FKTP DPP dr. MUHAMMAD YUNUS, M.

Kes
SIP. 440/031/VIII/2010
Jl. Lanud Wolter Monginsidi No. 47 Kecamatan Ranomeeto-Ka.Konawe Selatan
Lampiran Klaim PERSALINAN , ANC, dan PNC Pasien BPJS pada Bidan Jejaring
NAMA FKTP : DPU DR. MUHAMMAD YUNUS, M.KES
NAMA JEJARING : BIDAN KETUT ANDRIYANI, S.ST dan BIDAN SRIATIN, Am.Keb
BULAN PELAYANAN : JANUARI 2015
PEMERIKSAAN KEHAMILAN (ANC) Persalinan PNC
PISA

Alamat/No. HP Nama Bidan

Umur
(Thn)

No Nama Penderita Nomor Kartu

Pasien Jejaring
K1 K2 K3 K4 Tgl Tindakan KN1=KF1 KN2= KF2 KN3 KF3
1 2 3 4 5 6 7 8 9 10 11 12 17 18 19 20
NY. DWI
1 I 34 0001793140492 Kel. Ranomeeto 6/12/2014 8/28/2014 10/30/2014 1/1/2015 1/8/2015 APN 1/9/2015 1/13/2015 2/2/2015 2/15/2015 Sriatin, Am.Keb
WAHYUNINGSIH

2 NY. FAIZAH I 37 0000829753391 Ds. Langgea 6/14/2014 8/30/2014 11/15/2014 1/3/2015 1/10/2015 APN 1/11/2015 1/15/2015 1/25/2015 2/13/2015 Sriatin, Am.Keb

3 NY. SYAHRATI, S.Pd. I 29 0000133894901 Ds. Langgea 6/17/2014 9/20/2014 11/18/2014 1/6/2015 1/13/2015 APN 1/14/2015 1/17/2015 1/27/2015 2/14/2015 Sriatin, Am.Keb

4 NY. JUMI I 24 0000953470034 Ds. Boro-Boro R 7/3/2014 9/25/2014 12/4/2014 1/22/2015 1/29/2015 APN 1/30/2015 2/3/2015 2/14/2015 3/2/2015 Sriatin, Am.Keb

5 NY. HASMANI I 36 0001380019768 Ds. Onewila 8/21/2014 11/20/2014 12/25/2014 1/1/2015 APN 1/2/2015 1/5/2015 1/17/2015 2/6/2015 Ketut A.

6 NY. SUMARNI I 32 0001251463511 Ds. Onewila 6/7/2014 8/16/2014 11/22/2014 1/17/2015 1/21/2015 APN 1/23/2015 1/26/2015 2/13/2015 3/2/2015 Ketut A.

NY. KAMALIA
7 I 20 0001812591358 Ds. Langgea 6/7/2014 8/16/2014 11/22/2014 1/17/2015 1/24/2015 APN 1/25/2015 1/28/2015 2/11/2015 3/4/2015 Ketut A.
PARAWATI

JUMLAH TOTAL TAGIHAN (Rp.) 350,000 350,000 350,000 350,000 4,200,000 175,000 175,000 175,000 175,000 6,300,000

Mengetahui Bidan Jejaring 1 Bidan Jejaring 2

Dokter Pembina

dr. Muhammad Yunus, M.Kes Ketut Andriani, SST Sriatin, Am.Keb

SIP. 440/031/VIII/2010

FKTP DPP dr. MUHAMMAD YUNUS, M.Kes

SIP. 440/031/VIII/2010
Jl. Lanud Wolter Monginsidi No. 47 Kecamatan Ranomeeto-Ka.Konawe Selatan
Lampiran Klaim PERSALINAN , ANC, dan PNC Pasien BPJS pada Bidan Jejaring
NAMA FKTP : DPU DR. MUHAMMAD YUNUS, M.KES
NAMA JEJARING : BIDAN KETUT ANDRIYANI, S.ST dan BIDAN SRIATIN, Am.Keb
BULAN PELAYANAN : FEBRUARI 2015
PEMERIKSAAN KEHAMILAN (ANC) Persalinan PNC
PISA

Alamat/No. HP Nama Bidan

Umur
(Thn)

No Nama Penderita Nomor Kartu Pasien Jejaring

 PISA
Alamat/No. HP Nama Bidan

Umur
(Thn)
No Nama Penderita Nomor Kartu Pasien Jejaring
K1 K2 K3 K4 Tgl Tindakan KN1=KF1 KN2= KF2 KN3 KF3
1 2 3 4 5 6 7 8 9 10 11 12 17 18 19 20

1 NY. FRANSISKA I 19 0000952265935 Ds. Kota Bangun 6/29/2014 10/19/2014 12/14/2014 2/1/2015 2/8/2015 APN 2/9/2015 2/12/2015 2/22/2015 3/14/2015 Sriatin, Am.Keb

2 NY. SAMSIDAR SAMIN I 28 0001110537505 Ds. Ranooha 7/2/2014 10/22/2014 11/26/2014 2/4/2015 2/11/2015 APN 2/12/2015 2/15/2015 2/26/2015 3/18/2015 Sriatin, Am.Keb

3 NY. NURDANI I 31 0001445334311 Kel. Ranomeeto 7/22/2014 10/14/2014 12/23/2014 2/10/2015 2/17/2015 APN 2/18/2015 2/21/2015 3/1/2015 3/26/2015 Sriatin, Am.Keb

4 NY. MASRIDA TASMAN I 36 0000133411511 Kel. Ranomeeto 7/19/2014 11/8/2014 1/3/2015 2/21/2015 2/28/2015 Pra Rujukan 3/6/2015 3/12/2015 4/3/2015 Sriatin, Am.Keb

5 NY. RAHMATIA I 29 0001812133203 BTN Anoa Green 6/8/2014 8/24/2014 11/23/2014 1/25/2015 2/1/2015 APN 2/2/2015 2/5/2015 2/14/2015 3/10/2015 Ketut A.

6 NY. KUSMIATI I 23 0001449588352 BTN Tawang Alun 6/22/2014 9/7/2014 11/16/2014 1/25/2015 2/1/2015 APN 2/2/2015 2/5/2015 2/12/2015 3/8/2015 Ketut A.

7 NY. UMMU RUBIAH I 30 0000133784583 Jl. MJ. Katamso 7/10/2014 9/16/2014 11/27/2014 1/29/2015 2/5/2015 APN 2/5/2015 2/9/2015 2/22/2015 3/4/2015 Ketut A.

8 NY. IRMA JAYANTI I 20 0001822212303 Ds. Rambu-Rambu 7/24/2014 9/16/2014 12/9/2014 2/7/2015 2/14/2015 APN 2/14/2015 2/18/2015 2/24/2015 3/18/2015 Ketut A.

9 NY. ESI I 44 0001479293346 Ds. Kota Bangun 8/2/2014 10/4/2014 11/29/2014 2/7/2015 2/14/2015 APN 2/14/2015 2/18/2015 2/24/2015 3/23/2015 Ketut A.

10 NY. RAMLIA JULIANA I 24 0001824854466 Ds. Sindang Kasih 7/1/2014 10/14/2014 12/16/2014 2/17/2015 2/24/2015 APN 2/25/2015 2/28/2015 3/9/2015 3/26/2015 Ketut A.

