REKAPITULASI BIAYA RETRIBUSI PASIEN JAMKESDA MASKIN NON MASKIN

PUSKESMAS / PUSTU / POSKESDES / : NAILAN

JENIS KUNJUNGAN
TOTAL JUMLAH KLAIM
NO TANGGAL NON KUNJUNGAN Px.JAMKESDA JUMLAH UANG
BPJS MASKIN MASKIN ASKES CPW LUAR KAB.

10 =
1 2 3 4 5 6 7 8 9 3+4+5+6+7+8+ 11 = 4+5 12= 11xRp6000
9
1 01/02/2021 18 0 9 4 31 9 54,000
2 02/02/2021 17 0 4 1 22 4 24,000
3 03/02/2021 9 0 3 0 12 3 18,000
4 04/02/2021 11 0 6 1 18 6 36,000
5 05/02/2021 11 0 6 3 20 6 36,000
6 06/02/2021 10 0 3 1 14 3 18,000
7 07/02/2021 0 0 0 0 0 0 -
8 08/02/2021 20 0 6 5 31 6 36,000
9 09/02/2021 14 0 5 2 21 5 30,000
10 10/02/2021 15 0 3 1 19 3 18,000
11 11/02/2021 12 0 6 2 20 6 36,000
12 12/02/2021 0 0 0 0 0 0 -
13 13/02/2021 11 0 3 2 16 3 18,000
14 14/02/2021 0 0 0 0 0 0 -
15 15/02/2021 25 0 13 6 44 13 78,000
16 16/02/2021 11 0 11 5 27 11 66,000
17 17/02/2021 12 0 7 0 19 7 42,000
18 18/02/2021 21 0 6 2 29 6 36,000
19 19/02/2021 14 0 7 2 23 7 42,000
20 20/02/2021 7 0 0 2 9 0 -
21 21/02/2021 0 0 0 0 0 0 -
22 22/02/2021 23 0 10 2 35 10 60,000
23 23/02/2021 12 0 5 1 18 5 30,000
24 24/02/2021 14 0 11 3 28 11 66,000
25 25/02/2021 16 0 5 3 24 5 30,000
26 26/02/2021 13 0 2 0 15 2 12,000
27 27/02/2021 8 0 3 1 12 3 18,000
28 28/02/2021 0 0 0 0 0 0 -

JUMLAH 324 0 134 49 0 0 507 134 804,000

MENGETAHUI
KEPALA PUSKESMAS NAILAN PENGELOLA PROGRAM JAMKESDA

dr. HENY TRI RACHMAWATI ANNI ISTIQOMAH, S.ST

NIP. 19820613 201001 2 026 NIP. 19740808 200604 2 022
 REKAPITULASI BIAYA RETRIBUSI PASIEN JAMKESDA MASKIN NON MASKIN

PUSKESMAS / PUSTU / POSKESDES / : PUSTU DURI

JENIS KUNJUNGAN
TOTAL JUMLAH
NO TANGGAL JAMKESMAS JAMKESDA SURAT KLAIM JUMLAH UANG
KUNJUNGAN
NON ASKES CPW SEHAT / LUAR KAB. Px.JAMKESDA
BPJS MASKIN
MASKIN SAKIT

