REKAP PENGAJUAN KLAIM RIT REKAP PENGAJUAN KLAIM RITP PUSKESMAS BANTUR

BULAN JULI 2023

RAWAT INAP

NO NAMA NO KARTU ALAMAT NO TLPN DIAGNOSA JUMLAH JUMLAH

TGL MASUK TGL KELUAR TARIF PAKET
HARI

1 PAERAH ‘0000679729691 SUMBERBENING R11 6/29/2023 7/2/2023 3 Rp 750,000 Rp 750,000

2 SUPARIN ‘0000679033539 SRIGONCO A09 6/27/2023 7/1/2023 4 Rp 1,000,000 Rp 1,000,000
3 DIAN ROHMAH YUSTININGRUM ‘0002460584889 BANTUR J45.9 6/30/2023 7/4/2023 4 Rp 1,000,000 Rp 1,000,000
4 MARSINI ‘0000110226339 BANTUR A09.9 6/29/2023 7/1/2023 2 Rp 500,000 Rp 500,000
5 ALIF NURUL HIDAYAH ‘0002889727479 BANTUR R11 6/29/2023 7/2/2023 3 Rp 750,000 Rp 750,000
6 ACHMAD TUKIMIN ‘0001728235956 PRINGGODANI A09 7/1/2023 7/4/2023 3 Rp 750,000 Rp 750,000
7 JUMAL ‘0000678312303 BANTUR J44 7/5/2023 7/8/2023 3 Rp 750,000 Rp 750,000
8 TRIMAN ‘0002865437267 BANTUR J44 7/1/2023 7/4/2023 3 Rp 750,000 Rp 750,000
9 MUKRI ‘0000677974241 TUMPAKREJO I22.9 7/1/2023 7/4/2023 3 Rp 750,000 Rp 750,000
10 WAHYUDI ‘0003246326054 KARANGSARI R10 7/7/2023 7/9/2023 2 Rp 500,000 Rp 500,000
11 MISTRI ‘0002680656186 BANTUR B00 7/10/2023 7/12/2023 2 Rp 500,000 Rp 500,000
12 SHEVA ZILDJIAN AL MUHAJIRIN ‘0003535941036 TUMPAKREJO R50 7/23/2023 7/26/2023 3 Rp 750,000 Rp 750,000
13 SUNARSIH ‘0002159152064 TUMPAKREJO R10 7/16/2023 7/20/2023 4 Rp 1,000,000 Rp 1,000,000
14 SUMIANI ‘0001339614707 BANTUR R10 7/9/2023 7/13/2023 4 Rp 1,000,000 Rp 1,000,000
15 SUPIATUN ‘0003186455231 BANTUR I10 7/12/2023 7/15/2023 3 Rp 750,000 Rp 750,000
16 HANIN RAIHANA SYAHIRA ‘0002885232543 SRIGONCO A09 7/8/2023 7/12/2023 4 Rp 1,000,000 Rp 1,000,000
17 SINTA ‘0000678148672 BANTUR A88.1 7/8/2023 7/11/2023 3 Rp 750,000 Rp 750,000
18 TUNI ‘0002273870744 SRIGONCO R06 7/8/2023 7/12/2023 4 Rp 1,000,000 Rp 1,000,000
19 SUMIATI ULWA DILLAH ‘0001732049741 KARANGSARI A09 7/10/2023 7/13/2023 3 Rp 750,000 Rp 750,000
20 rivki ridho pratama ‘0002090195414 SUMBERBENING R50 7/11/2023 7/14/2023 3 Rp 750,000 Rp 750,000
21 ADNAN HAFIZH ARRASYA ‘0003513280814 SRIGONCO R11 7/14/2023 7/17/2023 3 Rp 750,000 Rp 750,000
22 SAMURI ‘0000678910454 KARANGSARI A09 7/11/2023 7/14/2023 3 Rp 750,000 Rp 750,000
23 KHALISA AGHNIA MIKAILA SATYA ‘0003098710552 BANTUR R50 7/13/2023 7/16/2023 3 Rp 750,000 Rp 750,000
24 SINARTI DARMIATI ‘0001869613659 REJOSARI A09 7/14/2023 7/16/2023 2 Rp 500,000 Rp 500,000
25 ACHMAD SAMSUL SODIK ‘0001093651918 BANTUR J20.9 7/14/2023 7/18/2023 4 Rp 1,000,000 Rp 1,000,000