JUMLAH TOTAL TAGIHAN (Rp.) 500,000 500,000 500,000 500,000 5,525,000 225,000 250,000 250,000 250,000 8,500,000

Mengetahui Bidan Jejaring 1 BidanJejaring 2

Dokter Pembina

dr. Muhammad Yunus, M.Kes Ketut Andriani, SST Sriatin, Am.Keb

SIP. 440/031/VIII/2010

FKTP DPP dr. MUHAMMAD YUNUS, M.Kes

SIP. 440/031/VIII/2010
Jl. Lanud Wolter Monginsidi No. 47 Kecamatan Ranomeeto-Ka.Konawe Selatan
Lampiran Klaim PERSALINAN , ANC, dan PNC Pasien BPJS pada Bidan Jejaring
NAMA FKTP : DPU DR. MUHAMMAD YUNUS, M.KES
NAMA JEJARING : BIDAN KETUT ANDRIYANI, S.ST dan BIDAN SRIATIN, Am.Keb
BULAN PELAYANAN : MARET 2015
PEMERIKSAAN KEHAMILAN (ANC) Persalinan PNC
PISA

Alamat/No. HP Nama Bidan

Umur
(Thn)

No Nama Penderita Nomor Kartu Pasien Jejaring

K1 K2 K3 K4 Tgl Tindakan KN1=KF1 KN2= KF2 KN3 KF3
1 2 3 4 5 6 7 8 9 10 11 12 17 18 19 20

1 NY. DEWI I 26 0000169663421 Ds. Kota Bangun 7/28/2014 11/17/2014 1/12/2015 3/2/2015 3/9/2015 APN 3/10/2015 3/13/2015 4/2/2015 4/10/2015 Sriatin, Am.Keb

NY. RIDHA FAHRUNING

2 I 27 0001251412931 Ds. Ranooha 8/14/2014 11/6/2014 2/26/2015 3/19/2015 3/26/2015 APN 3/27/2015 3/30/2015 4/15/2015 4/30/2015 Sriatin, Am.Keb
SYAH PUTRI

3 NY. KOMANG SUASNI I 29 0001177210438 BTN Maleo I 3/3/2015 APN 3/4/2015 3/7/2015 3/16/2015 4/8/2015 Ketut A.
4 NY. MARWATI JAFAR I 28 0000955600918 Baruga 7/8/2014 10/7/2014 12/23/2014 2/24/2015 3/3/2015 APN 3/3/2015 3/8/2015 3/13/2015 4/7/2015 Ketut A.

5 NY. ASMARITA I 17 0001831781665 Ds. Amoito Siama 7/14/2014 10/6/2014 1/12/2015 3/2/2015 3/9/2015 APN 3/10/2015 3/13/2015 3/20/2015 4/13/2015 Ketut A.

NY. WA ODE
6 I 31 0001251413155 Ds. Onewila 7/20/2014 10/19/2014 1/18/2015 3/8/2015 3/15/2015 APN 3/15/2015 3/19/2015 3/25/2015 4/19/2015 Ketut A.
ROSNAWATI

7 NY. MIRANTI I 19 0001841725776 Ds. Ranooha 8/4/2014 11/3/2014 2/2/2015 3/23/2015 3/30/2015 APN 3/30/2015 4/3/2015 4/8/2015 5/5/2015 Ketut A.

8 NY. FIKA ENI I 26 0000952237012 JL. MALEO 8/5/2014 11/4/2014 2/3/2015 3/24/2015 3/31/2015 APN 4/1/2015 4/4/2015 4/9/2015 5/6/2015 Ketut A.

JUMLAH TOTAL TAGIHAN (Rp.) 350,000 350,000 350,000 350,000 4,800,000 200,000 200,000 200,000 200,000 7,000,000

Mengetahui Bidan Jejaring 1 BidanJejaring 2

Dokter Pembina

dr. Muhammad Yunus, M.Kes Ketut Andriani, SST Sriatin, Am.Keb

SIP. 440/031/VIII/2010

FKTP DPP dr. MUHAMMAD YUNUS, M.Kes

SIP. 440/031/VIII/2010
Jl. Lanud Wolter Monginsidi No. 47 Kecamatan Ranomeeto-Ka.Konawe Selatan
Lampiran Klaim PERSALINAN , ANC, dan PNC Pasien BPJS pada Bidan Jejaring
NAMA FKTP : DPU DR. MUHAMMAD YUNUS, M.KES
NAMA JEJARING : BIDAN KETUT ANDRIYANI, S.ST dan BIDAN SRIATIN, Am.Keb
BULAN PELAYANAN : APRIL 2015
PEMERIKSAAN KEHAMILAN (ANC) Persalinan PNC
PISA

Alamat/No. HP Nama Bidan

Umur
(Thn)

No Nama Penderita Nomor Kartu Pasien Jejaring

K1 K2 K3 K4 Tgl Tindakan KN1=KF1 KN2= KF2 KN3 KF3
1 2 3 4 5 6 7 8 9 10 11 12 17 18 19 20

1 NY. MARWATI I 41 0001836648235 KONDA I 8/21/2014 11/20/2014 1/22/2015 3/26/2015 4/2/2015 APN 4/2/2015 4/6/2015 4/11/2015 Ketut A.

MALEO 2
2 NY. JUMARIAH I 31 0001265257754 8/15/2014 11/21/2014 2/13/2015 4/3/2015 4/10/2015 APN 4/10/2015 4/14/2015 4/19/2015 5/9/2015 Ketut A.
RANOMEETO

3 NY. DIANA I 37 0001074857984 DS. AMOITO SIAMA 8/22/2014 11/21/2014 2/20/2015 4/3/2015 4/10/2015 APN 4/10/2015 4/14/2015 4/20/2015 Ketut A.

4 NY. WA ODE OSNAWATI I 25 0001267966372 BTN MALEO I 8/23/2014 11/22/2014 2/21/2015 4/11/2015 4/18/2015 APN 4/19/2015 4/22/2015 4/28/2015 5/18/2015 Ketut A.

5 NY. RISNAWATI I 30 0001183445278 AMBAIPUA 8/20/2014 12/3/2014 2/4/2015 4/15/2015 4/22/2015 APN 4/22/2015 4/26/2015 5/2/2015 5/21/2015 Ketut A.

JUMLAH TOTAL TAGIHAN (Rp.) 250,000 250,000 250,000 250,000 3,000,000 125,000 125,000 125,000 75,000 4,450,000

Mengetahui Bidan Jejaring 1

Dokter Pembina Tot.Klaim 26,250,000
Bayar 9/4/2015 25,000,000
 dr. Muhammad Yunus, M.Kes Ketut Andriani, SST Ditolak 1,250,000
SIP. 440/031/VIII/2010

FKTP DPP dr. MUHAMMAD YUNUS, M.Kes

SIP. 440/031/VIII/2010
Jl. Lanud Wolter Monginsidi No. 47 Kecamatan Ranomeeto-Ka.Konawe Selatan
Lampiran Klaim PERSALINAN , ANC, dan PNC Pasien BPJS pada Bidan Jejaring
NAMA FKTP : DPU DR. MUHAMMAD YUNUS, M.KES
NAMA JEJARING : BIDAN KETUT ANDRIYANI, S.ST dan BIDAN SRIATIN, Am.Keb
BULAN PELAYANAN : MEI 2015
PEMERIKSAAN KEHAMILAN (ANC) Persalinan PNC
PISA

Alamat/No. HP Nama Bidan

Umur
(Thn)

No Nama Penderita Nomor Kartu

Pasien Jejaring
K1 K2 K3 K4 Tgl Tindakan KN1=KF1 KN2= KF2 KN3 KF3
1 2 3 4 5 6 7 8 9 10 11 12 17 18 19 20

1 NY. FITRI YULIANTI I 31 0000162302231 BTN TAWANG ALUNG 9/9/2014 12/9/2014 3/10/2015 4/28/2015 5/5/2015 APN 5/6/2015 5/9/2015 5/15/2015 5/6/2015 Ketut A.

2 NY. HASRATI I 27 0001483636678 DS. AMBAIPUA 9/10/2014 11/26/2014 2/18/2015 4/29/2015 5/6/2015 APN 5/6/2015 5/10/2015 5/16/2015 6/8/2015 Ketut A.

3 NY. ROHANA I 30 0000952675694 DS. AMOITO SIAMA 9/6/2014 11/29/2014 2/21/2015 5/2/2015 5/9/2015 APN 5/9/2015 5/13/2015 5/25/2015 6/11/2015 Ketut A.

4 NY. JULIANTI I 30 0001191483584 DS. ONEWILA 9/6/2014 11/29/2014 3/21/2015 5/2/2015 5/9/2015 APN 5/10/2015 5/14/2015 5/25/2015 6/12/2015 Ketut A.

5 NY. SANTI M.LUMINTANG I 26 0001832909062 LEPO-LEPO 9/13/2014 12/6/2014 2/28/2015 5/9/2015 5/16/2015 APN 5/16/2015 5/20/2015 5/25/2015 6/17/2015 Ketut A.

6 NY. RIANTI I 22 0000952246315 DS. KOTA BANGUN 9/13/2014 12/13/2014 3/14/2015 5/9/2015 5/16/2015 APN 5/17/2015 5/20/2015 5/26/2015 6/15/2015 Ketut A.