10 =
1 2 3 4 5 6 7 8 9 3+4+5+6+7+8+9 11 = 4+5 12= 11xRp6000

1 01/02/2020 3 0 2 0 5 2 12,000
2 02/02/2020 3 0 2 0 5 2 12,000
3 03/02/2020 2 0 2 0 4 2 12,000
4 04/02/2020 2 0 2 1 5 2 12,000
5 05/02/2020 3 0 2 0 5 2 12,000
6 06/02/2020 3 0 2 0 5 2 12,000
7 07/02/2020 0 0 0 0 0 0 -
8 08/02/2020 2 0 3 0 5 3 18,000
9 09/02/2020 3 0 2 0 5 2 12,000
10 10/02/2020 3 0 1 1 5 1 6,000
11 11/02/2020 3 0 2 0 5 2 12,000
12 12/02/2020 0 0 0 0 0 0 -
13 13/02/2020 1 0 3 1 5 3 18,000
14 14/02/2020 0 0 0 0 0 0 -
15 15/02/2020 3 0 2 0 5 2 12,000
16 16/02/2020 1 0 4 0 5 4 24,000
17 17/02/2020 4 0 1 0 5 1 6,000
18 18/02/2020 4 0 1 0 5 1 6,000
19 19/02/2020 1 0 4 0 5 4 24,000
20 20/02/2020 4 0 1 0 5 1 6,000
21 21/02/2020 0 0 0 0 0 0 -
22 22/02/2020 4 0 1 0 5 1 6,000
23 23/02/2020 2 0 2 1 5 2 12,000
24 24/02/2020 3 0 0 0 3 0 -
25 25/02/2020 0 0 1 1 2 1 6,000
26 26/02/2020 2 0 0 1 3 0 -
27 27/02/2020 3 0 0 0 3 0 -
28 28/02/2020 0 0 0 0 0 0 -

JUMLAH 59 0 40 6 0 0 105 40 240,000

MENGETAHUI
KEPALA PUSKESMAS NAILAN PENGELOLA PROGRAM JAMKESDA

dr. HENY TRI RACHMAWATI ANNI ISTIQOMAH, S.ST

NIP. 19820613 201001 2 026 NIP. 19740808 200604 2 022
 REKAPITULASI BIAYA RETRIBUSI PASIEN JAMKESDA MASKIN NON MASKIN

PUSKESMAS / PUSTU / POSKESDES / : KAMBENG

JENIS KUNJUNGAN
JUMLAH
JAMKESMAS JAMKESDA TOTAL KLAIM
NO TANGGAL SURAT JUMLAH UANG
KUNJUNGAN Px.JAMKESD
ASKES CPW SEHAT LUAR KAB. A
NON
BPJS MASKIN MASKIN / SAKIT

10 =
1 2 3 4 5 6 7 8 9 11 = 4+5 12= 11xRp6000
3+4+5+6+7+8+9
1 01/02/2020 3 0 1 0 4 1 6,000
2 02/02/2020 3 0 1 0 4 1 6,000
3 03/02/2020 4 0 1 0 5 1 6,000
4 04/02/2020 3 0 1 0 4 1 6,000
5 05/02/2020 2 0 1 0 3 1 6,000
6 06/02/2020 2 0 1 0 3 1 6,000
7 07/02/2020 0 0 0 0 0 0 -
8 08/02/2020 2 0 1 0 3 1 6,000
9 09/02/2020 2 0 1 0 3 1 6,000
10 10/02/2020 3 0 1 0 4 1 6,000
11 11/02/2020 3 0 1 0 4 1 6,000
12 12/02/2020 0 0 0 0 0 0 -
13 13/02/2020 4 0 0 0 4 0 -
14 14/02/2020 0 0 0 0 0 0 -
15 15/02/2020 5 0 1 0 6 1 6,000
16 16/02/2020 5 0 1 0 6 1 6,000
17 17/02/2020 4 0 1 0 5 1 6,000
18 18/02/2020 3 0 1 0 4 1 6,000
19 19/02/2020 2 0 2 1 5 2 12,000
20 20/02/2020 4 0 0 0 4 0 -
21 21/02/2020 0 0 0 0 0 0 -
22 22/02/2020 1 0 2 1 4 2 12,000
23 23/02/2020 2 0 2 0 4 2 12,000
24 24/02/2020 2 0 2 1 5 2 12,000
25 25/02/2020 3 0 1 0 4 1 6,000
26 26/02/2020 3 0 0 0 3 0 -
27 27/02/2020 3 0 0 0 3 0 -
28 28/02/2020 0 0 0 0 0 0 -