26 RIANTI ‘0001818654928 BANTUR E11 7/14/2023 7/18/2023 4 Rp 1,000,000 Rp 1,000,000
27 IKA PUTRI AFRILIA ‘0002916431019 SRIGONCO K29 7/15/2023 7/19/2023 4 Rp 1,000,000 Rp 1,000,000
28 CIKO PUTRA ALDANI ‘0003143383784 TUMPAKREJO R50 7/16/2023 7/21/2023 5 Rp 1,250,000 Rp 1,250,000
29 MARSINI ‘0000110226339 BANTUR A09 7/16/2023 7/20/2023 4 Rp 1,000,000 Rp 1,000,000
30 ERLAN WIBISONO ‘0002245362895 JABUNG A09 7/17/2023 7/20/2023 3 Rp 750,000 Rp 750,000
31 LIA NURJANAH ‘0002609131105 SRIGONCO O21.1 7/18/2023 7/21/2023 3 Rp 750,000 Rp 750,000
32 NABILA BILQIS HUMAIRO ‘0003186448907 BANTUR A09 7/19/2023 7/23/2023 4 Rp 1,000,000 Rp 1,000,000
33 MISTIKAH ‘0002004843115 BANTUR R100 7/20/2023 7/24/2023 4 Rp 1,000,000 Rp 1,000,000
34 subandi ‘0001817764942 BANTUR A09 7/21/2023 7/24/2023 3 Rp 750,000 Rp 750,000
35 SITINAH ‘0000680075188 TUMPAKREJO J45.9 7/1/2023 7/6/2023 5 Rp 1,250,000 Rp 1,250,000
36 AGUS SUSILO JUNIANTO ‘0002263382122 BANTUR R50 7/22/2023 7/26/2023 4 Rp 1,000,000 Rp 1,000,000
37 FARIDATUL AMALIA ‘0002883428289 SUMBERBENING A09 7/23/2023 7/26/2023 3 Rp 750,000 Rp 750,000
38 RUSMINING ‘0002004851834 BANTUR A09 7/22/2023 7/26/2023 4 Rp 1,000,000 Rp 1,000,000
39 ACHMAD GALANG SAPUTRA ‘0003142977243 BANTUR R50 7/24/2023 7/27/2023 3 Rp 750,000 Rp 750,000
40 JUPRI ‘0000408744639 TUMPAKREJO A09 7/24/2023 7/27/2023 3 Rp 750,000 Rp 750,000
41 RENDIK A ‘0001038171587 BANTUR R11 7/25/2023 7/28/2023 3 Rp 750,000 Rp 750,000
42 SURIYATI ‘0000110227252 REJOSARI A09 7/20/2023 7/23/2023 3 Rp 750,000 Rp 750,000
43 SUYATMI ‘0002842910662 TUMPAKREJO I15 7/26/2023 7/29/2023 3 Rp 750,000 Rp 750,000
44 SLAMET ‘0000679366091 PRINGGODANI A09 7/27/2023 7/30/2023 3 Rp 750,000 Rp 750,000
45 KANTHI RAHAYU ‘0000677411829 WONOREJO A09 7/26/2023 7/29/2023 3 Rp 750,000 Rp 750,000
46 PAIT ZULKARNAIN ‘0000678354614 TUMPAKREJO E11 7/9/2023 7/12/2023 3 Rp 750,000 Rp 750,000
47 DITA INDAH RAMADHANA ‘0003012689171 SRIGONCO A09.9 7/15/2023 7/19/2023 4 Rp 1,000,000 Rp 1,000,000
48 LASMINTEN ‘0000679924686 BANTUR J11 7/19/2023 7/22/2023 3 Rp 750,000 Rp 750,000
49 SUTIANI ‘0000678565203 BANDUNGREJO A09 7/25/2023 7/28/2023 3 Rp 750,000 Rp 750,000
50 SUTJIPTO ADI ‘0001831113674 WONOREJO I15 7/7/2023 7/11/2023 4 Rp 1,000,000 Rp 1,000,000
51 IKLIL ZAKARIYA ‘0003085467952 PRINGGODANI A09 7/3/2023 7/6/2023 3 Rp 750,000 Rp 750,000