7 NY. KURSIAH I 32 0001292150619 KEL. RANOMEETO 9/26/2015 1/2/2015 4/10/2015 5/15/2015 5/22/2015 APN 5/23/2015 5/28/2015 6/8/2015 6/24/2015 Ketut A.

8 NY. NI WAYAN SUPARMI I 34 0000207633745 KEL. RANOMEETO 10/4/2014 1/3/2015 4/4/2015 5/16/2015 5/24/2015 APN 5/24/2015 5/28/2015 6/4/2015 6/25/2015 Ketut A.

9 NY. RAHMA SARI I 19 0000209075027 DS. RANOOHA 10/4/2015 12/27/2014 3/21/2015 4/25/2015 5/2/2015 APN 5/3/2015 5/6/2015 6/6/2015 5/26/2015 Sriatin

10 NY. DESI YANA AYU

LESTARI I 21 0001836253236 DS. RANOOHA 10/7/2014 12/30/2014 3/24/2015 4/28/2015 5/5/2015 APN 5/6/2015 5/9/2015 6/9/2015 5/29/2015 Sriatin

11 NY. ASRIANTI I 27 0001843539344 DS. KOTA BANGUN 11/16/2014 1/11/2015 4/5/2015 5/10/2015 5/17/2015 APN 5/18/2015 5/21/2015 6/11/2015 6/24/2015 Sriatin
KEL. LAMOERI-
12 NY. ANA SUSILOWATI I 28 0000953364396 ANGATA 11/13/2014 1/22/2015 3/5/2015 5/7/2015 5/14/2015 APN 5/15/2015 5/18/2015 6/8/2015 6/21/2015 Sriatin

13 NY. TASYA I 20 0000952995148 DS. TOROBULU 10/22/2015 2/11/2015 3/11/2015 5/13/2015 5/26/2015 APN 5/21/2015 5/24/2015 6/9/2015 6/19/2015 Sriatin

JUMLAH TOTAL TAGIHAN (Rp.)

Mengetahui Bidan Jejaring 1 BidanJejaring 2

Dokter Pembina
 dr. Muhammad Yunus, M.Kes Ketut Andriani, SST Sriatin, Am.Keb
SIP. 440/031/VIII/2010
FKTP DPP dr. MUHAMMAD YUNUS, M.Kes
SIP. 440/031/VIII/2010
Jl. Lanud Wolter Monginsidi No. 47 Kecamatan Ranomeeto-Ka.Konawe Selatan
Lampiran Klaim PERSALINAN , ANC, dan PNC Pasien BPJS pada Bidan Jejaring
NAMA FKTP : DPU DR. MUHAMMAD YUNUS, M.KES
NAMA JEJARING : BIDAN KETUT ANDRIYANI, S.ST dan BIDAN SRIATIN, Am.Keb
BULAN PELAYANAN : MEI 2015
PEMERIKSAAN KEHAMILAN (ANC) Persalinan PNC
PISA

Alamat/No. HP Nama Bidan

Umur
(Thn)

No Nama Penderita Nomor Kartu Pasien Jejaring

K1 K2 K3 K4 Tgl Tindakan KN1=KF1 KN2= KF2 KN3 KF3
1 2 3 4 5 6 7 8 9 10 11 12 17 18 19 20

1 NY. FITRI YULIANTI I 31 0000162302231 BTN TAWANG ALUNG 11/4/2014 12/9/2014 3/10/2015 4/28/2015 5/5/2015 APN 5/6/2015 5/9/2015 5/15/2015 5/6/2015 Ketut A.

2 NY. HASRATI I 27 0001483636678 DS. AMBAIPUA 11/5/2014 11/26/2014 2/18/2015 4/29/2015 5/6/2015 APN 5/6/2015 5/10/2015 5/16/2015 6/8/2015 Ketut A.

3 NY. ROHANA I 30 0000952675694 DS. AMOITO SIAMA 11/5/2014 11/29/2014 2/21/2015 5/2/2015 5/9/2015 APN 5/9/2015 5/13/2015 5/25/2015 6/11/2015 Ketut A.

4 NY. JULIANTI I 30 0001191483584 DS. ONEWILA 11/7/2014 11/29/2014 3/21/2015 5/2/2015 5/9/2015 APN 5/10/2015 5/14/2015 5/25/2015 6/12/2015 Ketut A.

5 NY. SANTI M.LUMINTANG I 26 0001832909062 LEPO-LEPO 11/12/2014 12/6/2014 2/28/2015 5/9/2015 5/16/2015 APN 5/16/2015 5/20/2015 5/25/2015 6/17/2015 Ketut A.

6 NY. RIANTI I 22 0000952246315 DS. KOTA BANGUN 11/14/2014 12/13/2014 3/14/2015 5/9/2015 5/16/2015 APN 5/17/2015 5/20/2015 5/26/2015 6/15/2015 Ketut A.

7 NY. KURSIAH I 32 0001292150619 KEL. RANOMEETO 11/20/2014 1/2/2015 4/10/2015 5/15/2015 5/22/2015 APN 5/23/2015 5/28/2015 6/8/2015 6/24/2015 Ketut A.

8 NY. NI WAYAN SUPARMI I 34 0000207633745 KEL. RANOMEETO 11/20/2014 1/3/2015 4/4/2015 5/16/2015 5/24/2015 APN 5/24/2015 5/28/2015 6/4/2015 6/25/2015 Ketut A.

9 NY. RAHMA SARI I 19 0000209075027 DS. RANOOHA 11/1/2014 12/27/2014 3/21/2015 4/25/2015 5/2/2015 APN 5/3/2015 5/6/2015 5/26/2015 6/6/2015 Sriatin

10 NY. DESI YANA AYU

LESTARI I 21 0001836253236 DS. RANOOHA 11/4/2014 12/30/2014 3/24/2015 4/28/2015 5/5/2015 APN 5/6/2015 5/9/2015 5/29/2015 6/9/2015 Sriatin

11 NY. ASRIANTI I 27 0001843539344 DS. KOTA BANGUN 11/16/2014 1/11/2015 4/5/2015 5/10/2015 5/17/2015 APN 5/18/2015 5/21/2015 6/11/2015 6/24/2015 Sriatin
KEL. LAMOERI-
12 NY. ANA SUSILOWATI I 28 0000953364396 ANGATA 11/13/2014 1/22/2015 3/5/2015 5/7/2015 5/14/2015 APN 5/15/2015 5/18/2015 6/8/2015 6/21/2015 Sriatin

13 NY. TASYA I 20 0000952995148 DS. TOROBULU 11/25/2014 2/11/2015 3/11/2015 5/13/2015 5/26/2015 APN 5/21/2015 5/24/2015 6/9/2015 6/19/2015 Sriatin

JUMLAH TOTAL TAGIHAN (Rp.)

Mengetahui Bidan Jejaring 1 BidanJejaring 2

Dokter Pembina

dr. Muhammad Yunus, M.Kes Ketut Andriani, SST Sriatin, Am.Keb

SIP. 440/031/VIII/2010
FKTP DPP dr. MUHAMMAD YUNUS, M.Kes
SIP. 440/031/VIII/2010
Jl. Lanud Wolter Monginsidi No. 47 Kecamatan Ranomeeto-Ka.Konawe Selatan
Lampiran Klaim PERSALINAN , ANC, dan PNC Pasien BPJS pada Bidan Jejaring
NAMA FKTP : DPU DR. MUHAMMAD YUNUS, M.KES
NAMA JEJARING : BIDAN KETUT ANDRIYANI, S.ST dan BIDAN SRIATIN, Am.Keb
BULAN PELAYANAN : JUNI 2015
PEMERIKSAAN KEHAMILAN (ANC) Persalinan PNC

PISA
Alamat/No. HP Nama Bidan

Umur
(Thn)
No Nama Penderita Nomor Kartu Pasien Jejaring
K1 K2 K3 K4 Tgl Tindakan KN1=KF1 KN2= KF2 KN3 KF3
1 2 3 4 5 6 7 8 9 10 11 12 17 18 19 20

1 NY. IDA PRIANI I 32 0001822889643 DS.KOTA BANGUN 11/23/2014 2/1/2015 4/26/2015 5/31/2015 6/7/2015 APN 6/8/2015 6/12/2015 6/27/2015 7/12/2015 Sriatin

2 NY. SRI ISMAYANTI I 33 0000951772803 DS. DUDURIA 11/26/2014 2/4/2015 4/15/2015 6/3/2015 6/10/2015 APN 6/11/2015 6/16/2015 7/1/2015 7/14/2015 Sriatin

3 NY. SUNARTI I 26 0000951664678 DS. LANGGEA 11/24/2014 2/16/2015 4/27/2015 6/15/2015 6/22/2015 Pra Rujukan 6/27/2015 7/10/2015 7/30/2015 sriatin

4 NY. SARI RASANTI I 26 0000950783534 DS. ANGGOHU 12/25/2014 2/19/2015 5/28/2015 6/18/2015 6/25/2015 APN 6/26/2015 7/1/2015 7/15/2015 7/28/2015 Sriatin

5 NY. SRI NUZULIATI SARATI I 29 0001850506468 DS. KOTA BANGUN 12/15/2014 2/23/2015 5/18/2015 6/22/2015 6/29/2015 APN 6/30/2015 7/4/2015 7/16/2015 8/2/2015 sriatin

10

11

12

13

JUMLAH TOTAL TAGIHAN (Rp.)