JUMLAH 68 0 23 3 0 0 0 94 23 138,000

MENGETAHUI
KEPALA PUSKESMAS NAILAN PENGELOLA PROGRAM JAMKESDA

dr. HENY TRI RACHMAWATI ANNI ISTIQOMAH, S.ST

NIP. 19820613 201001 2 026 NIP. 19740808 200604 2 022
 REKAPITULASI BIAYA RETRIBUSI PASIEN JAMKESDA MASKIN NON MASKIN

PUSKESMAS / PUSTU / POSKESDES / : CRABAK

JENIS KUNJUNGAN
JUMLAH
JAMKESMAS JAMKESDA TOTAL KLAIM
NO TANGGAL SURAT JUMLAH UANG
KUNJUNGAN Px.JAMKESD
NON ASKES CPW SEHAT / LUAR KAB. A
BPJS MASKIN
MASKIN SAKIT

10 =
1 2 3 4 5 6 7 8 9 11 = 4+5 12= 11xRp6000
3+4+5+6+7+8+9
1 01/02/2020 1 0 1 0 2 1 6,000
2 02/02/2020 1 0 1 0 2 1 6,000
3 03/02/2020 0 0 1 0 1 1 6,000
4 04/02/2020 0 0 0 1 1 0 -
5 05/02/2020 1 0 0 0 1 0 -
6 06/02/2020 0 0 0 0 0 0 -
7 07/02/2020 0 0 0 0 0 0 -
8 08/02/2020 1 0 1 0 2 1 6,000
9 09/02/2020 1 0 1 0 2 1 6,000
10 10/02/2020 2 0 0 0 2 0 -
11 11/02/2020 0 0 0 0 0 0 -
12 12/02/2020 0 0 0 0 0 0 -
13 13/02/2020 3 0 1 0 4 1 6,000
14 14/02/2020 0 0 0 0 0 0 -
15 15/02/2020 4 0 2 0 6 2 12,000
16 16/02/2020 6 0 0 0 6 0 -
17 17/02/2020 2 0 3 0 5 3 18,000
18 18/02/2020 2 0 0 0 2 0 -
19 19/02/2020 3 0 1 1 5 1 6,000
20 20/02/2020 1 0 0 0 1 0 -
21 21/02/2020 0 0 0 0 0 0 -
22 22/02/2020 2 0 4 0 6 4 24,000
23 23/02/2020 1 0 2 0 3 2 12,000
24 24/02/2020 2 0 1 0 3 1 6,000
25 25/02/2020 3 0 0 1 4 0 -
26 26/02/2020 4 0 0 1 5 0 -
27 27/02/2020 5 0 0 0 5 0 -
28 28/02/2020 0 0 0 0 0 0 -

JUMLAH 45 0 19 4 0 0 68 19 114,000

MENGETAHUI
KEPALA PUSKESMAS NAILAN PENGELOLA PROGRAM JAMKESDA

dr. HENY TRI RACHMAWATI ANNI ISTIQOMAH, S.ST

NIP. 19820613 201001 2 026 NIP. 19740808 200604 2 022
 REKAPITULASI BIAYA RETRIBUSI PASIEN JAMKESDA MASKIN NON MASKIN

PUSKESMAS / PUSTU / POSKESDES / : GUNDIK

JENIS KUNJUNGAN
JUMLAH
JAMKESMAS JAMKESDA SURAT TOTAL KLAIM
NO TANGGAL KUNJUNGAN Px.JAMKESD JUMLAH UANG
NON ASKES CPW SEHAT / LUAR KAB. A
BPJS MASKIN
MASKIN SAKIT
10 =
1 2 3 4 5 6 7 8 9 3+4+5+6+7+8+9 11 = 4+5 12= 11xRp6000