Rp 42,250,000

Bantur, Agustus 2023

Kepala UPT Puskesmas Bantur

SOEBAGIJONO, S.Kep, M.Mkes

NIP. 19681009 199003 1 003

REKAP PENGAJUAN KLAIM RIT REKAP PENGAJUAN KLAIM RITP PUSKESMAS BANTUR

BULAN AGUSTUS 2023

RAWAT INAP

NO NAMA NO KARTU ALAMAT NO TLPN DIAGNOSA JUMLAH JUMLAH

TGL MASUK TGL KELUAR TARIF PAKET
HARI

1 PAERAH ‘0000679729691 SUMBERBENING R11 6/29/2023 7/2/2023 3 Rp 750,000 Rp 750,000

2 SUPARIN ‘0000679033539 SRIGONCO A09 6/27/2023 7/1/2023 4 Rp 1,000,000 Rp 1,000,000
3 DIAN ROHMAH YUSTININGRUM ‘0002460584889 BANTUR J45.9 6/30/2023 7/4/2023 4 Rp 1,000,000 Rp 1,000,000
4 MARSINI ‘0000110226339 BANTUR A09.9 6/29/2023 7/1/2023 2 Rp 500,000 Rp 500,000
5 ALIF NURUL HIDAYAH ‘0002889727479 BANTUR R11 6/29/2023 7/2/2023 3 Rp 750,000 Rp 750,000
6 ACHMAD TUKIMIN ‘0001728235956 PRINGGODANI A09 7/1/2023 7/4/2023 3 Rp 750,000 Rp 750,000
7 JUMAL ‘0000678312303 BANTUR J44 7/5/2023 7/8/2023 3 Rp 750,000 Rp 750,000
8 TRIMAN ‘0002865437267 BANTUR J44 7/1/2023 7/4/2023 3 Rp 750,000 Rp 750,000
9 MUKRI ‘0000677974241 TUMPAKREJO I22.9 7/1/2023 7/4/2023 3 Rp 750,000 Rp 750,000
10 WAHYUDI ‘0003246326054 KARANGSARI R10 7/7/2023 7/9/2023 2 Rp 500,000 Rp 500,000
11 MISTRI ‘0002680656186 BANTUR B00 7/10/2023 7/12/2023 2 Rp 500,000 Rp 500,000
12 SHEVA ZILDJIAN AL MUHAJIRIN ‘0003535941036 TUMPAKREJO R50 7/23/2023 7/26/2023 3 Rp 750,000 Rp 750,000
13 SUNARSIH ‘0002159152064 TUMPAKREJO R10 7/16/2023 7/20/2023 4 Rp 1,000,000 Rp 1,000,000
14 SUMIANI ‘0001339614707 BANTUR R10 7/9/2023 7/13/2023 4 Rp 1,000,000 Rp 1,000,000
15 SUPIATUN ‘0003186455231 BANTUR I10 7/12/2023 7/15/2023 3 Rp 750,000 Rp 750,000
16 HANIN RAIHANA SYAHIRA ‘0002885232543 SRIGONCO A09 7/8/2023 7/12/2023 4 Rp 1,000,000 Rp 1,000,000
17 SINTA ‘0000678148672 BANTUR A88.1 7/8/2023 7/11/2023 3 Rp 750,000 Rp 750,000
18 TUNI ‘0002273870744 SRIGONCO R06 7/8/2023 7/12/2023 4 Rp 1,000,000 Rp 1,000,000
19 SUMIATI ULWA DILLAH ‘0001732049741 KARANGSARI A09 7/10/2023 7/13/2023 3 Rp 750,000 Rp 750,000
20 rivki ridho pratama ‘0002090195414 SUMBERBENING R50 7/11/2023 7/14/2023 3 Rp 750,000 Rp 750,000
21 ADNAN HAFIZH ARRASYA ‘0003513280814 SRIGONCO R11 7/14/2023 7/17/2023 3 Rp 750,000 Rp 750,000
22 SAMURI ‘0000678910454 KARANGSARI A09 7/11/2023 7/14/2023 3 Rp 750,000 Rp 750,000
23 KHALISA AGHNIA MIKAILA SATYA ‘0003098710552 BANTUR R50 7/13/2023 7/16/2023 3 Rp 750,000 Rp 750,000
24 SINARTI DARMIATI ‘0001869613659 REJOSARI A09 7/14/2023 7/16/2023 2 Rp 500,000 Rp 500,000