Mengetahui Bidan Jejaring 1 BidanJejaring 2

Dokter Pembina

dr. Muhammad Yunus, M.Kes Ketut Andriani, SST Sriatin, Am.Keb

SIP. 440/031/VIII/2010

FKTP DPP dr. MUHAMMAD YUNUS, M.Kes

SIP. 440/031/VIII/2010
Jl. Lanud Wolter Monginsidi No. 47 Kecamatan Ranomeeto-Ka.Konawe Selatan
Lampiran Klaim PERSALINAN , ANC, dan PNC Pasien BPJS pada Bidan Jejaring
NAMA FKTP : DPU DR. MUHAMMAD YUNUS, M.KES
NAMA JEJARING : BIDAN KETUT ANDRIYANI, S.ST dan BIDAN SRIATIN, Am.Keb
BULAN PELAYANAN : JULI 2015
PEMERIKSAAN KEHAMILAN (ANC) Persalinan PNC
PISA

Alamat/No. HP Nama Bidan

Umur
(Thn)

No Nama Penderita Nomor Kartu Pasien Jejaring

K1 K2 K3 K4 Tgl Tindakan KN1=KF1 KN2= KF2 KN3 KF3
1 2 3 4 5 6 7 8 9 10 11 12 17 18 19 20

1 NY. RAHMAWATI I 30 0001815659706 KEL. RANOMEETO 1/7/2015 3/4/2015 5/27/2015 7/1/2015 7/8/2015 APN 7/9/2015 7/13/2015 7/28/2015 8/13/2015 Sriatin

2 NY. SITTI SALMA I 34 0001859650547 DS. KOTA BANGUN 12/26/2014 3/20/2015 6/12/2015 7/17/2015 7/24/2015 Pra Rujukan 7/30/2015 8/8/2015 8/27/2015 Sriatin

3 NY. EMY SIMAK I 37 0000133584131 DS. KOTA BANGUN 12/30/2014 4/7/2015 6/16/2015 7/21/2015 7/28/2015 APN 7/29/2015 8/2/2015 8/17/2015 9/1/2015 Sriatin
 4 NY. SRI SULASTRI I 28 0001251410962 DS. KOTA BANGUN 1/16/2015 4/10/2015 6/5/2015 7/24/2015 7/31/2015 Pra Rujukan 8/6/2015 8/23/2015 9/6/2015 Sriatin

Mengetahui Bidan Jejaring 1 BidanJejaring 2

Dokter Pembina

dr. Muhammad Yunus, M.Kes Ketut Andriani, SST Sriatin, Am.Keb

SIP. 440/031/VIII/2010

FKTP DPP dr. MUHAMMAD YUNUS, M.Kes

SIP. 440/031/VIII/2010
Jl. Lanud Wolter Monginsidi No. 47 Kecamatan Ranomeeto-Ka.Konawe Selatan
Lampiran Klaim PERSALINAN , ANC, dan PNC Pasien BPJS pada Bidan Jejaring
NAMA FKTP : DPU DR. MUHAMMAD YUNUS, M.KES
NAMA JEJARING : BIDAN KETUT ANDRIYANI, S.ST dan BIDAN SRIATIN, Am.Keb
BULAN PELAYANAN : AGUSTUS 2015
PEMERIKSAAN KEHAMILAN (ANC) Persalinan PNC
PISA

Alamat/No. HP Nama Bidan

Umur
(Thn)

No Nama Penderita Nomor Kartu Pasien Jejaring

K1 K2 K3 K4 Tgl Tindakan KN1=KF1 KN2= KF2 KN3 KF3
1 2 3 4 5 6 7 8 9 10 11 12 17 18 19 20

1 NY. MARLINA POSSOYO I 27 0001251410556 DS. KOTA BANGUN 2/3/2015 4/21/2015 8/4/2015 8/11/2015 8/18/2015 APN 8/19/2015 8/23/2015 9/7/2015 9/22/2015 Sriatin

2 NY. SULISTIANINGSIH I 31 0000134356871 DS. LAIKAAHA 1/26/2015 4/20/2015 8/10/2015 8/17/2015 8/24/2015 Pra Rujukan 8/29/2015 9/19/2015 9/29/2015 Sriatin
DS. RAMBU-RAMBU
3 NY. KUSNIATI I 32 0001251415012 JAYA 2/9/2015 4/20/2015 8/10/2015 8/17/2015 8/24/2015 APN 8/25/2015 8/30/2015 9/13/2015 10/1/2015 Sriatin

4 NY. ENDAH LESTARI I 29 0000206453531 RANOMEETO 2/14/2015 5/19/2015 7/18/2015 8/22/2015 8/29/2015 APN 8/30/2015 9/4/2015 9/18/2015 10/5/2015 Sriatin

Mengetahui Bidan Jejaring 1 BidanJejaring 2

Dokter Pembina

dr. Muhammad Yunus, M.Kes Ketut Andriani, SST Sriatin, Am.Keb

SIP. 440/031/VIII/2010

FKTP DPP dr. MUHAMMAD YUNUS, M.Kes

SIP. 440/031/VIII/2010
Jl. Lanud Wolter Monginsidi No. 47 Kecamatan Ranomeeto-Ka.Konawe Selatan
Lampiran Klaim PERSALINAN , ANC, dan PNC Pasien BPJS pada Bidan Jejaring
NAMA FKTP : DPU DR. MUHAMMAD YUNUS, M.KES
NAMA JEJARING : BIDAN KETUT ANDRIYANI, S.ST dan BIDAN SRIATIN, Am.Keb
BULAN PELAYANAN : SEPTEMBER 2015
PEMERIKSAAN KEHAMILAN (ANC) Persalinan PNC
PISA

Alamat/No. HP Nama Bidan

Umur
(Thn)

No Nama Penderita Nomor Kartu

Pasien Jejaring
 PISA
Alamat/No. HP Nama Bidan

Umur
(Thn)
No Nama Penderita Nomor Kartu
Pasien Jejaring
K1 K2 K3 K4 Tgl Tindakan KN1=KF1 KN2= KF2 KN3 KF3
1 2 3 4 5 6 7 8 9 10 11 12 17 18 19 20
NY. MARSELINA BUNGA
1 SAPANG I 21 0001320744914 DS. KOTA BANGUN 2/28/2015 5/23/2015 8/22/2015 9/5/2015 9/12/2015 APN 9/13/2015 9/17/2015 10/2/2015 10/16/2015 Sriatin

2 NY. HASMIATI I 31 0001806057977 RANOMEETO 2/14/2015 5/30/2015 7/4/2015 9/5/2015 9/12/2015 Pra Rujukan 9/17/2015 9/30/2015 10/16/2015 Sriatin

3 NY. SUSILOWATI I 28 0001828736616 DS. KOTA BANGUN 2/14/2015 5/9/2015 8/29/2015 9/5/2015 9/12/2015 APN 9/13/2015 9/17/2015 10/4/2015 10/20/2015 Sriatin

4 NY. AISYAH I 21 0001843537612 DS. LANGGEA 3/8/2015 5/17/2015 9/6/2015 9/13/2015 9/20/2015 Pra Rujukan 9/25/2015 10/10/2015 10/28/2015 Sriatin
DS. RAMBU-RAMBU
5 NY. CHOLISHOTIN I 42 0000952568278 JAYA 2/24/2015 6/2/2015 9/8/2015 9/15/2015 9/22/2015 APN 9/23/2015 9/28/2015 10/12/2015 10/27/2015 Sriatin

