BPJS Kesehatan Cab.

UNGARAN
FORMULIR PENGAJUAN KLAIM

Nomor FPK : L1802000000272

Provider : Susukan
Bulan Pelayanan : February, 2018
Pelayanan : Promotif

Total Data : 20

Total Tagihan : 500,000

NO TRANSAKSI TANGGAL NAMA PESERTA JENIS KLAIM Biaya

11020301L1802059890 01/02/201 WIWIK WIJAYANTI IVA 25,000
11020301L1802059893 01/02/201 MUSLIKHAH IVA 25,000
11020301L1802059899 08/02/201 SUANTIMAH IVA 25,000
11020301L1802059906 08/02/201 PURWANTI IVA 25,000
11020301L1802059908 08/02/201 SAIDAH IVA 25,000
11020301L1802059911 08/02/201 SITI FATIMAH IVA 25,000
11020301L1802059912 08/02/201 NUR ALIFIYAH IVA 25,000
11020301L1802059916 08/02/201 ANDRIANI PRABAWATI IVA 25,000
11020301L1802059919 15/02/201 NGATIRAH IVA 25,000
11020301L1802059921 15/02/201 NGATEMI IVA 25,000
11020301L1802059924 15/02/201 SALBIYAH IVA 25,000
11020301L1802059925 15/02/201 BASIROH IVA 25,000
11020301L1802059928 15/02/201 TRIYANI IVA 25,000
11020301L1802059930 22/02/201 BEKTI ANANIYAH IVA 25,000
11020301L1802059933 22/02/201 YAMINI IVA 25,000
11020301L1802059943 22/02/201 FRANSISKA MAELANI IVA 25,000
11020301L1802059946 22/02/201 SRI WAHYUNI IVA 25,000
11020301L1802059948 22/02/201 SITI ALFIAH IVA 25,000
11020301L1802059950 22/02/201 HASTUTI IVA 25,000
11020301L1802059954 22/02/201 HARTATIK IVA 25,000
 Tanggal,
Pengaju Klaim,

27/02/2018 14.35.13