PT ASURANSI JIWA INHEALTH INDONESIA

BUKTI PENGAMBILAN OBAT

IF RS Columbia Asia Jakarta

Nomor SJP : 0903A0580124X000376 Tanggal Pelayanan : 25-11-2023

Nomor Claim : 0903R0521123X000502 Tanggal Resep : 18-11-2023
Nomor Resep : 25/11/23 Jenis Obat : OBAT RITL
Asal Resep : RS COLUMBIA ASIA

Nama Peserta : RITHA ELFRIDA SIBURIAN Tanggal Lahir : 29-11-1959

Nomor Kepesertaan : 1011006150456 Produk : GOLD
Badan Usaha : MANDIRI HEALTHCARE

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

1 N FI0100510 Furosemide INFA inj 10 mg/ml amp 2 ml 2 7.593

2 N FI0101776 Lyrica 75 PFIZ kaps 75 mg 4 45.424
3 N FI0101939 Starfolat DEXA tab 0,4 mg 2 801
4 N FI0102539 Aricept Evess 5 EISA tab dispersible 5 mg 2 27.686
5 N FI0102829 Ceftriaxone Sodium HEXP serb inj 1 g vial 2 23.577
6 N FI0102982 Urdahex DANK kaps 250 mg 1 7.167
7 N FI0102984 Canderin 16 DEXA tab 16 mg 1 9.458
8 N FI0103028 Atorvastatin Calcium HEXP tab 20 mg 1 3.706
9 N FI0103040 Ondansetron HCl HEXP inj 8 mg/4 ml amp 4 ml 3 20.020
10 N FI0103598 Pumpisel SANB serb inj 40 mg 1 98.690
11 N FI0103911 Natrium Bikarbonat APTK kaps 500 mg 3 1.343
12 N FI0104887 Prorenal NOVE kapl salut selaput Komb 3 15.387
13 N FI0105332 Mecobalamine NOVE inj 500 mcg/ml amp 1 ml 3 24.376
14 N FORRS.01 Trajenta Duo BOEH tab salut selaput Komb 2 51.490
15 N FORRS.02 Brainact 1000 DANK inj 125 mg/ml amp 8 ml 2 333.120
16 N STFDH.01 Nitrokaf Retard KIFA kaps 2,5 mg 3 9.933
TOTAL 679.771

Mengetahui:

Pasien / Penerima Obat,

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