1 01/02/2020 3 0 0 0 3 0 -
2 02/02/2020 1 0 2 0 3 2 12,000
3 03/02/2020 5 0 1 0 6 1 6,000
4 04/02/2020 0 0 1 0 1 1 6,000
5 05/02/2020 1 0 0 0 1 0 -
6 06/02/2020 0 0 0 0 0 0 -
7 07/02/2020 0 0 0 0 0 0 -
8 08/02/2020 3 0 7 0 10 7 42,000
9 09/02/2020 2 0 1 0 3 1 6,000
10 10/02/2020 0 0 1 0 1 1 6,000
11 11/02/2020 3 0 0 0 3 0 -
12 12/02/2020 0 0 0 0 0 0 -
13 13/02/2020 3 0 2 0 5 2 12,000
14 14/02/2020 0 0 0 0 0 0 -
15 15/02/2020 2 0 2 0 4 2 12,000
16 16/02/2020 4 0 3 0 7 3 18,000
17 17/02/2020 2 0 1 0 3 1 6,000
18 18/02/2020 2 0 1 0 3 1 6,000
19 19/02/2020 2 0 2 0 4 2 12,000
20 20/02/2020 2 0 0 0 2 0 -
21 21/02/2020 0 0 0 0 0 0 -
22 22/02/2020 1 0 0 0 1 0 -
23 23/02/2020 4 0 1 1 6 1 6,000
24 24/02/2020 4 0 1 0 5 1 6,000
25 25/02/2020 0 0 2 0 2 2 12,000
26 26/02/2020 2 0 0 0 2 0 -
27 27/02/2020 3 0 0 0 3 0 -
28 28/02/2020 0 0 0 0 0 0 -

JUMLAH 49 0 28 1 0 0 78 28 168,000

MENGETAHUI
KEPALA PUSKESMAS NAILAN PENGELOLA PROGRAM JAMKESDA

dr. HENY TRI RACHMAWATI ANNI ISTIQOMAH, S.ST

NIP. 19820613 201001 2 026 NIP. 19740808 200604 2 022
 REKAPITULASI BIAYA RETRIBUSI PASIEN JAMKESDA MASKIN NON MASKIN

PUSKESMAS / PUSTU / POSKESDES / : SIMO

JENIS KUNJUNGAN
JUMLAH
JAMKESMAS JAMKESDA TOTAL KLAIM
NO TANGGAL SURAT Px.JAMKESD JUMLAH UANG
NON ASKES CPW SEHAT / LUAR KAB. KUNJUNGAN
A
BPJS MASKIN MASKI SAKIT
N

1 2 3 4 5 6 7 8 9 10 = 11 = 4+5 12= 11xRp6000

3+4+5+6+7+8+9
1 01/02/2020 1 0 4 0 5 4 24,000
2 02/02/2020 5 0 0 0 5 0 -
3 03/02/2020 3 0 1 0 4 1 6,000
4 04/02/2020 1 0 1 1 3 1 6,000
5 05/02/2020 2 0 0 0 2 0 -
6 06/02/2020 0 0 0 0 0 0 -
7 07/02/2020 0 0 0 0 0 0 -
8 08/02/2020 5 0 0 0 5 0 -
9 09/02/2020 2 0 0 0 2 0 -
10 10/02/2020 3 0 4 1 8 4 24,000
11 11/02/2020 3 0 2 0 5 2 12,000
12 12/02/2020 0 0 0 0 0 0 -
13 13/02/2020 0 0 1 0 1 1 6,000
14 14/02/2020 0 0 0 0 0 0 -
15 15/02/2020 3 0 2 0 5 2 12,000
16 16/02/2020 3 0 5 0 8 5 30,000
17 17/02/2020 0 0 2 0 2 2 12,000
18 18/02/2020 1 0 2 0 3 2 12,000
19 19/02/2020 0 0 0 0 0 0 -
20 20/02/2020 1 0 0 0 1 0 -
21 21/02/2020 0 0 0 0 0 0 -
22 22/02/2020 1 0 1 1 3 1 6,000
23 23/02/2020 5 0 2 0 7 2 12,000
24 24/02/2020 0 0 0 0 0 0 -
25 25/02/2020 2 0 2 1 5 2 12,000
26 26/02/2020 2 0 0 0 2 0 -
27 27/02/2020 3 0 0 0 3 0 -
28 28/02/2020 0 0 0 0 0 0 -