25 ACHMAD SAMSUL SODIK ‘0001093651918 BANTUR J20.9 7/14/2023 7/18/2023 4 Rp 1,000,000 Rp 1,000,000
26 RIANTI ‘0001818654928 BANTUR E11 7/14/2023 7/18/2023 4 Rp 1,000,000 Rp 1,000,000
27 IKA PUTRI AFRILIA ‘0002916431019 SRIGONCO K29 7/15/2023 7/19/2023 4 Rp 1,000,000 Rp 1,000,000
28 CIKO PUTRA ALDANI ‘0003143383784 TUMPAKREJO R50 7/16/2023 7/21/2023 5 Rp 1,250,000 Rp 1,250,000
29 MARSINI ‘0000110226339 BANTUR A09 7/16/2023 7/20/2023 4 Rp 1,000,000 Rp 1,000,000
30 ERLAN WIBISONO ‘0002245362895 JABUNG A09 7/17/2023 7/20/2023 3 Rp 750,000 Rp 750,000
31 LIA NURJANAH ‘0002609131105 SRIGONCO O21.1 7/18/2023 7/21/2023 3 Rp 750,000 Rp 750,000
32 NABILA BILQIS HUMAIRO ‘0003186448907 BANTUR A09 7/19/2023 7/23/2023 4 Rp 1,000,000 Rp 1,000,000
33 MISTIKAH ‘0002004843115 BANTUR R100 7/20/2023 7/24/2023 4 Rp 1,000,000 Rp 1,000,000
34 subandi ‘0001817764942 BANTUR A09 7/21/2023 7/24/2023 3 Rp 750,000 Rp 750,000
35 SITINAH ‘0000680075188 TUMPAKREJO J45.9 7/1/2023 7/6/2023 5 Rp 1,250,000 Rp 1,250,000
36 AGUS SUSILO JUNIANTO ‘0002263382122 BANTUR R50 7/22/2023 7/26/2023 4 Rp 1,000,000 Rp 1,000,000
37 FARIDATUL AMALIA ‘0002883428289 SUMBERBENING A09 7/23/2023 7/26/2023 3 Rp 750,000 Rp 750,000
38 RUSMINING ‘0002004851834 BANTUR A09 7/22/2023 7/26/2023 4 Rp 1,000,000 Rp 1,000,000
39 ACHMAD GALANG SAPUTRA ‘0003142977243 BANTUR R50 7/24/2023 7/27/2023 3 Rp 750,000 Rp 750,000
40 JUPRI ‘0000408744639 TUMPAKREJO A09 7/24/2023 7/27/2023 3 Rp 750,000 Rp 750,000
41 RENDIK A ‘0001038171587 BANTUR R11 7/25/2023 7/28/2023 3 Rp 750,000 Rp 750,000
42 SURIYATI ‘0000110227252 REJOSARI A09 7/20/2023 7/23/2023 3 Rp 750,000 Rp 750,000
43 SUYATMI ‘0002842910662 TUMPAKREJO I15 7/26/2023 7/29/2023 3 Rp 750,000 Rp 750,000
44 SLAMET ‘0000679366091 PRINGGODANI A09 7/27/2023 7/30/2023 3 Rp 750,000 Rp 750,000
45 KANTHI RAHAYU ‘0000677411829 WONOREJO A09 7/26/2023 7/29/2023 3 Rp 750,000 Rp 750,000
46 PAIT ZULKARNAIN ‘0000678354614 TUMPAKREJO E11 7/9/2023 7/12/2023 3 Rp 750,000 Rp 750,000
47 DITA INDAH RAMADHANA ‘0003012689171 SRIGONCO A09.9 7/15/2023 7/19/2023 4 Rp 1,000,000 Rp 1,000,000
48 LASMINTEN ‘0000679924686 BANTUR J11 7/19/2023 7/22/2023 3 Rp 750,000 Rp 750,000
49 SUTIANI ‘0000678565203 BANDUNGREJO A09 7/25/2023 7/28/2023 3 Rp 750,000 Rp 750,000
50 SUTJIPTO ADI ‘0001831113674 WONOREJO I15 7/7/2023 7/11/2023 4 Rp 1,000,000 Rp 1,000,000
51 IKLIL ZAKARIYA ‘0003085467952 PRINGGODANI A09 7/3/2023 7/6/2023 3 Rp 750,000 Rp 750,000

