Rekap Klaim Non Kapts 2015&2016 &bon..

REKAPITULASI KLAIM RAWAT INAP JAMINAN KESEHATAN NASIONAL (JKN)
Nama UPT Puskesmas Rawat Inap Jatinangor

Bulan : April 2018
Pelayanan : RITP
No Nama No Peserta Alamat Diagnosa Tgl Masuk
1 Ujang Sutisna 0001892367786 H.Manah S . Thypoid 30/ 3/20 18

2 Yati 00004622473572 Jatiroke S . Thypoid 31/ 3/20 18
3 Karmini 0000462104937 Cileles Gastritis 31/ 3/20 18
4 Ebey 0001008250569 Cipacing ulcus Pept 1/4/20 18
5 Bustomi 0000429808662 Cileles S . Thypoid 2/4/20 18
6 Apong 0000462637247 Sayang Vertigo-Gast 2/4/20 18
7 Nurhayati 0001126226575 H.Manah Gastritis 2/4/20 18
8 M. Jajang 0002425103122 H.Manah Astma 3/4/20 18
9 Apong Tarsiah 0000462319975 Jatimukti Gastritis 4/4/20 18
10 Erna Ermawati 0000462854981 Cileles Gastritis+anemia 3/4/20 18
11 Widia Oktavia 0001466019235 Jatimukti Gastritis 4/4/20 18
12 Cepi Gunawan 000046261266 Cisempur Susp. Dhf 4/4/20 18
13 Usep 0001778821942 Cileunyi Gastritis 7/4/20 18
14 Elah 0004661949445 Cisempur Gastritis 7/4/20 18
15 Sariah 0000462938409 H.Manah Gastritis 7/4/20 18
16 Wila 0000461925808 H.Manah Gastritis 7/4/20 18
17 Wiwin 0000461740724 Cibeusi S.DC + Stroke 8/4/20 18
18 Lilis Siti M 00004462159246 Cipacing 1/5 Gastritis 10/4/20 18
19 Tita Rosita 0000462732344 Cipacing 1/11 S . Thypoid 11/4/20 18
20 Raditya Nugraha 0000462486554 Sayang S . Thypoid 11/4/20 18
21 Nenden R 0001008279268 H.Manah 2/13 Gastritis 12/4/20 18
22 Dian Raja S 0001003834967 Cileunyi 4/20 S . Thypoid 12/4/20 18
23 Sri Rohaeti 00010082551807 Cipacing 1/2 Gastritis 12/4/20 18
24 Mamat 0000058017971 Cileles 1/6 Hypertensi 12/4/20 18
25 Umar 0000065331382 H.Manah 2/11 Gastritis 15/4/20 18
26 Sarmanah 0001008262697 Mekargalih 3/10 Gastritis 15/4/20 18
27 Mamat 0001008280078 H.Manah 1/6 Gastritis 16/4/20 18
28 Jubaedah 0000462494891 Sayang 2/10 Gastritis 16/4/20 18
29 Nunu Mulyana 0001008280078 Cilayung 1/10 Susp. Dhf 17/4/20 18
30 Anisa Suciyati 0001008296324 H.Manah 4/13 Gastritis 16/4/20 18
31 Dede Ali 0001008278921 Cipacing 1/7 Gastritis 15/4/20 18
32 Zidan N 0001383815261 Tanjung Sari S . Thypoid 15/4/20 18
33 Aprita Pratiwi 0001522055081 Cileles 2/1 Gastritis 13/4/20 18
34 Fajar 0001008292893 Cileles 2/1 Gastritis 13/4/20 18
35 Neneng Siti 0000419553821 Cileunyi wetan Susp. Dhf 23/4/20 18
36 Mansur 0000463099138 Mekarsari 1/1 S . Thypoid 23/4/20 18
37 Nonih 0000463099138 H.Manah 1/2 Gastritis 20/4/20 18
38 Tati 0000463099138 Cileles 2/4 S . Thypoid 19/4/20 18
39 Undang Rukmana 0000463099138 Cikeruh 3/2 Gastritis 18/4/20 18
40 Aom Djumroni 0000463099138 Cikeruh 2/6 S . Thypoid 17/4/20 18
41 Dede Tarliah 0000463099138 Cintamulya 9/3 Gastritis 17/4/20 18
42 Sri Suryani 0000461636177 Cibeusi 1/9 Gastritis 16/4/20 18
43 Rizal Ramdan 0002439885363 Jatimukti 2/7 Susp. Dhf 23/4/20 18
44 Euis 0000462040345 Cisempur2/1r Gastritis 23/4/20 18
45 Dedeh K 0000462790078 Jatisari 3/1 Gastritis 23/4/20 18
46 Muhammad R N 0002214162562 Hegarmanah 5/11 S . Thypoid 24/4/20 18
47 Nanan 0000463110366 Jatimukti 1/5 Gastritis 25/4/20 18
48 Supyan 0000149350015 Cileles 5/6 Susp.App+Gast 26/4/20 18
49 Sumirah 0001008279369 Hegarmanah Anemia 27/4/20 18
50 Risma 0002290805403 Sawah Dadap Gastritis 29/4/20 18
Jumlah
Terbilang " Dua Puluh Empat Juta Empat Ratus Ribu Rupiah"
Mengetahui Kepala
Puskesmas Rawat Inap Jatinangor
drg. Amie Fitiah, M.H.Kes

