.000

    Tanggal terima FPK, Tanggal, 18/08/2023


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