JUMLAH 46 0 29 4 0 0 79 29 174,000

MENGETAHUI
KEPALA PUSKESMAS NAILAN PENGELOLA PROGRAM JAMKESDA

dr. HENY TRI RACHMAWATI ANNI ISTIQOMAH, S.ST

NIP. 19820613 201001 2 026 NIP. 19740808 200604 2 022
 REKAPITULASI BIAYA RETRIBUSI PASIEN JAMKESDA MASKIN NON MASKIN

PUSKESMAS / PUSTU / POSKESDES / : NGLONING

JENIS KUNJUNGAN
JUMLAH
JAMKESMAS JAMKESDA TOTAL KLAIM
NO TANGGAL SURAT KUNJUNGAN Px.JAMKESD JUMLAH UANG
ASKES CPW SEHAT / LUAR KAB.
BPJS MASKIN NON SAKIT
A
MASKIN
10 =
1 2 3 4 5 6 7 8 9 3+4+5+6+7+8+ 11 = 4+5 12= 11xRp6000
9
1 01/02/2020 3 0 0 0 3 0 -
2 02/02/2020 3 0 0 0 3 0 -
3 03/02/2020 2 0 2 0 4 2 12,000
4 04/02/2020 2 0 1 0 3 1 6,000
5 05/02/2020 1 0 2 0 3 2 12,000
6 06/02/2020 2 0 0 0 2 0 -
7 07/02/2020 0 0 0 0 0 0 -
8 08/02/2020 2 0 0 0 2 0 -
9 09/02/2020 2 0 0 0 2 0 -
10 10/02/2020 1 0 1 0 2 1 6,000
11 11/02/2020 2 0 1 0 3 1 6,000
12 12/02/2020 0 0 0 0 0 0 -
13 13/02/2020 2 0 1 0 3 1 6,000
14 14/02/2020 0 0 0 0 0 0 -
15 15/02/2020 3 0 0 0 3 0 -
16 16/02/2020 1 0 2 0 3 2 12,000
17 17/02/2020 3 0 0 0 3 0 -
18 18/02/2020 2 0 1 0 3 1 6,000
19 19/02/2020 2 0 1 0 3 1 6,000
20 20/02/2020 2 0 0 0 2 0 -
21 21/02/2020 0 0 0 0 0 0 -
22 22/02/2020 3 0 1 0 4 1 6,000
23 23/02/2020 2 0 1 0 3 1 6,000
24 24/02/2020 2 0 2 0 4 2 12,000
25 25/02/2020 3 0 2 0 5 2 12,000
26 26/02/2020 2 0 0 1 3 0 -
27 27/02/2020 3 0 2 0 5 2 12,000
28 28/02/2020 0 0 0 0 0 0 -

JUMLAH 50 0 20 1 0 0 71 20 120,000

MENGETAHUI
KEPALA PUSKESMAS NAILAN PENGELOLA PROGRAM JAMKESDA

dr. HENY TRI RACHMAWATI ANNI ISTIQOMAH, S.ST

NIP. 19820613 201001 2 026 NIP. 19740808 200604 2 022
 REKAPITULASI BIAYA RETRIBUSI PASIEN JAMKESDA MASKIN NON MASKIN

PUSKESMAS / PUSTU / POSKESDES / : PLANCUNGAN

JENIS KUNJUNGAN
JUMLAH
NO TANGGAL JAMKESMAS JAMKESDA TOTAL KLAIM JUMLAH UANG
SURAT KUNJUNGAN Px.JAMKESD
ASKES CPW SEHAT / LUAR KAB. A
NON
BPJS MASKIN
MASKIN
SAKIT
10 =
1 2 3 4 5 6 7 8 9 3+4+5+6+7+8+ 11 = 4+5 12= 11xRp6000
9
1 01/02/2020 1 0 2 0 3 2 12,000
2 02/02/2020 2 0 0 1 3 0 -
3 03/02/2020 3 0 0 0 3 0 -
4 04/02/2020 3 0 0 0 3 0 -
5 05/02/2020 3 0 0 0 3 0 -
6 06/02/2020 3 0 0 0 3 0 -
7 07/02/2020 0 0 0 0 0 0 -
8 08/02/2020 0 0 2 1 3 2 12,000
9 09/02/2020 2 0 1 0 3 1 6,000
10 10/02/2020 2 0 1 0 3 1 6,000
11 11/02/2020 2 0 1 0 3 1 6,000
12 12/02/2020 0 0 0 0 0 0 -
13 13/02/2020 2 0 1 0 3 1 6,000
14 14/02/2020 0 0 0 0 0 0 -
15 15/02/2020 2 0 1 0 3 1 6,000
16 16/02/2020 2 0 1 0 3 1 6,000
17 17/02/2020 2 0 1 0 3 1 6,000
18 18/02/2020 2 0 1 0 3 1 6,000
19 19/02/2020 3 0 0 0 3 0 -
20 20/02/2020 2 0 1 0 3 1 6,000
21 21/02/2020 0 0 0 0 0 0 -
22 22/02/2020 1 0 2 0 3 2 12,000
23 23/02/2020 2 0 0 0 2 0 -
24 24/02/2020 3 0 0 0 3 0 -
25 25/02/2020 2 0 0 1 3 0 -
26 26/02/2020 2 0 1 0 3 1 6,000
27 27/02/2020 4 0 2 0 6 2 12,000
28 28/02/2020 0 0 0 0 0 0 -

