PT.

ASURANSI JIWA INHEALTH INDONESIA

LAMPIRAN FORMULIR PENGAJUAN KLAIM
NAMA PPK

KLINIK MEDIS BENOWO (PHC)

BULAN PELAYANAN

Februari 2015

TINGKAT PELAYANAN

RJTP

NO FPK

1301K021031501

No

No SJP

Noka Inhealth

Nama Peserta

1301K0210215X000001

1001011250981

DEDY RUDIJANTO, S.KOM.

32.500

1301K0210215X000002

1001011268632

NY.SUMARSIH JD ABUBAKAR RODJA

32.500

1301K0210215X000003

1011011277947

NY.ENDANG RATNAWATI

32.500

1301K0210215X000004

1001011248663

SUDARMAN

32.500

1301K0210215X000005

1001011277902

S. WAHYUDI

32.500

1301K0210215X000006

1011011245841

RUSANA

32.500

1301K0210215X000007

1001011270757

EFFENDI YUNUS.

32.500

1301K0210215X000008

1001011269341

NY. SUJATUN

32.500

1301K0210215X000009

1041011250805

ALLUFTHY SABIRIN

32.500

10

1301K0210215X000010

1001011253602

BAIQ NURUL HIKMAWATI, SE. MM.

32.500

11

1301K0210215X000011

1001011253602

BAIQ NURUL HIKMAWATI, SE. MM.

22.000

12

1301K0210215X000012

1051011250986

AIRLANGGA NIZHAR MEGANTARA

32.500

13

1301K0210215X000013

1051011250896

ZASKIA NAURA SURYA SAFITRI

132.500

14

1301K0210215X000014

1001011250891

SURYONO

79.500

15

1301K0210215X000015

1011011246076

RUMHARTUTIK

79.500

16

1301K0210215X000016

1041011246079

NURKHAYANI

39.500

17

1301K0210215X000017

1011011262535

ETI SUMARIYATI

32.500

18

1301K0210215X000018

1051012953843

RISTY AL FITRI DAMAYANTI

32.500

19

1301K0210215X000019

1011011242421

DIYAH LILIK SRIYANTI

134.000

20

1301K0210215X000020

1001011247561

DIAH UTARI, A.MD.

32.500

21

1301K0210215X000021

1001011279566

SUNARJONO.

32.500

22

1301K0210215X000022

1011011265224

MUJAYANAH

110.000

23

1301K0210215X000023

1051011247195

AUDREY TAMAMAH KURNIAWAN

32.500

24

1301K0210215X000024

1041011247194

KAYYISAH ISNAIN KURNIAWAN

32.500

25

1301K0210215X000025

1041011250129

CHINDY RAMADHANI ICHSAN

79.500

26

1301K0210215X000026

1011011265224

MUJAYANAH

32.500

27

1301K0210215X000027

1001011281287

NY. SITI MARIYAH JD. MOH. SOEB

32.500

28

1301K0210215X000028

1001011279702

SUDJONO.

32.500

29

1301K0210215X000029

1001011278306

SAIFUL IBRAHIM

32.500

30

1301K0210215X000030

1011011252027

LIDIA NUR AININ

49.000

31

1301K0210215X000031

1051011248714

MOHAMAD ZAKI AFANDI

32.500

32

1301K0210215X000032

1041011259401

BILAL ABYAN

32.500

Lampiran FPK; page 1 of 4; printed 3/2/2015 4:06:16 AM

PISA

Biaya

33

1301K0210215X000033

1041011250129

CHINDY RAMADHANI ICHSAN

32.500

34

1301K0210215X000034

1011011248675

JAMILAH JOENOES

32.500

35

1301K0210215X000035

1001011248731

HARUN ROSID

32.500

36

1301K0210215X000036

1011011262535

ETI SUMARIYATI

32.500

37

1301K0210215X000037

1041011250129

CHINDY RAMADHANI ICHSAN

32.500

38

1301K0210215X000038

1011011247279

NINIK SRI MURYANI

32.500

39

1301K0210215X000039

1041011250129

CHINDY RAMADHANI ICHSAN

87.500

40

1301K0210215X000040

1041011247273

KINENGGAR RARAS SELASIH

32.500

41

1301K0210215X000041

1011011265224

MUJAYANAH

86.500

42

1301K0210215X000042

1001011265223

BONIRIN

74.500

43

1301K0210215X000043

1011014210979

SITI NAFSIYAH

39.500

44

1301K0210215X000044

1051011248714

MOHAMAD ZAKI AFANDI

32.500

45

1301K0210215X000045

1041011242424

PRIMO RAJENDRA PRAYOGA

32.500

46

1301K0210215X000046

1011011242421

DIYAH LILIK SRIYANTI

32.500

47

1301K0210215X000047

1011011252027

LIDIA NUR AININ

32.500

48

1301K0210215X000048

1041011246676

ZAHRA ATHIRAH M.