Rp 42,250,000

Bantur, Agustus 2023

Kepala UPT Puskesmas Bantur

SOEBAGIJONO, S.Kep, M.Mkes

NIP. 19681009 199003 1 003
1
REKAP PENGAJUAN KLAIM PERSALINAN PUSKESMAS BANTUR
Bulan JUNI 2023
PERSALINAN JUMLAH
TGL TARIF BIDAN
NO NAMA NO KARTU ALAMAT NO TLPN DIAGNOSA
PELAYANAN PAKET

1 IKE RETNASARI '0003246252581 BANTUR O80 6/17/2023 Rp 800,000 Rp 800,000 sukemi

2 SITI MUSYAROFAH '0000677614904 BANTUR O80 6/13/2023 Rp 800,000 Rp 800,000 dr nevy
3 GAFITRA NINGSIH '0003012689733 SRIGONCO O80 6/5/2023 Rp 800,000 Rp 800,000 sukemi
4 NIDA OHANA '0000677989732 BANDUNGREJO O80 6/15/2023 Rp 800,000 Rp 800,000 sukemi
5 SITI LUTVIANA '0001038169956 BANTUR O80 6/30/2023 Rp 800,000 Rp 800,000
6 PUJI LESTARI '0003237016217 BANTUR O80 6/30/2023 Rp 800,000 Rp 800,000
7
8
9
10
11 TOTAL Rp4,800,000 Rp 4,800,000

Bantur, JULI 2023

Kepala UPT Puskesmas Bantur

SOEBAGIJONO, S.Kep, M.Mkes

NIP. 19681009 199003 1 003

1
REKAP PENGAJUAN KLAIM PERSALINAN PUSKESMAS BANTUR
Bulan JUNI 2023
PERSALINAN JUMLAH
BIDAN
NO NAMA NO KARTU ALAMAT NO TLPN DIAGNOSA
 TGL TARIF BIDAN
NO NAMA NO KARTU ALAMAT NO TLPN DIAGNOSA
PELAYANAN PAKET

1 IKE RETNASARI '0003246252581 BANTUR O80 6/17/2023 Rp 800,000 Rp 800,000 sukemi

2 SITI MUSYAROFAH '0000677614904 BANTUR O80 6/13/2023 Rp 800,000 Rp 800,000 dr nevy
3 GAFITRA NINGSIH '0003012689733 SRIGONCO O80 6/5/2023 Rp 800,000 Rp 800,000 sukemi
4 NIDA OHANA '0000677989732 BANDUNGREJO O80 6/15/2023 Rp 800,000 Rp 800,000 sukemi
5 SITI LUTVIANA '0001038169956 BANTUR O80 6/30/2023 Rp 800,000 Rp 800,000
6 PUJI LESTARI '0003237016217 BANTUR O80 6/30/2023 Rp 800,000 Rp 800,000
7
8
9
10
11 TOTAL Rp4,800,000 Rp 4,800,000

Bantur, JULI 2023

Kepala UPT Puskesmas Bantur

SOEBAGIJONO, S.Kep, M.Mkes

NIP. 19681009 199003 1 003
 REKAP PENGAJUAN KLAIM RJTP ( Ambulance ) PUSKESMAS BANTUR
BULAN JULI 2023

NO POL
NO NAMA NO KARTU ALAMAT DIAGNOSA ALASAN DOKTER PERU FASKES TUJUAN TGL MRS TGL DIRUJUK KM AMBULANC DRIVER TARIF
E

PERAWATAN LEBIH
1 SAKRI 0003247278491 TUMPAKREJO R60.1 INTENSIF DR NEVY RS MITRA DELIMA 7/4/2023 7/4/2023 31 N1140E0P SUPARDI Rp360,000

PERAWATAN LEBIH
2 BUDI SANTOSO 0002919129344 BANTUR E87.5 INTENSIF DR NEVY RSUDK 7/5/2023 7/5/2023 29 N1140E0P SUPARDI Rp340,000

PERAWATAN LEBIH
3 SIMIN 0002327639062 BANTUR I63.9 INTENSIF DR NEVY RSUDK 7/18/2023 7/18/2023 29 N 1058 EP PITOYO Rp340,000

PERAWATAN LEBIH
4 PAIT ZULKARNAIN 0000678354614 TUMPAKREJO E11 INTENSIF DR NEVY RS MITRA DELIMA 7/9/2023 7/12/2023 31 N1140E0P SUPARDI Rp360,000

PERAWATAN LEBIH
5 JAKINEM 0000678144846 BANTUR R06 INTENSIF DR NEVY RSUDK 7/22/2023 7/22/2023 29 N 1058 EP PITOYO Rp340,000

PERAWATAN LEBIH
6 SITI 0000677880718 SUMBERBENING I50.9 INTENSIF DR NEVY RS MITRA DELIMA 7/27/2023 7/27/2023 31 N 1058 EP PITOYO Rp360,000

PERAWATAN LEBIH
7 HADI SUNARKO 0001105466747 KEPANJEN S83.1 INTENSIF DR NEVY RS SOEPRAOEN 7/28/2023 7/28/2023 46 N 1058 EP PITOYO Rp510,000

PERAWATAN LEBIH
8 WIJIATI 0003246167013 PRINGGONDANI I50.9 INTENSIF DR NEVY RS MITRA DELIMA 7/30/2023 7/30/2023 31 N 1058 EP PITOYO Rp360,000