NIP: 10721111 200604 2 017
(JKN)
Biaya
Tgl Keluar Jumlah
HP UC/Hari
2/4/20 18 3 200,000 600,000
5/4/20 18 5 200,000 1,000,000
3/4/20 18 3 200,000 600,000
3/4/20 18 3 200,000 400,000
5/4/20 18 3 200,000 600,000
5/4/20 18 3 200,000 600,000
6/4/20 18 4 200,000 800,000
6/4/20 18 3 200,000 600,000
10/4/20 18 6 200,000 1,200,000
4/4/20 18 1 200,000 200,000
6/4/20 18 2 200,000 400,000
6/4/20 18 2 200,000 400,000
9/4/20 18 2 200,000 400,000
9/4/20 18 2 200,000 400,000
10/4/20 18 3 200,000 600,000
9/4/20 18 2 200,000 400,000
9/4/20 18 1 200,000 200,000
13/4/20 18 3 200,000 600,000
13/4/20 18 2 200,000 400,000
16/4/20 18 5 200,000 1,000,000
13/4/20 18 1 200,000 200,000
16/4/20 18 4 200,000 800,000
13/4/20 18 1 200,000 200,000
16/4/20 18 4 200,000 800,000
17/4/20 18 2 200,000 400,000
17/4/20 18 2 200,000 400,000
17/4/20 18 1 200,000 200,000
18/4/20 18 2 200,000 400,000
19/4/20 18 2 200,000 400,000
19/4/20 18 3 200,000 600,000
17/4/20 18 2 200,000 400,000
17/4/20 18 2 200,000 400,000
16/4/20 18 3 200,000 600,000
16/4/20 18 3 200,000 600,000
25/4/20 18 2 200,000 400,000
24/4/20 18 1 200,000 200,000
23/4/20 18 3 200,000 600,000
21/4/20 18 2 200,000 400,000
23/4/20 18 5 200,000 1,000,000
19/4/20 18 2 200,000 400,000
18/4/20 18 1 200,000 200,000
17/4/20 18 1 200,000 200,000
27/4/20 18 4 200,000 800,000
26/4/20 18 3 200,000 600,000
25/4/20 18 2 200,000 400,000
25/4/20 18 1 200,000 200,000
26/4/20 18 1 200,000 200,000
27/4/20 18 1 200,000 200,000
30/4/20 18 3 200,000 600,000
30/4/20 18 1 200,000 200,000
24,400,000
h"
Jatinangor, 3 Mei 2018

Bendahara BLUD Puskesmas Rawat Inap Jatinangor
Rina Mariani AMK

NIP.19701221.199803.2.003
REKAPITULASI KLAIM RAWAT INAP JAMINAN KESEHATAN NASIONAL (JK

Bulan : Februari 2018
Pelayanan : RITP
No Nama No Peserta Alamat Diagnosa
1 Yoyoh 0000054091956 Cipacing 3/9 S . Thypoid

