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  • Admedika

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    bambang wahyu
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    This document is a medical insurance claim form containing information about a patient named Afrieta Kusuma. It provides details of her insurance plan and membership, including her member ID, plan type, coverage dates, and gender. The form also lists the diagnosis of "082-Single delivery by caesarean section" and amounts incurred and approved for the claim. A deduction of Rp. 1,000,000 was made, leaving a payable amount of Rp. 25,356,500 for the caesarean section procedure.

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    admedika

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    This document is a medical insurance claim form containing information about a patient named Afrieta Kusuma. It provides details of her insurance plan and membership, including her member ID, plan type, coverage dates, and gender. The form also lists the diagnosis of "082-Single delivery by caesarean section" and amounts incurred and approved for the claim. A deduction of Rp. 1,000,000 was made, leaving a payable amount of Rp. 25,356,500 for the caesarean section procedure.

    Hak Cipta:

    © All Rights Reserved
    Unduh sebagai PDF, TXT atau baca online dari Scribd
    Tandai sebagai konten tidak pantas
    8 tayangan1 halaman

    Admedika

    Diunggah oleh

    bambang wahyu
    This document is a medical insurance claim form containing information about a patient named Afrieta Kusuma. It provides details of her insurance plan and membership, including her member ID, plan type, coverage dates, and gender. The form also lists the diagnosis of "082-Single delivery by caesarean section" and amounts incurred and approved for the claim. A deduction of Rp. 1,000,000 was made, leaving a payable amount of Rp. 25,356,500 for the caesarean section procedure.

    Hak Cipta:

    © All Rights Reserved
    Unduh sebagai PDF, TXT atau baca online dari Scribd
    Tandai sebagai konten tidak pantas
    dari 1

    7

    UP

    MBA\MtrYA (KEUANGAN)

    PT.

    P:1of1

    Administrasi Medika

    T:

    Janl13/2015 Tuc 08:57

    FORi,I F

    Electronlc Healthcard Netr/llork

    MEMBER'S II{FO
    Patient llsme
    Prirtlp.l Nrme

    Relatiortrtip

    i PRINCIPAL

    PAYO& CORPROATE Ano puen INFO.


    : pT, I6UMNSI ADiM DINAI4IM
    lryo,
    CorEute
    I Pf BANK DANAMoN INDoNiSilA IB<

    Cid

    Ho

    ilemher ID
    strtuc

    DOD

    AFRIETA KUSUMA

    | 60003308C1371364

    litembeEhip

    r E063432

    Plan

    : Actiye

    Sbil Date

    ; Fb-28.1989
    : Jul-01-2014
    :Female

    Sinca

    6cndcr

    ID

    Rofqrgncc

    Approvll

    : BDIC{rX7911-00
    r l4Al 45Ol
    I iulCl-2014 To .un-3c-20,-5 [Enfcrce.d]

    frcdG

    AdmiaCon DqtE

    ;5072t929

    obchrEe DrE

    : AEC-2+2011
    I DEC-28-2014

    t{o, of Days

    r5

    Cotcragc
    Clainr Status

    ; IIAT - PERS4UNA|I
    : 40 - VALID CLAIti

    : 147 FS, PUTRI ( RS


    ; o82-Sinqle celiwry by caesoreon s;ton (nrelahirlen

    Dirgn06it
    Di6rbititv No.

    &nount Incurrd

    Rp. 26,356,500

    Amount Approvd

    36;SEC|I0 CAESAR]A, pER TCMMIUN

    )x

    AXHlRi PlAo DSIMN

    )I0AYAR'PENGURANGN{

    P(eFareiSi
    NLR i-A:LA

    TAGIT{AN RP. 1;oo0,ooo KARENA Rs.

    nevljr orr-Lnc Acc r'r&\ wrDyA

    F.A.]RI

    Fboe

    I of

    (KEUANGAT,I)

    Jan i3-2015 08:56:08 Atl

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