6 NY. ALBINA MARINI I 23 0001150035445 DS. KOTA BANGUN 3/11/2015 6/3/2015 9/9/2015 9/16/2015 9/23/2015 APN 9/24/2015 9/28/2015 10/15/2015 10/31/2015 Sriatin

7 NY. YELSHI I 19 0001867550635 PONDIDAHA 3/15/2015 6/7/2015 9/13/2015 9/20/2015 9/27/2015 APN 9/28/2015 10/2/2015 10/21/2015 11/3/2015 Sriatin

Mengetahui Bidan Jejaring 1 BidanJejaring 2

Dokter Pembina

dr. Muhammad Yunus, M.Kes Ketut Andriani, SST Sriatin, Am.Keb

SIP. 440/031/VIII/2010

FKTP DPP dr. MUHAMMAD YUNUS, M.Kes

SIP. 440/031/VIII/2010
Jl. Lanud Wolter Monginsidi No. 47 Kecamatan Ranomeeto-Ka.Konawe Selatan
Lampiran Klaim PERSALINAN , ANC, dan PNC Pasien BPJS pada Bidan Jejaring
NAMA FKTP : DPU DR. MUHAMMAD YUNUS, M.KES
NAMA JEJARING : BIDAN KETUT ANDRIYANI, S.ST dan BIDAN SRIATIN, Am.Keb
BULAN PELAYANAN : NOVEMBER 2015
PEMERIKSAAN KEHAMILAN (ANC) Persalinan PNC
PISA

Alamat/No. HP Nama Bidan

Umur
(Thn)

No Nama Penderita Nomor Kartu Pasien Jejaring

K1 K2 K3 K4 Tgl Tindakan KN1=KF1 KN2= KF2 KN3 KF3
1 2 3 4 5 6 7 8 9 10 11 12 17 18 19 20

1 NY. THITIN I 40 0001167244773 DS. KOTA BANGUN 4/24/2015 7/29/2015 9/9/2015 10/28/2015 11/4/2015 APN 11/5/2015 11/9/2015 11/24/2015 09/12/12015 Sriatin

2 NY. SITTI HIJRAT NIKMAH I 21 0001895399291 DS. LANGGEA 5/10/2015 8/2/2015 10/25/2015 11/1/2015 11/8/2015 APN 11/9/2015 11/13/2015 11/28/2015 12/12/2015 Sriatin

3 NY. NOVA FITRIA ASTUTI I 25 0001898446522 RANOMEETO 5/23/2015 8/15/2015 10/24/2015 11/14/2015 11/21/2015 APN 11/22/2015 11/26/2015 12/11/2015 12/25/2015 Sriatin

4 I

Mengetahui Bidan Jejaring 1 BidanJejaring 2

Dokter Pembina

dr. Muhammad Yunus, M.Kes Ketut Andriani, SST Sriatin, Am.Keb

SIP. 440/031/VIII/2010
 FKTP DPP dr. MUHAMMAD YUNUS, M.Kes
SIP. 440/031/VIII/2010
Jl. Lanud Wolter Monginsidi No. 47 Kecamatan Ranomeeto-Ka.Konawe Selatan
Lampiran Klaim PERSALINAN , ANC, dan PNC Pasien BPJS pada Bidan Jejaring
NAMA FKTP : DPU DR. MUHAMMAD YUNUS, M.KES
NAMA JEJARING : BIDAN KETUT ANDRIYANI, S.ST dan BIDAN SRIATIN, Am.Keb
BULAN PELAYANAN : DESEMBER 2015
PEMERIKSAAN KEHAMILAN (ANC) Persalinan PNC
PISA

Alamat/No. HP Nama Bidan

Umur
(Thn)

No Nama Penderita Nomor Kartu Pasien Jejaring

K1 K2 K3 K4 Tgl Tindakan KN1=KF1 KN2= KF2 KN3 KF3
1 2 3 4 5 6 7 8 9 10 11 12 17 18 19 20

1 NY. WA ECI I 29 0000153012363 RANOMEETO 6/8/2015 8/31/2015 11/9/2015 11/30/2015 12/7/2015 Pra Rujukan 12/13/2015 12/27/2015 1/14/2016 Sriatin

2 NY.SUKARSIH I 25 0001819762571 DS. KOTA BANGUN 6/14/2015 8/9/2015 11/1/2015 12/6/2015 12/13/2015 APN 12/14/2015 12/18/2015 1/7/2016 1/16/2016 Sriatin

3 NY.YULIANA FAJAR WATI I 33 0001882992374 RANOOHA 6/17/2015 8/26/2015 12/2/2015 12/9/2015 12/16/2015 APN 12/17/2015 12/21/2015 1/5/2016 1/21/2016 Sriatin

4 NY. EMILIA WATI I 26 0000953483343 DS. BORO-BORO R 6/9/2015 8/18/2015 12/8/2015 12/15/2015 12/22/2015 Pra Rujukan 12/27/2015 1/11/2016 1/25/2016 Sriatin

Mengetahui Bidan Jejaring 1 BidanJejaring 2

Dokter Pembina

dr. Muhammad Yunus, M.Kes Ketut Andriani, SST Sriatin, Am.Keb

SIP. 440/031/VIII/2010

FKTP DPP dr. MUHAMMAD YUNUS, M.Kes

SIP. 440/031/VIII/2010
Jl. Lanud Wolter Monginsidi No. 47 Kecamatan Ranomeeto-Ka.Konawe Selatan
Lampiran Klaim PERSALINAN , ANC, dan PNC Pasien BPJS pada Bidan Jejaring
NAMA FKTP : DPU DR. MUHAMMAD YUNUS, M.KES
NAMA JEJARING : BIDAN KETUT ANDRIYANI, S.ST dan BIDAN SRIATIN, Am.Keb
BULAN PELAYANAN : JANUARI 2016
PEMERIKSAAN KEHAMILAN (ANC) Persalinan PNC
PISA

Alamat/No. HP Nama Bidan

Umur
(Thn)

No Nama Penderita Nomor Kartu Pasien Jejaring

K1 K2 K3 K4 Tgl Tindakan KN1=KF1 KN2= KF2 KN3 KF3
1 2 3 4 5 6 7 8 9 10 11 12 17 18 19 20

1 NY. NUR HUDHA I 27 0001801571422 RANOMEETO 7/26/2015 10/18/2015 12/27/2015 1/17/2016 1/24/2016 APN 1/25/2016 1/29/2016 2/13/2016 2/25/2016 Sriatin

2 NY. KARTIYEM I 35 0001710920395 DS. KOTA BANGUN 7/17/2015 9/25/2015 1/1/2016 1/22/2016 1/29/2016 APN 1/30/2016 2/3/2016 2/20/2016 3/2/2016 Sriatin
 3

Mengetahui Bidan Jejaring 1 BidanJejaring 2

Dokter Pembina

dr. Muhammad Yunus, M.Kes Ketut Andriani, SST Sriatin, Am.Keb

SIP. 440/031/VIII/2010

FKTP DPP dr. MUHAMMAD YUNUS, M.Kes

SIP. 440/031/VIII/2010
Jl. Lanud Wolter Monginsidi No. 47 Kecamatan Ranomeeto-Ka.Konawe Selatan
Lampiran Klaim PERSALINAN , ANC, dan PNC Pasien BPJS pada Bidan Jejaring
NAMA FKTP : DPU DR. MUHAMMAD YUNUS, M.KES
NAMA JEJARING : BIDAN KETUT ANDRIYANI, S.ST dan BIDAN SRIATIN, Am.Keb
BULAN PELAYANAN : FEBRUARI 2016
PEMERIKSAAN KEHAMILAN (ANC) Persalinan PNC
PISA

Alamat/No. HP Nama Bidan

Umur
(Thn)

No Nama Penderita Nomor Kartu

Pasien Jejaring
K1 K2 K3 K4 Tgl Tindakan KN1=KF1 KN2= KF2 KN3 KF3
1 2 3 4 5 6 7 8 9 10 11 12 17 18 19 20

1 NY. SUGIARSI I 34 0001251411761 RANOMEETO 7/23/2015 10/1/2015 1/7/2016 1/28/2016 2/4/2016 APN 2/5/2016 2/9/2016 2/24/2016 3/9/2016 Sriatin