2 Hani Fitriyah 0000461540485 Cintamulya 3/9 Gastritis
3 Osih 0002292443537 Cileunyi 1/9 Gastritis
4 Popon 0000462668218 Sukasari 5/7 S . Thypoid
5 Rula Milda 0000462547337 Cisempur 2/10 S. DHF
6 Triani Novita 0001008284951 Cikeruh 3/3 S . Thypoid
7 Juju Juhriah 0001008252819 Cipacing 6/7 GEA
8 Ajat 0000195482259 Cileles 1/5 S . Thypoid
9 Ati 0000418401099 Cimekar 5/27 S . Thypoid
10 Dedi Jaelani 0002285932037 Cintamulya 4/8 Gastritis
11 Dasuki 0001008294996 Cilayung 1/6 S . Thypoid
12 Silmi Safira 0001981367289 Cintamulya 8/3 Gastritis
13 Coom 0000461988718 Cileles 3/9 GEA
14 Rianto Wibowo 0000461940377 Cikeruh 4/4 GEA
15 Rio Hermansyah 0001105892976 Jatiroke 3/5 GEA
16 Fatan Mulyawan 0002181073419 Nanggerang 2/9 S . Thypoid
17 Nana Rukmana 0001291160902 Cileles 2/1 Gastritis
18 Yosep Rizal 0001008260638 Sukarasa 3/1 Gastritis
19 Ginar Maulana 0001284919413 Cintamulya Gastritis
20 Hadmi 0002042131331 Jatiroke 2/4 GEA
21 Warliyah 0000462792262 Selacau 5/3 GEA
22 Intan 0000461736549 Cilayung 1/7 S . Thypoid
23 Fitriana 000151712127 Cisempur 3/3 Gastritis
24 Cucu M 0000463159719 Cisempur 3/9 GEA
25 E. Karmilah 0000462767578 Cileles 1/9 Gastritis
26 Atay 0000461964611 W. Kalde GEA
27 Rizal 0001008265285 Mekargalih Gastritis
28 Usep Dodo 0001666339806 Dangder DM
29 Suparman 0001127549643 Cimekar S . Thypoid
30 Nenden Dewi K 0001008691345 Hegarmanah 2/6 S . Thypoid
31 Hendi Sutisna 0000462610776 Cileles S . Thypoid
32 Ekem 0000463859739 Nanggerang 3/9 HT+ Stroke
33 Juju Juhriah 0001008252819 Cipacing 6/7 Gastritis
34 Juju 0000463907575 Nanggerang 3/9 GEA
35 Anih 0000461940232 Jatimukti 2/7 Gastritis
36 Kartiman 0002326568332 Kutamandiri 1/3 Gastritis
37 Kartini 0001008296425 Cilayung 3/8 S. DHF
38 Icah 0000463428156 Banyuresmi 3/1 S. Broncopneumonia
39 Widia 0002320128821 Cilayung 3/8 S. Thypoid
40 Rohmat 0000463502654 Cilayung 1/2 Anemia
41 Abdul Alamin 0000064943853 Cikeruh 4/9 BRPN
42 Sutiono 0000461167031 Cilayung 1/3 CHF
43 Yohanah 0000065331573 Hegarmanah 2/7 HHD
JUMLAH
Terbilang " Sembilan Belas Juta Enam Ratus Ribu Rupiah"
Mengetahui Kepala