PERAWATAN LEBIH
9 WIWIT TRISNAWATI 0002680652092 SUMBERBENING O73.0 INTENSIF DR NEVY RS WAVA HUSADA 7/7/2023 7/7/2023 29 N 1058 EP PITOYO Rp340,000

PERAWATAN LEBIH
10 HALIMAH 0000678089766 BANTUR D64.9 INTENSIF DR NEVY RS WAVA HUSADA 7/1/2023 7/1/2023 29 N 1058 EP PITOYO Rp340,000

Rp3,650,000

Bantur, Agustus 2023

Kepala UPT Puskesmas Bantur

SOEBAGIJONO, S.Kep, M.Mkes

NIP. 19681009 199003 1 003

REKAP PENGAJUAN KLAIM RJTP ( Ambulance ) PUSKESMAS BANTUR

BULAN JULI 2023

NO POL
NO NAMA NO KARTU ALAMAT DIAGNOSA ALASAN DOKTER PERU FASKES TUJUAN TGL MRS TGL DIRUJUK KM AMBULANC DRIVER TARIF
E

PERAWATAN LEBIH
1 SAKRI 0003247278491 TUMPAKREJO R60.1 INTENSIF DR NEVY RS MITRA DELIMA 7/4/2023 7/4/2023 31 N1140E0P SUPARDI Rp360,000

PERAWATAN LEBIH
2 BUDI SANTOSO 0002919129344 BANTUR E87.5 INTENSIF DR NEVY RSUDK 7/5/2023 7/5/2023 29 N1140E0P SUPARDI Rp340,000

PERAWATAN LEBIH
3 SIMIN 0002327639062 BANTUR I63.9 INTENSIF DR NEVY RSUDK 7/18/2023 7/18/2023 29 N 1058 EP PITOYO Rp340,000
 PERAWATAN LEBIH
4 PAIT ZULKARNAIN 0000678354614 TUMPAKREJO E11 INTENSIF DR NEVY RS MITRA DELIMA 7/9/2023 7/12/2023 31 N1140E0P SUPARDI Rp360,000

PERAWATAN LEBIH
5 JAKINEM 0000678144846 BANTUR R06 INTENSIF DR NEVY RSUDK 7/22/2023 7/22/2023 29 N 1058 EP PITOYO Rp340,000

PERAWATAN LEBIH
6 SITI 0000677880718 SUMBERBENING I50.9 INTENSIF DR NEVY RS MITRA DELIMA 7/27/2023 7/27/2023 31 N 1058 EP PITOYO Rp360,000

PERAWATAN LEBIH
7 HADI SUNARKO 0001105466747 KEPANJEN S83.1 INTENSIF DR NEVY RS SOEPRAOEN 7/28/2023 7/28/2023 46 N 1058 EP PITOYO Rp510,000

PERAWATAN LEBIH
8 WIJIATI 0003246167013 PRINGGONDANI I50.9 INTENSIF DR NEVY RS MITRA DELIMA 7/30/2023 7/30/2023 31 N 1058 EP PITOYO Rp360,000

PERAWATAN LEBIH
9 WIWIT TRISNAWATI 0002680652092 SUMBERBENING O73.0 INTENSIF DR NEVY RS WAVA HUSADA 7/7/2023 7/7/2023 29 N 1058 EP PITOYO Rp340,000

PERAWATAN LEBIH
10 HALIMAH 0000678089766 BANTUR D64.9 INTENSIF DR NEVY RS WAVA HUSADA 7/1/2023 7/1/2023 29 N 1058 EP PITOYO Rp340,000

Rp3,650,000

Bantur, Agustus 2023

Kepala UPT Puskesmas Bantur

SOEBAGIJONO, S.Kep, M.Mkes

NIP. 19681009 199003 1 003
 REKAP PENGAJUAN KLAIM ANC-INC-PNC DI FASKES TK I BULAN AGUSTUS

TANGGAL JENIS PELAYANAN BESARAN TARIF NAKES YANG

NO NAMA PENDERITA NOMOR KARTU BPJS ALAMAT NO.TELP /HP
PELAYANAN (ANC/INC/PNC) PAKET MELAYANI
1 PURWATI NURSIATI 0000677839735 BANTUR 7/4/2023 ANC DENGAN USG Rp 140,000 DR NEVY