32.500

49

1301K0210215X000049

1001011265223

BONIRIN

32.500

50

1301K0210215X000050

1001011251868

ERNAWATI, SH.

32.500

51

1301K0210215X000051

1051011251864

JHANTER ANNAS SIMORANGKIR

32.500

52

1301K0210215X000052

1011011249924

MUNTIANI

32.500

53

1301K0210215X000053

1001014016624

SITI CHOLIFAH

127.500

54

1301K0210215X000054

1061011242292

KARINA DIARAFITA TONDANG

32.500

55

1301K0210215X000055

1001011281287

NY. SITI MARIYAH JD. MOH. SOEB

74.500

56

1301K0210215X000056

1001011281287

NY. SITI MARIYAH JD. MOH. SOEB

116.500

57

1301K0210215X000057

1011011265224

MUJAYANAH

210.000

58

1301K0210215X000058

1001011277902

S. WAHYUDI

32.500

59

1301K0210215X000059

1041011253663

NAFISA ALSYAFANI

32.500

60

1301K0210215X000060

1011011248708

ISTIANAH

32.500

61

1301K0210215X000061

1001011280286

CHURIYATI

32.500

62

1301K0210215X000062

1051011248714

MOHAMAD ZAKI AFANDI

32.500

63

1301K0210215X000063

1001013786696

SUPRIYATI

32.500

64

1301K0210215X000064

1011014210979

SITI NAFSIYAH

79.500

65

1301K0210215X000065

1051011248692

IQBAL ANDITHO

32.500

66

1301K0210215X000066

1061011242292

KARINA DIARAFITA TONDANG

32.500

67

1301K0210215X000067

1001011249923

SUGIYANTO

32.500

68

1301K0210215X000068

1001011246029

ARIES MOCHAMAD HASAN

32.500

69

1301K0210215X000069

1051011248736

SEPTINA DWI WIJAYANTI

32.500

70

1301K0210215X000070

1051011253664

ALISHA AYUNINDYA

32.500

71

1301K0210215X000071

1051011248714

MOHAMAD ZAKI AFANDI

32.500

72

1301K0210215X000072

1041013894882

ANANDA HENDI PRATAMA S

32.500

73

1301K0210215X000073

1001013894887

HENDRIK MARTHEN SIAHAILATUA

32.500

74

1301K0210215X000074

1051011250986

AIRLANGGA NIZHAR MEGANTARA

32.500

Lampiran FPK; page 2 of 4; printed 3/2/2015 4:06:16 AM

75

1301K0210215X000075

1041011247273

KINENGGAR RARAS SELASIH

32.500

76

1301K0210215X000076

1051011250896

ZASKIA NAURA SURYA SAFITRI

32.500

77

1301K0210215X000077

1001011250891

SURYONO

132.500

78

1301K0210215X000078

1011011269059

SITI LAIYINAH

210.000

79

1301K0210215X000079

1001011269058

MUCHAMAD ARIF

32.500

80

1301K0210215X000080

1051011261494

DINI SETYA NUR RIZKI

32.500

81

1301K0210215X000081

1001011250632

SLAMET RIYANTO, SE.

32.500

82

1301K0210215X000082

1001011248663

SUDARMAN

32.500

83

1301K0210215X000083

1001011280837

DJUWONO.