NIP: 10721111 200604 2 017
INAP JAMINAN KESEHATAN NASIONAL (JKN)
Biaya
Tgl Masuk Tgl Keluar Jumlah
HP UC/Hari
29/ 1/20 18 2/2/20 18 4 200,000 800,000
29/ 1/20 18 1/2/20 18 3 200,000 600,000
29/ 1/20 18 1/2/20 18 3 200,000 600,000
30/ 1/20 18 1/2/20 18 2 200,000 400,000
30/ 1/20 18 2/2/20 18 3 200,000 600,000
1/2/20 18 3/2/20 18 2 200,000 400,000
2/2/20 18 5/2/20 18 3 200,000 600,000
2/2/20 18 6/2/20 18 4 200,000 800,000
6/2/20 18 8/2/20 18 2 200,000 400,000
6/2/20 18 8/2/20 18 2 200,000 400,000
6/2/20 18 8/2/20 18 2 200,000 400,000
7/2/20 18 9/2/20 18 2 200,000 400,000
8/2/20 18 9/2/20 18 1 200,000 200,000
9/2/20 18 11/2/20 18 2 200,000 400,000
10/2/20 18 11/2/20 18 1 200,000 200,000
10/2/20 18 12/2/20 18 2 200,000 400,000
12/2/20 18 13/2/20 18 1 200,000 200,000
12/2/20 18 14/2/20 18 2 200,000 400,000
13/2/20 18 14/2/20 18 1 200,000 200,000
12/2/20 18 14/2/20 18 2 200,000 400,000
13/2/20 18 17/2/20 18 4 200,000 800,000
13/2/20 18 17/2/20 18 4 200,000 800,000
14/2/20 18 17/2/20 18 3 200,000 600,000
14/2/20 18 17/2/20 18 3 200,000 600,000
15/2/20 18 17/2/20 18 2 200,000 400,000
16/2/20 18 20/2/20 18 4 200,000 800,000
17/2/20 18 20/2/20 18 3 200,000 600,000
17/2/20 18 20/2/20 18 3 200,000 600,000
17/2/20 18 20/2/20 18 3 200,000 600,000
19/2/20 18 21/2/20 18 2 200,000 400,000
21/2/20 18 23/2/20 18 2 200,000 400,000
22/2/20 18 23/2/20 18 1 200,000 200,000
22/2/20 18 23/2/20 18 1 200,000 200,000
23/2/20 18 24/2/20 18 1 200,000 200,000
23/2/20 18 26/2/20 18 3 200,000 600,000
23/2/20 18 26/2/20 18 3 200,000 600,000
23/2/20 18 26/2/20 18 3 200,000 600,000
2/24/2018 26/2/20 18 2 200,000 400,000
2/24/2018 26/2/20 18 2 200,000 400,000
2/27/2018 2/28/2018 1 200,000 200,000
2/26/2018 2/28/2018 2 200,000 400,000
2/27/2018 2/28/2018 1 200,000 200,000
2/27/2018 1/28/2018 1 200,000 200,000
AH 19,600,000
Belas Juta Enam Ratus Ribu Rupiah"
Jatinangor, 2 Maret 2018

Rina Mariani AMK

NIP.19701221.199803.2.003
REKAPITULASI KLAIM KEBIDANAN DAN NEONATAL JAMINAN KESEHATAN NASIONAL (J
Nama UPTD : Puskesmas DTP Jatinangor
Bulan : June 2015
Pelayanan : RITP
Tanggal Pelayanan
No Nama Pasien No Peserta Alamat No Hp.
Tanggal Masuk Tanggal
Pulang
1 Rahmawati 0000461976794 Cipacing 6/1/2015
2 Leni 0000461976794 Cileles 6/3/2015
3 Siti Nurjanah 0000461976794 Hegarmanah 6/1/2015
4 Roshayanti 0000461976794 Sayang 6/1/2015
5 Fitri RatnaSari 0000461976794 Cileunyi 6/1/2015
6 Elis Trisnawati 0000461976794 Cilayung 6/1/2015
7 Ela Siti Nurlela 0000461976794 Mekargalih 6/1/2015
8 Ina Kartina 0000461976794 Cikeruh 6/1/2015
9 Erna Suhaeni 0000461976794 Hegarmanah 6/1/2015
10 Romlah satori 0000461976794 Mekargalih 6/1/2015
11 Lusi Andriati 0000461976794 Sayang 6/1/2015
12 Tuti Hasanah 0000461976794 Hegarmanah 6/1/2015
13 Yanti Priyanti 0000461976794 Cintamulya 6/1/2015
14 Mia rahmi 0000461976794 Sayang 6/1/2015
15 Wartini 0000461976794 Jatimukti 6/1/2015
Jumlah
Terbilang : Tujuh Juta Dua Ratus Lima Puluh Ribu Rupiah
Mengetahui
Kepala Puskesmas DTP Jatinangor
dr Haris Fatah Kristofa