2 RIWAYATI 0003335836342 TUMPAKREJO 7/4/2023 ANC DENGAN USG Rp 140,000 DR NEVY

3 I'IF PRAVITA SARI 0002229041103 BANTUR 7/4/2023 ANC DENGAN USG Rp 140,000 DR NEVY

4 TITIK RIWAYATI 0003335496478 TUMPAKREJO 7/4/2023 ANC DENGAN USG Rp 140,000 DR NEVY

5 TITI 0003116740612 SRIGONCO 7/4/2023 ANC DENGAN USG Rp 140,000 DR NEVY

6 SUMIANI 0000677916099 SUMBERBENING 7/4/2023 ANC DENGAN USG Rp 140,000 DR NEVY

7 LAILATUL FITRIAH 0002004874582 SUMBERBENING 7/4/2023 ANC DENGAN USG Rp 140,000 DR NEVY

8 ISNAINI RAHAYU 0001396086232 SURABAYA 7/4/2023 ANC DENGAN USG Rp 140,000 DR NEVY

9 UTI HANIAN 0003528634217 BANTUR 7/11/2023 ANC DENGAN USG Rp 140,000 DR NEVY

10 FAIDATUL FATONAH 0003246172345 SUMBERBENING 7/11/2023 ANC DENGAN USG Rp 140,000 DR NEVY

11 ULFA MAWADDATURROKHMAH 0000718580272 MEGERSARI 7/11/2023 ANC DENGAN USG Rp 140,000 DR NEVY

12 SITI JUBA'IDAH 0003523484608 SUMBERBENING 7/11/2023 ANC DENGAN USG Rp 140,000 DR NEVY

13 CITRA 0000677841164 BANDUNGREJO 7/11/2023 ANC DENGAN USG Rp 140,000 DR NEVY

14 LUTFIATUN NAFI'A 0003246414963 BANTUR 7/11/2023 ANC DENGAN USG Rp 140,000 DR NEVY

15 SITI KOMARIYAH 0002680658741 BANTUR 7/18/2023 ANC DENGAN USG Rp 140,000 DR NEVY

16 SITI LESTARI 0002873854653 SRIGONCO 7/18/2023 ANC DENGAN USG Rp 140,000 DR NEVY

17 RIWAYATI MAYANGSARI 0000678509403 BANTUR 7/18/2023 ANC DENGAN USG Rp 140,000 DR NEVY
18 MISENAH 0000679064861 TUMPAKREJO 7/18/2023 ANC DENGAN USG Rp 140,000 DR NEVY

19 IKA PUJIATI 0002680654702 SRIGONCO 7/18/2023 ANC DENGAN USG Rp 140,000 DR NEVY

20 ERNI 0000679161159 PRINGGODANI 7/18/2023 ANC DENGAN USG Rp 140,000 DR NEVY

21 ERY NUR BHAETHY ROHMA 0002803714402 SUMBERBENING 7/18/2023 ANC DENGAN USG Rp 140,000 DR NEVY

22 SUMIATI 0000678742817 BANTUR 7/25/2023 ANC DENGAN USG Rp 140,000 DR NEVY

23 SITI MUDAIYAH 0003246145503 BANTUR 7/25/2023 ANC DENGAN USG Rp 140,000 DR NEVY

24 SANTIA DESY WULANDARI 0001594888683 WONOREJO 7/25/2023 ANC DENGAN USG Rp 140,000 DR NEVY

25 LAILATUL FITRIYAH 0003337044906 KANIGORO 7/28/2023 ANC DENGAN USG Rp 140,000 DR NEVY

Rp 3,500,000

Bantur, AGUSTUS 2023

Kepala UPT
Puskesmas Bantur

SOEBAGIJONO, S.Kep, M.Mkes

NIP. 19681009
199003 1 003
 REKAP PENGAJUAN KLAIM RJTP ( KB ) PUSKESMAS BANTUR
BULAN JULI 2023
TANGGAL JENIS TARIF
BIDAN
PELY KB PAKET
NO NAMA NO KARTU ALAMAT DIAGNOSA