2 NY. SARMIATI I 35 0001801577114 RANOMEETO 7/18/2015 10/10/2015 1/16/2016 1/30/2016 2/5/2016 Pra Rujukan 2/28/2016 3/14/2016 Sriatin

3 NY. SRI YENIK I 34 0001824746995 LANDONO 7/17/2015 10/23/2015 12/18/2015 2/5/2016 2/12/2016 APN 2/13/2016 2/17/2016 3/3/2016 3/19/2016 Sriatin

4 NY. MUSTIKAWATI I 35 0001898770893 DS. LANGGEA 8/3/2015 10/12/2015 1/4/2016 2/8/2016 2/15/2016 APN 2/16/2016 2/20/2016 3/5/2016 3/21/2016 Sriatin

5 NY. SUDARYANTI I 26 0001074762246 ANDOOLO UTAMA 8/11/2015 10/20/2015 1/26/2016 2/16/2016 2/23/2016 APN 2/24/2016 2/28/2016 3/14/2016 4/1/2016 Sriatin

6 NY. DIAN I 32 0001959473158 RANOMEETO 7/30/2015 10/22/2015 1/14/2016 2/18/2016 2/25/2016 Pra Rujukan 3/14/2016 4/1/2016 Sriatin

7 NY. MUTMAINNAH I 38 0001074860054 RANOMEETO 8/2/2015 10/25/2015 1/17/2016 2/21/2016 2/28/2016 APN 2/29/2016 3/4/3016 3/19/2016 4/3/2016 Sriatin
Mengetahui Bidan Jejaring 1 Bidan Jejaring 2
Dokter Pembina

dr. Muhammad Yunus, M.Kes Ketut Andriani, SST Sriatin, Am.Keb

SIP. 440/031/VIII/2010

FKTP DPP dr. MUHAMMAD YUNUS, M.Kes

SIP. 440/031/VIII/2010
 Jl. Lanud Wolter Monginsidi No. 47 Kecamatan Ranomeeto-Ka.Konawe Selatan
Lampiran Klaim PERSALINAN , ANC, dan PNC Pasien BPJS pada Bidan Jejaring
NAMA FKTP : DPU DR. MUHAMMAD YUNUS, M.KES
NAMA JEJARING : BIDAN KETUT ANDRIYANI, S.ST dan BIDAN SRIATIN, Am.Keb
BULAN PELAYANAN : MARET 2016
PISA PEMERIKSAAN KEHAMILAN (ANC) Persalinan PNC
Alamat/No. HP Nama Bidan
Umur
(Thn)
No Nama Penderita Nomor Kartu Pasien Jejaring
K1 K2 K3 K4 Tgl Tindakan KN1=KF1 KN2= KF2 KN3 KF3
1 2 3 4 5 6 7 8 9 10 11 12 17 18 19 20

1 NY. LINDA ADRIANA I 33 0001888189255 DS. RAMBU-RAMBU 8/4/2015 10/27/2015 1/26/2016 2/23/2016 3/1/2016 Pra Rujkan 3/16/2016 4/7/2016 Sriatin
APN/Pra
2 NY. DESI YANTI I 34 0001854907255 RANOMEETO 9/8/2015 11/17/2015 1/26/2016 3/15/2016 3/22/2016 3/27/2016 4/9/2016 4/27/2016 Sriatin
Rujukan
3

Mengetahui Bidan Jejaring 1 BidanJejaring 2

Dokter Pembina

dr. Muhammad Yunus, M.Kes Ketut Andriani, SST Sriatin, Am.Keb

SIP. 440/031/VIII/2010
 FKTP DPP dr. MUHAMMAD YUNUS, M.Kes
SIP. 440/031/VIII/2010
Jl. Lanud Wolter Monginsidi No. 47 Kecamatan Ranomeeto-Ka.Konawe Selatan
Lampiran Klaim PERSALINAN , ANC, dan PNC Pasien BPJS pada Bidan Jejaring
NAMA FKTP : DPU DR. MUHAMMAD YUNUS, M.KES
NAMA JEJARING : BIDAN KETUT ANDRIYANI, S.ST dan BIDAN SRIATIN, Am.Keb
BULAN PELAYANAN : APRIL 2016
PEMERIKSAAN KEHAMILAN (ANC) Persalinan PNC
PISA

Alamat/No. HP Nama Bidan

Umur
(Thn)

No Nama Penderita Nomor Kartu Pasien Jejaring

K1 K2 K3 K4 Tgl Tindakan KN1=KF1 KN2= KF2 KN3 KF3
1 2 3 4 5 6 7 8 9 10 11 12 17 18 19 20

1 NY. ROSNIATI I 25 0002044649632 BUKE 12/09/2015 05/12/2015 12/03/2016 02/04/2016 09/04/2016 APN 10/04/2016 14/04/2016 30/04/2016 14/05/2016 Sriatin

2 NY. RIZKI DWI FEBRYASTI I 23 0000173649341 DS. KOTA BANGUN 29/09/2015 08/12/2015 01/03/2016 05/04/2016 12/04/2016 APN 13/04/2016 17/04/2016 04/05/2016 17/05/2016 Sriatin

Mengetahui Bidan Jejaring 1 BidanJejaring 2

Dokter Pembina

dr. Muhammad Yunus, M.Kes Ketut Andriani, SST Sriatin, Am.Keb

SIP. 440/031/VIII/2010
 FKTP DPP dr. MUHAMMAD YUNUS, M.Kes
SIP. 440/031/VIII/2010
Jl. Lanud Wolter Monginsidi No. 47 Kecamatan Ranomeeto-Ka.Konawe Selatan
Lampiran Klaim PERSALINAN , ANC, dan PNC Pasien BPJS pada Bidan Jejaring
NAMA FKTP : DPU DR. MUHAMMAD YUNUS, M.KES
NAMA JEJARING : BIDAN KETUT ANDRIYANI, S.ST dan BIDAN SRIATIN, Am.Keb
BULAN PELAYANAN : MEI 2016
PEMERIKSAAN KEHAMILAN (ANC) Persalinan PNC
PISA

Alamat/No. HP Nama Bidan

Umur
(Thn)

No Nama Penderita Nomor Kartu Pasien Jejaring

K1 K2 K3 K4 Tgl Tindakan KN1=KF1 KN2= KF2 KN3 KF3
1 2 3 4 5 6 7 8 9 10 11 12 17 18 19 20

1 NY. KASRI I 43 0000953726523 DS. Amoito 08/10/2015 28/01/2016 24/03/2016 28/04/2016 05/05/2016 Pra Rujukan 10/05/2016 25/05/2016 10/06/2016 Sriatin

2 NY. TINA RALIANTI I 25 0002047553144 DS. ONEWILA 08/11/2015 17/01/2016 27/03/2016 01/05/2016 08/05/2016 APN 09/05/2016 13/05/2016 28/05/2016 13/06/2016 Sriatin

3 NY. ERNI I 34 0000954811359 DS. LAEYA 02/11/2015 25/01/2016 04/04/2016 09/05/2016 16/05/2016 Pra Rujukan 22/05/2016 05/06/2016 22/06/2016 Sriatin

4 NY. SITI KOSMATUN I 24 0002049432489 WUA-WUA 04/11/2015 27/01/2016 06/04/2016 11/05/2016 18/05/2016 APN 19/05/2016 23/05/2016 06/06/2016 23/06/2016 Sriatin

5 NY. SITI NURSIDAH I 30 0002032116974 DS. LANGGEA 21/10/2015 13/01/2016 20/04/2016 11/05/2016 18/05/2016 APN 19/05/2016 22/05/2016 04/06/2016 22/06/2016 Sriatin

6 NY. SURYA NINGSIH I 24 0001555187488 DS. TOBIMEITA 23/10/2015 15/01/2016 08/04/2016 13/05/2016 20/05/2016 APN 21/05/2016 25/05/2016 10/06/2016 21/06/2016 Sriatin

7 NY. RESTIANI I 24 0001548091517 DS. KOTA BANGUN 06/11/2015 29/01/2016 22/04/2016 13/05/2016 20/05/2016 APN 21/05/2016 25/05/2016 04/06/2016 25/06/2016 Sriatin