JUMLAH 50 0 18 3 0 0 71 18 108,000

MENGETAHUI
KEPALA PUSKESMAS NAILAN PENGELOLA PROGRAM JAMKESDA

dr. HENY TRI RACHMAWATI ANNI ISTIQOMAH, S.ST

NIP. 19820613 201001 2 026 NIP. 19740808 200604 2 022
 REKAPITULASI BIAYA RETRIBUSI PASIEN JAMKESDA MASKIN NON MASKIN

PUSKESMAS / PUSTU / POSKESDES / : GOMBANG

JENIS KUNJUNGAN
JUMLAH
JAMKESMAS JAMKESDA TOTAL KLAIM
NO TANGGAL SURAT JUMLAH UANG
KUNJUNGAN Px.JAMKESD
ASKES CPW SEHAT / LUAR KAB. A
BPJS MASKIN NON SAKIT
MASKIN

10 =
1 2 3 4 5 6 7 8 9 11 = 4+5 12= 11xRp6000
3+4+5+6+7+8+9
1 01/02/2020 4 0 2 0 6 2 12,000
2 02/02/2020 3 0 1 0 4 1 6,000
3 03/02/2020 3 0 1 0 4 1 6,000
4 04/02/2020 0 0 1 0 1 1 6,000
5 05/02/2020 1 0 0 0 1 0 -
6 06/02/2020 0 0 0 0 0 0 -
7 07/02/2020 0 0 0 0 0 0 -
8 08/02/2020 3 0 4 0 7 4 24,000
9 09/02/2020 0 0 1 0 1 1 6,000
10 10/02/2020 2 0 1 0 3 1 6,000
11 11/02/2020 2 0 1 0 3 1 6,000
12 12/02/2020 0 0 0 0 0 0 -
13 13/02/2020 1 0 2 0 3 2 12,000
14 14/02/2020 0 0 0 0 0 0 -
15 15/02/2020 2 0 2 0 4 2 12,000
16 16/02/2020 1 0 0 1 2 0 -
17 17/02/2020 0 0 0 0 0 0 -
18 18/02/2020 2 0 1 1 4 1 6,000
19 19/02/2020 2 0 0 0 2 0 -
20 20/02/2020 1 0 2 0 3 2 12,000
21 21/02/2020 0 0 0 0 0 0 -
22 22/02/2020 3 0 6 0 9 6 36,000
23 23/02/2020 2 0 2 2 6 2 12,000
24 24/02/2020 0 0 1 0 1 1 6,000
25 25/02/2020 0 0 1 0 1 1 6,000
26 26/02/2020 0 0 0 0 0 0 -
27 27/02/2020 0 0 0 0 0 0 -
28 28/02/2020 0 0 0 0 0 0 -

JUMLAH 32 0 29 4 0 0 0 65 29 174,000

MENGETAHUI
KEPALA PUSKESMAS NAILAN PENGELOLA PROGRAM JAMKESDA

dr. HENY TRI RACHMAWATI ANNI ISTIQOMAH, S.ST

NIP. 19820613 201001 2 026 NIP. 19740808 200604 2 022
 REKAPITULASI BIAYA RETRIBUSI PASIEN JAMKESDA MASKIN NON MASKIN

PUSKESMAS / PUSTU / POSKESDES / : MOJOPITU

JENIS KUNJUNGAN
JAMKESMAS JAMKESDA JUMLAH
SURAT TOTAL KLAIM
NO TANGGAL JUMLAH UANG
ASKES CPW SEHAT /LUAR KAB. KUNJUNGAN Px.JAMKESD
NON A
BPJS MASKIN
MASKIN
SAKIT