1 FERAWATI 0002682000336 BANTUR Z30.4 7/3/2023 SUNTIK Rp 20,000 SITI YUNI M

2 KARTINI 0002004767471 BANTUR Z30.1 7/3/2023 LEPAS IMPLANT Rp 105,000 SITI YUNI M
3 WAGIYEM 0001480385193 BANTUR Z30.4 7/3/2023 SUNTIK Rp 20,000 SITI YUNI M
4 YAYUK Y 0000679637643 BANDUNGREJO Z30.8 7/4/2023 IMPLANT Rp 105,000 SITI YUNI M
5 HOSTIYEH 0003012683398 BANTUR Z30.4 7/10/2023 SUNTIK Rp 20,000 dr. NEVY LUSIA C
6 KHUSNUL KHOTIMAH 0001812764193 SRIGONCO Z30.8 7/10/2023 IMPLANT Rp 105,000 dr. NEVY LUSIA C
7 LIS WINARSIH 0000678172678 BANTUR Z30.8 7/12/2023 IMPLANT Rp 105,000 dr. NEVY LUSIA C
8 NUR LATIFA 0000679552839 BANTUR Z30.4 7/11/2023 SUNTIK Rp 20,000 dr. NEVY LUSIA C
9 SULIHA 0002599589564 BANDUNGREJO Z30.8 7/13/2023 IMPLANT Rp 105,000 dr. NEVY LUSIA C
10 RUSMININGSIH 0002600952243 BANTUR Z30.4 7/15/2023 SUNTIK Rp 20,000 dr. NEVY LUSIA C
11 FINDA DUWI OKTAFIA 0000677668419 BANDUNGREJO Z30.8 7/24/2023 IMPLANT Rp 105,000 dr. NEVY LUSIA C
12 LASMINTEN 0000679924686 BANTUR Z30.8 7/25/2023 IMPLANT Rp 105,000 dr. NEVY LUSIA C
13 MAZIDATUL FARIYAH 0002842758483 BANTUR Z30.8 7/25/2023 IMPLANT Rp 105,000 dr. NEVY LUSIA C
14 ELIA AYU ASMARANI 0000680797901 SRIGONCO Z30.4 7/28/2023 SUNTIK Rp 20,000 SITI YUNI M
15 YULAIKAH 0000679843192 BANTUR Z30.4 7/27/2023 SUNTIK Rp 20,000 SITI YUNI M

Rp 980,000
Bantur, AGUSTUS 2023
Kepala UPT Puskesmas Bantur

SOEBAGIJONO, S.Kep, M.Mkes

NIP. 19681009 199003 1 003
 REKAP PENGAJUAN KLAIM RJTP ( KB ) PUSKESMAS BANTUR
BULAN JULI 2023
TANGGAL JENIS TARIF
BIDAN
PELY KB PAKET
NO NAMA NO KARTU ALAMAT DIAGNOSA

1 FERAWATI 0002682000336 BANTUR Z30.4 7/3/2023 SUNTIK Rp 20,000 SITI YUNI M

2 KARTINI 0002004767471 BANTUR Z30.1 7/3/2023 LEPAS IMPLANT Rp 105,000 SITI YUNI M
3 WAGIYEM 0001480385193 BANTUR Z30.4 7/3/2023 SUNTIK Rp 20,000 SITI YUNI M
4 YAYUK Y 0000679637643 BANDUNGREJO Z30.8 7/4/2023 IMPLANT Rp 105,000 SITI YUNI M
5 HOSTIYEH 0003012683398 BANTUR Z30.4 7/10/2023 SUNTIK Rp 20,000 dr. NEVY LUSIA C
6 KHUSNUL KHOTIMAH 0001812764193 SRIGONCO Z30.8 7/10/2023 IMPLANT Rp 105,000 dr. NEVY LUSIA C
7 LIS WINARSIH 0000678172678 BANTUR Z30.8 7/12/2023 IMPLANT Rp 105,000 dr. NEVY LUSIA C
8 NUR LATIFA 0000679552839 BANTUR Z30.4 7/11/2023 SUNTIK Rp 20,000 dr. NEVY LUSIA C
9 SULIHA 0002599589564 BANDUNGREJO Z30.8 7/13/2023 IMPLANT Rp 105,000 dr. NEVY LUSIA C
10 RUSMININGSIH 0002600952243 BANTUR Z30.4 7/15/2023 SUNTIK Rp 20,000 dr. NEVY LUSIA C
11 FINDA DUWI OKTAFIA 0000677668419 BANDUNGREJO Z30.8 7/24/2023 IMPLANT Rp 105,000 dr. NEVY LUSIA C
12 LASMINTEN 0000679924686 BANTUR Z30.8 7/25/2023 IMPLANT Rp 105,000 dr. NEVY LUSIA C
13 MAZIDATUL FARIYAH 0002842758483 BANTUR Z30.8 7/25/2023 IMPLANT Rp 105,000 dr. NEVY LUSIA C
14 ELIA AYU ASMARANI 0000680797901 SRIGONCO Z30.4 7/28/2023 SUNTIK Rp 20,000 SITI YUNI M
15 YULAIKAH 0000679843192 BANTUR Z30.4 7/27/2023 SUNTIK Rp 20,000 SITI YUNI M

Rp 980,000
Bantur, AGUSTUS 2023
Kepala UPT Puskesmas Bantur

SOEBAGIJONO, S.Kep, M.Mkes

NIP. 19681009 199003 1 003