Mengetahui Bidan Jejaring 1 BidanJejaring 2

Dokter Pembina

dr. Muhammad Yunus, M.Kes Ketut Andriani, SST Sriatin, Am.Keb

SIP. 440/031/VIII/2010
 FKTP DPP dr. MUHAMMAD YUNUS, M.Kes
SIP. 440/031/VIII/2010
Jl. Lanud Wolter Monginsidi No. 47 Kecamatan Ranomeeto-Ka.Konawe Selatan
Lampiran Klaim PERSALINAN , ANC, dan PNC Pasien BPJS pada Bidan Jejaring
NAMA FKTP : DPU DR. MUHAMMAD YUNUS, M.KES
NAMA JEJARING : BIDAN KETUT ANDRIYANI, S.ST dan BIDAN SRIATIN, Am.Keb
BULAN PELAYANAN : JUNI 2016
PEMERIKSAAN KEHAMILAN (ANC) Persalinan PNC
PISA

Alamat/No. HP Nama Bidan

Umur
(Thn)

No Nama Penderita Nomor Kartu

Pasien Jejaring
K1 K2 K3 K4 Tgl Tindakan KN1=KF1 KN2= KF2 KN3 KF3
1 2 3 4 5 6 7 8 9 10 11 12 17 18 19 20

1 NY. SURATMI NINGSI l 38 0002044618852 DS.Langgea 05/12/2015 27/02/2016 14/05/2016 28/05/2016 04/06/2016 APN 05/06/2016 10/06/2016 24/06/2016 10/07/2016 Sriatin

2 NY. MISNA PURWATI I 23 0002056976818 DS. AMBAIPUA 09/11/2015 18/01/2016 09/05/2016 30/05/2016 06/06/2016 APN 07/06/2016 11/06/2016 24/06/2016 11/07/2016 Sriatin

3 NY. DEWI TRIDARWati I 21 0001074861268 DS.Langgea 10/11/2015 19/01/2016 26/04/2016 31/05/2016 07/06/2016 Pra Rujukan 12/06/2016 27/06/2016 12/07/2016 Sriatin

4 NY. HERLINA I 36 0000133895812 DS. KOTA BANGUN 09/12/2015 17/02/2016 25/05/2016 15/06/2016 22/06/2016 APN 23/06/2016 27/06/2016 12/07/2016 27/07/2016 Sriatin
5
6

Mengetahui Bidan Jejaring 1 BidanJejaring 2

Dokter Pembina

dr. Muhammad Yunus, M.Kes Ketut Andriani, SST Sriatin, Am.Keb

SIP. 440/031/VIII/2010
 FKTP DPP dr. MUHAMMAD YUNUS, M.Kes
SIP. 440/031/VIII/2010
Jl. Lanud Wolter Monginsidi No. 47 Kecamatan Ranomeeto-Ka.Konawe Selatan
Lampiran Klaim PERSALINAN , ANC, dan PNC Pasien BPJS pada Bidan Jejaring
NAMA FKTP : DPU DR. MUHAMMAD YUNUS, M.KES
NAMA JEJARING : BIDAN KETUT ANDRIYANI, S.ST dan BIDAN SRIATIN, Am.Keb
BULAN PELAYANAN : JULI 2016
PEMERIKSAAN KEHAMILAN (ANC) Persalinan PNC
PISA

Alamat/No. HP Nama Bidan

Umur
(Thn)

No Nama Penderita Nomor Kartu Pasien Jejaring

K1 K2 K3 K4 Tgl Tindakan KN1=KF1 KN2= KF2 KN3 KF3
1 2 3 4 5 6 7 8 9 10 11 12 17 18 19 20

1 NY. HASNAWATI I 39 0002061326597 RANOMEETO 11/06/2016 02/07/2016 09/07/2016 APN 10/07/2016 14/07/2016 29/07/2016 16/08/2016 Sriatin

2 NY. ROSMAWATI I 33 0002062644344 DS KOTA BANGUN 12/07/2016 19/07/2016 APN 20/07/2016 24/07/2016 11/08/2016 Sriatin

3 Sriatin

4 Sriatin

Mengetahui Bidan Jejaring 1 BidanJejaring 2

Dokter Pembina

dr. Muhammad Yunus, M.Kes Ketut Andriani, SST Sriatin, Am.Keb

SIP. 440/031/VIII/2010
 FKTP DPP dr. MUHAMMAD YUNUS, M.Kes
SIP. 440/031/VIII/2010
Jl. Lanud Wolter Monginsidi No. 47 Kecamatan Ranomeeto-Ka.Konawe Selatan
Lampiran Klaim PERSALINAN , ANC, dan PNC Pasien BPJS pada Bidan Jejaring
NAMA FKTP : DPU DR. MUHAMMAD YUNUS, M.KES
NAMA JEJARING : BIDAN KETUT ANDRIYANI, S.ST dan BIDAN SRIATIN, Am.Keb
BULAN PELAYANAN : AGUSTUS 2016
PEMERIKSAAN KEHAMILAN (ANC) Persalinan PNC
PISA

Alamat/No. HP Nama Bidan

Umur
(Thn)

No Nama Penderita Nomor Kartu Pasien Jejaring

K1 K2 K3 K4 Tgl Tindakan KN1=KF1 KN2= KF2 KN3 KF3
1 2 3 4 5 6 7 8 9 10 11 12 17 18 19 20

1 NY. RENA I 34 0001856508129 DS KOTA BANGUN 18/04/2016 27/06/2016 01/08/2016 APN 08/08/2016 9/8/82016 13/08/2016 01/09/2016 14/09/2016 Sriatin

2 NY. SRI MULYANINGSI I 21 0000952149071 LANGGEA 29/01/2016 22/04/2016 01/07/2016 05/08/2016 APN 12/08/2016 13/08/2016 17/08/2016 03/09/2016 19/09/2016 Sriatin

3 NY. ASIAH I 45 0002068595548 MORAMO 07/08/2016 14/08/2016 APN 21/08/2016 22/08/2016 26/08/2016 10/09/2016 29/09/2016 Sriatin

Mengetahui Bidan Jejaring 1 BidanJejaring 2

Dokter Pembina

dr. Muhammad Yunus, M.Kes Ketut Andriani, SST Sriatin, Am.Keb

SIP. 440/031/VIII/2010

FKTP DPP dr. MUHAMMAD YUNUS, M.Kes

SIP. 440/031/VIII/2010
Jl. Lanud Wolter Monginsidi No. 47 Kecamatan Ranomeeto-Ka.Konawe Selatan
Lampiran Klaim PERSALINAN , ANC, dan PNC Pasien BPJS pada Bidan Jejaring
NAMA FKTP : DPU DR. MUHAMMAD YUNUS, M.KES
NAMA JEJARING : BIDAN KETUT ANDRIYANI, S.ST dan BIDAN SRIATIN, Am.Keb
BULAN PELAYANAN : SEPTEMBER 2016
PEMERIKSAAN KEHAMILAN (ANC) Persalinan PNC
Umur (Thn)
PISA

Alamat/No. HP Nama Bidan

No Nama Penderita Nomor Kartu Pasien Jejaring
K1 K2 K3 K4 Tgl Tindakan KN1=KF1 KN2= KF2 KN3 KF3

1 2 3 4 5 6 7 8 9 10 11 12 17 18 19 20
1 NY. WAHYUNI I 35 0001539947946 DS KOTA BANGUN 03/03/2016 26/05/2016 18/08/2016 08/09/2016 15/09/2016 APN 16/09/2016 21/09/2016 08/10/2016 21/10/2016 Sriatin
2 I

