PT ASURANSI JIWA INHEALTH INDONESIA

BUKTI PENGAMBILAN OBAT

IF RS Columbia Asia Jakarta

Nomor SJP : 0903A0581023X000155 Tanggal Pelayanan : 30-08-2023

Nomor Claim : 0903R0520823X000745 Tanggal Resep : 30-08-2023
Nomor Resep : 1923 Jenis Obat : OBAT RITL
Asal Resep : RS COLUMBIA ASIA

Nama Peserta : BELIA HAPSARINI Tanggal Lahir : 13-09-1987

Nomor Kepesertaan : 1001640952078 Produk : GOLD
Badan Usaha : PT ANGKASA PURA II (PERSERO)

Jumlah
No R / NR Kode Obat Nama Obat Biaya Obat
Obat

1 N FI0100614 Ventolin Nebules GLAX cairan inh 0,1% amp 2,5 ml 4 43.994
2 N FI0100625 Pulmicort Respules 0,25 ASCA cairan inh 0,25 mg/ml resp 2 ml 3 53.547
3 N FI0101364 Otsu - Rl OTSU inf Komb btl 500 ml 2 29.704
4 N FI0102233 Domperidone HEXP tab 10 mg 3 1.080
5 N FI0102294 Acetylcysteine NOVE kaps 200 mg 3 3.269
6 N FI0102829 Ceftriaxone Sodium HEXP serb inj 1 g vial 4 46.754
7 N FI0103569 Ondansetron HCl HEXP inj 2 mg/ml amp 2 ml 3 14.786
8 N FI0103598 Pumpisel SANB serb inj 40 mg 4 393.562
9 N FI0103701 Dexketoprofen Trometamol NOVE inj 25 mg/ml amp 2 ml 3 73.926
10 N FI0103726 Rhinos SR DEXA kaps lepas lambat Komb 4 30.635
11 N FI0104553 Otsu - NS 100 OTSU inf 0,9% amp 100 ml 4 56.344
12 N FI0104997 Paracetamol HEXP inf 10 mg/ml btl 100 ml 3 74.326
TOTAL 821.927

Mengetahui:

Pasien / Penerima Obat,

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