10 =
1 2 3 4 5 6 7 8 9 3+4+5+6+7+8+ 11 = 4+5 12= 11xRp6000
9
1 01/02/2020 0 0 0 0 0 0 0 0 0 -
2 02/02/2020 2 0 0 1 0 0 0 3 0 -
3 03/02/2020 3 0 2 1 0 0 0 6 2 12,000
4 04/02/2020 1 0 0 0 0 0 0 1 0 -
5 05/02/2020 1 0 0 0 0 0 0 1 0 -
6 06/02/2020 0 0 0 1 0 0 0 1 0 -
7 07/02/2020 0 0 0 0 0 0 0 0 0 -
8 08/02/2020 3 0 1 0 0 0 0 4 1 6,000
9 09/02/2020 1 0 0 0 0 0 0 1 0 -
10 10/02/2020 2 0 0 0 0 0 0 2 0 -
11 11/02/2020 0 0 0 0 0 0 0 0 0 -
12 12/02/2020 0 0 0 0 0 0 0 0 0 -
13 13/02/2020 3 0 0 0 0 0 0 3 0 -
14 14/02/2020 0 0 0 0 0 0 0 0 0 -
15 15/02/2020 1 0 1 0 0 0 0 2 1 6,000
16 16/02/2020 0 0 0 0 0 0 0 0 0 -
17 17/02/2020 4 0 2 0 0 0 0 6 2 12,000
18 18/02/2020 2 0 0 0 0 0 0 2 0 -
19 19/02/2020 2 0 0 0 0 0 0 2 0 -
20 20/02/2020 1 0 0 0 0 0 0 1 0 -
21 21/02/2020 0 0 0 0 0 0 0 0 0 -
22 22/02/2020 1 0 1 0 0 0 0 2 1 6,000
23 23/02/2020 5 0 0 0 0 0 0 5 0 -
24 24/02/2020 1 0 1 0 0 0 0 2 1 6,000
25 25/02/2020 1 0 1 0 0 0 0 2 1 6,000
26 26/02/2020 3 0 0 0 0 0 0 3 0 -
27 27/02/2020 5 0 0 0 0 0 0 5 0 -
28 28/02/2020 0 0 0 0 0 0 0 0 0 -

JUMLAH 42 0 9 3 0 0 54 9 54,000

MENGETAHUI
KEPALA PUSKESMAS NAILAN PENGELOLA PROGRAM JAMKESDA

dr. HENY TRI RACHMAWATI ANNI ISTIQOMAH, S.ST

NIP. 19820613 201001 2 026 NIP. 19740808 200604 2 022
 REKAPITULASI BIAYA RETRIBUSI PASIEN JAMKESDA MASKIN NON MASKIN

PUSKESMAS / PUSTU / POSKESDES / : JANTI

JENIS KUNJUNGAN
JAMKESMAS JAMKESDA JUMLAH
TOTAL
NO TANGGAL SURAT KLAIM JUMLAH UANG
KUNJUNGAN Px.JAMKESDA
NON ASKES CPW SEHAT /LUAR KAB.
BPJS MASKIN
MASKIN SAKIT