3 I
 4 I

Mengetahui Bidan Jejaring 1 BidanJejaring 2

Dokter Pembina

dr. Muhammad Yunus, M.Kes Ketut Andriani, SST Sriatin, Am.Keb

SIP. 440/031/VIII/2010
10000000

2500
 TAHAP TAHAP TAHAP
PEMERIKSAAN TGL PEMERIKSAAN TGL PEMERIKSAAN

ANC I 10/3/2015 TW I ANC I 10/21/2015 TW I ANC I

ANC I 10/10/2015 TW I ANC I 10/28/2015 TW I ANC I
ANC I 10/17/2015 TW I ANC I 11/4/2015 TW I ANC I
ANC I 10/24/2015 TW I ANC I 11/11/2015 TW I ANC I
ANC I 10/31/2015 TW I ANC I 11/18/2015 TW I ANC I
ANC I 11/7/2015 TW I ANC I 11/25/2015 TW I ANC I
ANC I 11/14/2015 TW I ANC I 12/2/2015 TW I ANC I
ANC I 11/21/2015 TW I ANC I 12/9/2015 TW I ANC I
ANC I 11/28/2015 TW I ANC I 12/16/2015 TW I ANC I
ANC I 12/5/2015 TW I ANC I 12/23/2015 TW I ANC I
ANC II 12/26/2015 TW II ANC II 1/13/2016 TW II ANC II
ANC II 1/2/2016 TW II ANC II 1/20/2016 TW II ANC II
ANC II 1/9/2016 TW II ANC II 1/27/2016 TW II ANC II
ANC II 1/16/2016 TW II ANC II 2/3/2016 TW II ANC II
ANC II 1/23/2016 TW II ANC II 2/10/2016 TW II ANC II
ANC II 1/30/2016 TW II ANC II 2/17/2016 TW II ANC II
ANC II 2/6/2016 TW II ANC II 2/24/2016 TW II ANC II
ANC II 2/13/2016 TW II ANC II 3/2/2016 TW II ANC II
ANC II 2/20/2016 TW II ANC II 3/9/2016 TW II ANC II
ANC II 2/27/2016 TW II ANC II 3/16/2016 TW II ANC II
ANC III 3/19/2016 TWIII ANC III 4/6/2016 TWIII ANC III
ANC III 3/26/2016 TWIII ANC III 4/13/2016 TWIII ANC III
ANC III 4/2/2016 TWIII ANC III 4/20/2016 TWIII ANC III
ANC III 4/9/2016 TWIII ANC III 4/27/2016 TWIII ANC III
ANC III 4/16/2016 TWIII ANC III 5/4/2016 TWIII ANC III
ANC III 4/23/2016 TWIII ANC III 5/11/2016 TWIII ANC III
ANC III 4/30/2016 TWIII ANC III 5/18/2016 TWIII ANC III
ANC III 5/7/2016 TWIII ANC III 5/25/2016 TWIII ANC III
ANC III 5/14/2016 TWIII ANC III 6/1/2016 TWIII ANC III
ANC III 5/21/2016 TWIII ANC III 6/8/2016 TWIII ANC III
ANC IV 5/28/2016 ANC IV 6/15/2016 ANC IV
TGL. 6/4/2016 0:00
TGL. 6/22/2016 0:00
TGL.
PARTUS PARTUS PARTUS
suratmi ningsih herlina dewi

TANGGAL TANGGAL
PNC SEBAIKNYA PNC SEBAIKNYA PNC
KF1 dan KN1 6/4/2016 6:00 6 Jam I KF1 dan KN1 6/22/2016 6:00 6 Jam I KF1 dan KN1
KF1 dan KN1 6/5/2016 1 KF1 dan KN1 6/23/2016 1 KF1 dan KN1
KF1 dan KN1 6/6/2016 2 KF1 dan KN1 6/24/2016 2 KF1 dan KN1
KF2 dan KN2 6/8/2016 4 KF2 dan KN2 6/26/2016 4 KF2 dan KN2
KF2 dan KN2 6/9/2016 5 KF2 dan KN2 6/27/2016 5 KF2 dan KN2
KF2 dan KN2 6/10/2016 6 KF2 dan KN2 6/28/2016 6 KF2 dan KN2
KF2 dan KN2 6/11/2016 7 KF2 dan KN2 6/29/2016 7 KF2 dan KN2
KN3 6/13/2016 9 KN3 7/1/2016 9 KN3
KN3 6/14/2016 10 KN3 7/2/2016 10 KN3
KN3 6/15/2016 11 KN3 7/3/2016 11 KN3
KN3 6/16/2016 12 KN3 7/4/2016 12 KN3
KN3 6/17/2016 13 KN3 7/5/2016 13 KN3
KN3 6/18/2016 14 KN3 7/6/2016 14 KN3
KN3 6/19/2016 15 KN3 7/7/2016 15 KN3
KN3 6/20/2016 16 KN3 7/8/2016 16 KN3
KN3 6/21/2016 17 KN3 7/9/2016 17 KN3
KN3 6/22/2016 18 KN3 7/10/2016 18 KN3
KN3 6/23/2016 19 KN3 7/11/2016 19 KN3
KN3 6/24/2016 20 KN3 7/12/2016 20 KN3
KN3 6/25/2016 21 KN3 7/13/2016 21 KN3
KN3 6/26/2016 22 KN3 7/14/2016 22 KN3
KN3 6/27/2016 23 KN3 7/15/2016 23 KN3
KN3 6/28/2016 24 KN3 7/16/2016 24 KN3
KN3 6/29/2016 25 KN3 7/17/2016 25 KN3
KN3 6/30/2016 26 KN3 7/18/2016 26 KN3
KN3 7/1/2016 27 KN3 7/19/2016 27 KN3
KN3 7/2/2016 28 KN3 7/20/2016 28 KN3
KF3 7/3/2016 29 KF3 7/21/2016 29 KF3
KF3 7/4/2016 30 KF3 7/22/2016 30 KF3
KF3 7/5/2016 31 KF3 7/23/2016 31 KF3
KF3 7/6/2016 32 KF3 7/24/2016 32 KF3
KF3 7/7/2016 33 KF3 7/25/2016 33 KF3
KF3 7/8/2016 34 KF3 7/26/2016 34 KF3
KF3 7/9/2016 35 KF3 7/27/2016 35 KF3
KF3 7/10/2016 36 KF3 7/28/2016 36 KF3
KF3 7/11/2016 37 KF3 7/29/2016 37 KF3
KF3 7/12/2016 38 KF3 7/30/2016 38 KF3
KF3 7/13/2016 39 KF3 7/31/2016 39 KF3
KF3 7/14/2016 40 KF3 8/1/2016 40 KF3
KF3 7/15/2016 41 KF3 8/2/2016 41 KF3
KF3 7/16/2016 42 KF3 8/3/2016 42 KF3
 TGL
10/6/2015 TW I
10/13/2015 TW I
10/20/2015 TW I
10/27/2015 TW I
11/3/2015 TW I
11/10/2015 TW I
11/17/2015 TW I
11/24/2015 TW I
12/1/2015 TW I
12/8/2015 TW I
12/29/2015 TW II
1/5/2016 TW II
1/12/2016 TW II
1/19/2016 TW II
1/26/2016 TW II
2/2/2016 TW II
2/9/2016 TW II
2/16/2016 TW II
2/23/2016 TW II
3/1/2016 TW II
3/22/2016 TWIII
3/29/2016 TWIII
4/5/2016 TWIII
4/12/2016 TWIII
4/19/2016 TWIII
4/26/2016 TWIII
5/3/2016 TWIII
5/10/2016 TWIII
5/17/2016 TWIII
5/24/2016 TWIII
5/31/2016
6/7/2016 0:00

dewi

TANGGAL
SEBAIKNYA
6/7/2016 6:00 6 Jam I
6/8/2016 1
6/9/2016 2
6/11/2016 4
6/12/2016 5
6/13/2016 6
6/14/2016 7
6/16/2016 9
6/17/2016 10
6/18/2016 11
6/19/2016 12
6/20/2016 13
6/21/2016 14
6/22/2016 15
6/23/2016 16
6/24/2016 17
6/25/2016 18
6/26/2016 19
6/27/2016 20
6/28/2016 21
6/29/2016 22
6/30/2016 23
7/1/2016 24
7/2/2016 25
7/3/2016 26
 7/4/2016 27
7/5/2016 28
7/6/2016 29
7/7/2016 30
7/8/2016 31
7/9/2016 32
7/10/2016 33
7/11/2016 34
7/12/2016 35
7/13/2016 36
7/14/2016 37
7/15/2016 38
7/16/2016 39
7/17/2016 40
7/18/2016 41
7/19/2016 42
 KODE PELAYANAN KEBIDANAN

PEMERIKSAAN/ KODE
TINDAKAN
K1 , K2, K3, K4 Z34.9
PERSALINAN NORMAL O80.9
KN1, KN2, KN3, KF1,
KF2, KF3 Z39.2

JANGAN LUPA TANGGAL MASUK = TANGGAL KELUAR

KODE PELAYANAN KEBIDANAN

Diagnosa

Supervison of Normal Pregnancy, unspecified

Single Spontaneus delivery, unspecified

Routine Post Partum Follow Up

A TANGGAL MASUK = TANGGAL KELUAR