32.500

84

1301K0210215X000084

1041011248746

EVAN FAROS SALFATAH

32.500

85

1301K0210215X000085

1011011268969

DJUWARNING

32.500

86

1301K0210215X000086

1001011265223

BONIRIN

32.500

87

1301K0210215X000087

1011011272659

RIYANTO

32.500

88

1301K0210215X000088

1001011272658

SUHARTATI

32.500

89

1301K0210215X000089

1051011251122

FINAHARI RAHMADANYA

79.500

90

1301K0210215X000090

1001011248742

TJATUR RACHMAN SALFATAH, A.MD

79.500

91

1301K0210215X000091

1051011251752

MUHAMMAD RAHLIL AMARDI KORO

39.500

92

1301K0210215X000092

1051011248466

NADINE AURARELA MARSHA OWENA

32.500

93

1301K0210215X000093

1011011248462

AULANA SANARIKO

32.500

94

1301K0210215X000094

1051011248714

MOHAMAD ZAKI AFANDI

32.500

95

1301K0210215X000095

1001011278723

H.R. SABARUDIN

32.500

96

1301K0210215X000096

1011011278724

NY. INDAH SUWARTI

32.500

97

1301K0210215X000097

1041011251863

SALSABILA MUSTIKA ANNAS.

32.500

98

1301K0210215X000098

1041011250985

ASTRIED NADIA MAYASARI

32.500

99

1301K0210215X000099

1041011253988

AMALIA MUTIARA RACHMA

32.500

100

1301K0210215X000100

1001011247561

DIAH UTARI, A.MD.

32.500

101

1301K0210215X000101

1011011247562

BENNI EKO ARIBOWO, A.MD.

32.500

102

1301K0210215X000102

1041011246079

NURKHAYANI

32.500

103

1301K0210215X000103

1001011279702

SUDJONO.

32.500

104

1301K0210215X000105

1011011248719

SUTARTI

49.000

105

1301K0210215X000106

1051011251122

FINAHARI RAHMADANYA

111.500

106

1301K0210215X000107

1001011251058

SUPRAYITNO

32.500

107

1301K0210215X000108

1011011279703

NY.UMAIYAH

32.500

108

1301K0210215X000109

1011011268969

DJUWARNING

32.500

109

1301K0210215X000110

1011014210979

SITI NAFSIYAH

39.500

110

1301K0210215X000111

1001011280286

CHURIYATI

32.500

111

1301K0210215X000112

1011011267171

YULIANI

15.000

112

1301K0210215X000113

1001011250891

SURYONO

32.500

113

1301K0210215X000114

1041011252021

NAUFAL ZAYD ABDURRAHMAN

32.500

114

1301K0210215X000115

1061011248737

KARISMA TRI WAHYUNI

32.500

115

1301K0210215X000116

1001011248461

UMU FAROKHAH, SE

32.500

116

1301K0210215X000117

1011011248708

ISTIANAH

32.500

Lampiran FPK; page 3 of 4; printed 3/2/2015 4:06:16 AM

117

1301K0210215X000118

1011011267171

YULIANI

79.500

118

1301K0210215X000119

1051011246677

SHABINA M.

32.500

119

1301K0210215X000120

1001011278958

SANTOSO, SH.

32.500

120

1301K0210215X000121

1051011242302

ANNISA AGUSTI ANDINI

32.500

121

1301K0210215X000122

1051011246025

ARYA PUTRA KURNIAWAN

32.500

122

1301K0210215X000123

1051011259402

KHANAN AYESHA

79.500

123

1301K0210215X000124

1011011259407

RATNA FAUSIAH

32.500

124

1301K0210215X000125

1051011253664

ALISHA AYUNINDYA

32.500

125

1301K0210215X000126

1041011253663

NAFISA ALSYAFANI

32.500

126

1301K0210215X000127

1051011250615

LOUIS YOSEPHIN SANTOSO

32.500

127

1301K0210215X000128

1011011250611

DWI HARIJANTI

32.500

128

1301K0210215X000129

1011011265224

MUJAYANAH

74.500

129

1301K0210215X000130

1001011248742

TJATUR RACHMAN SALFATAH, A.MD

79.500

130

1301K0210215X000131

1041011242424

PRIMO RAJENDRA PRAYOGA

32.500

131

1301K0210215X000132

1051011249928

VIRA FIRNANDA

32.500

132

1301K0210215X000133

1011011249924

MUNTIANI

32.500

133

1301K0210215X000134

1001011250801

LASIARA, SE

32.500

Total

Lampiran FPK; page 4 of 4; printed 3/2/2015 4:06:16 AM

6.005.500