10 =
1 2 3 4 5 6 7 8 9 3+4+5+6+7+8+ 11 = 4+5 12= 11xRp6000
9
1 01/02/2020 4 0 3 0 7 3 18,000
2 02/02/2020 4 0 1 0 5 1 6,000
3 03/02/2020 4 0 0 0 4 0 -
4 04/02/2020 1 0 1 0 2 1 6,000
5 05/02/2020 2 0 0 1 3 0 -
6 06/02/2020 0 0 0 0 0 0 -
7 07/02/2020 0 0 0 0 0 0 -
8 08/02/2020 4 0 0 1 5 0 -
9 09/02/2020 2 0 0 0 2 0 -
10 10/02/2020 2 0 1 0 3 1 6,000
11 11/02/2020 3 0 0 0 3 0 -
12 12/02/2020 0 0 0 0 0 0 -
13 13/02/2020 4 0 0 0 4 0 -
14 14/02/2020 0 0 0 0 0 0 -
15 15/02/2020 4 0 0 0 4 0 -
16 16/02/2020 1 0 0 0 1 0 -
17 17/02/2020 5 0 1 0 6 1 6,000
18 18/02/2020 1 0 1 0 2 1 6,000
19 19/02/2020 0 0 0 0 0 0 -
20 20/02/2020 0 0 0 0 0 0 -
21 21/02/2020 0 0 0 0 0 0 -
22 22/02/2020 0 0 5 2 7 5 30,000
23 23/02/2020 3 0 0 0 3 0 -
24 24/02/2020 0 0 0 0 0 0 -
25 25/02/2020 4 0 0 0 4 0 -
26 26/02/2020 3 0 0 0 3 0 -
27 27/02/2020 0 0 0 0 0 0 -
28 28/02/2020 0 0 0 0 0 0 -

JUMLAH 51 0 13 4 0 0 68 13 78,000

MENGETAHUI
KEPALA PUSKESMAS NAILAN PENGELOLA PROGRAM JAMKESDA

dr. HENY TRI RACHMAWATI ANNI ISTIQOMAH, S.ST

NIP. 19820613 201001 2 026 NIP. 19740808 200604 2 022
 REKAPITULASI BIAYA RETRIBUSI PASIEN JAMKESDA MASKIN NON MASKIN

PUSKESMAS / PUSTU / POSKESDES / : NGILO ILO

JENIS KUNJUNGAN

JAMKESMAS JAMKESDA JUMLAH

TOTAL KLAIM
NO TANGGAL SURAT JUMLAH UANG
KUNJUNGAN Px.JAMKESD
ASKES CPW SEHAT / LUAR KAB. A
NON
BPJS MASKIN
MASKIN
SAKIT

10 =
1 2 3 4 5 6 7 8 9 11 = 4+5 12= 11xRp6000
3+4+5+6+7+8+9
1 01/02/2020 3 0 0 1 4 0 -
2 02/02/2020 2 0 2 0 4 2 12,000
3 03/02/2020 1 0 0 1 2 0 -
4 04/02/2020 5 0 1 0 6 1 6,000
5 05/02/2020 0 0 0 0 0 0 -
6 06/02/2020 0 0 0 0 0 0 -
7 07/02/2020 0 0 0 0 0 0 -
8 08/02/2020 6 0 0 0 6 0 -
9 09/02/2020 1 0 0 0 1 0 -
10 10/02/2020 3 0 0 1 4 0 -
11 11/02/2020 1 0 2 0 3 2 12,000
12 12/02/2020 0 0 0 0 0 0 -
13 13/02/2020 1 0 0 0 1 0 -
14 14/02/2020 0 0 0 0 0 0 -
15 15/02/2020 2 0 1 0 3 1 6,000
16 16/02/2020 2 0 0 0 2 0 -
17 17/02/2020 3 0 0 1 4 0 -
18 18/02/2020 3 0 0 0 3 0 -
19 19/02/2020 3 0 3 0 6 3 18,000
20 20/02/2020 0 0 0 0 0 0 -
21 21/02/2020 0 0 0 0 0 0 -
22 22/02/2020 0 0 0 0 0 0 -
23 23/02/2020 2 0 0 0 2 0 -
24 24/02/2020 0 0 1 0 1 1 6,000
25 25/02/2020 2 0 1 0 3 1 6,000
26 26/02/2020 4 0 0 0 4 0 -
27 27/02/2020 4 0 0 0 4 0 -
28 28/02/2020 0 0 0 0 0 0 -

JUMLAH 48 0 11 4 0 0 63 11 66,000

MENGETAHUI
KEPALA PUSKESMAS NAILAN PENGELOLA PROGRAM JAMKESDA

dr. HENY TRI RACHMAWATI ANNI ISTIQOMAH, S.ST

NIP. 19820613 201001 2 026 NIP. 19740808 200604 2 022