NIP.19641030.200212.1.002

Bulan : July 2015
Pelayanan : RITP
Tanggal Pelayanan
Tanggal
Tanggal Masuk Pulang
1 Ai Sari 0000461707187 Cilayung 7/1/2015 7/1/2015
2 Dewi Suciyanti 0001060876944 Jatiroke 7/2/2015 7/2/2015
3 Nurasiah Ismail 0000461811227 Cilayung 7/3/2015 7/3/2015
4 Desi Nurhandayani 0001854459652 Cileles 7/4/2015 7/4/2015
5 Yepi Agustina 0001175055478 Cipacing 7/4/2015 7/5/2015
6 Kristina Clara 0000460042571 Hegarmanah 7/5/2015 7/6/2015
7 Yuyun Nurhayati 0001855814534 Cibeusi 7/5/2015 7/6/2015
8 Milah Jamilah 0001522053246 Cibeusi 7/8/2015 7/9/2015
9 Iis Sugiarsih 0000462521305 Cipacing 7/9/2015 7/9/2015
10 Fitriyani 0001008255688 Sayang 7/9/2015 7/9/2015
11 Dede Rohimah 0000463465337 Cilayung 7/9/2015 7/10/2015
12 Sumiati 0001838113749 Cileles 7/10/2015 7/10/2015
13 Yanti Permatasari 0000461739857 Hegarmanah 7/13/2015 7/13/2015
14 Ibah 0000462448416 Jatiroke 7/13/2015 7/13/2015
15 Nurul Khotimah 0001153453948 Cileunyi 7/17/2015 7/18/2015
16 Eli Pratiwi Dewi 0001519859711 Cibeusi 7/17/2015 7/18/2015
17 Asatika Intan 0001854072167 Mekargalih 7/20/2015 7/18/2015
18 Watini 0000462571299 Cileles 7/21/2015 7/22/2015

19 Wiwin Supriatin 0001518061702 Cikeruh 7/28/2015 7/29/2015
20 Tuti 0000463100229 Sayang 7/31/2015 7/31/2015
Jumlah
Terbilang : Tujuh Juta Delapan Ratus Tujuh Puluh Lima Ribu Rupiah
Mengetahui

NIP.19641030.200212.1.002
Agustus
Bulan : August 2015
Pelayanan : RITP
Tanggal Pelayanan
No Nama Pasien No Peserta Alamat No Hp. Tanggal
1 Mimin 0000462486363 Cileles 8/5/2015 8/5/2015
2 Atik Sopiah 0001517921818 Hegarmanah 8/5/2015 8/6/2015
3 Reni 0000461673472 Cipacing 8/6/2015 8/6/2015
4 Rifa Wulan Sari 0001852318282 Hegarmanah 8/8/2015 8/8/2015
5 Yulia Anggraeni 0001810505935 Cibeusi 8/8/2015 8/8/2015
6 Dedah 0000462752954 Cileles 8/8/2015 8/8/2015
7 Nia Yuniarti 0001008262855 Mekargalih 8/8/2015 8/9/2015
8 Teni 0000462483415 Sayang 8/8/2015 8/9/2015

9 Dahlia 0000462587793 8/12/2015 8/13/2015
Sayang
10 Neng Yeni 0001826325279 Cileles 8/15/2015 8/16/2015
11 Yuyun 0000461449675 Cileles 8/16/2015 8/17/2015
12 Sariamah 0001840332677 Cileles 8/16/2015 8/17/2015
13 Nurmala 0000201129748 Cileles 8/21/2015 8/22/2015
14 Susilawati 0000411597843 Cilayung 8/23/2015 8/23/2015
15 Lia 0000462893117 Cibeusi 8/24/2015 8/24/2015
16 Fitriyani 0001859650334 Hegarmanah 8/24/2015 8/25/2015
17 Apong 0000463318481 Cilayung 8/25/2015 8/25/2015
18 Dewi Sinta 0000461783294 Cipacing 8/25/2015 8/26/2015
19 Siti Sarah 0000460038238 Hegarmanah 8/29/2015 8/30/2015
20 Regina 0001800635027 Sayang 8/30/2015 8/31/2015
Jumlah
Terbilang : Delapan Juta Sembilan Ratus Lima Puluh Ribu Rupiah
Mengetahui

NIP.19641030.200212.1.002

Bulan : September 2015
Pelayanan : RITP
Tanggal Pelayanan
1 Wiwin Winengsih 0000462488508 Cilayung 9/1/2015 9/1/2015
2 Heni anggraeni 0001856263858 Cipacing 9/1/2015 9/1/2015
3 Norma Yuniasari 00004623248562 Tanjung Sari 9/1/2015 9/1/2015
4 Risa Noverawati 0001847656089 Tanjung Sari 9/1/2015 9/2/2015
5 Siti Sondari 0000461780133 Cibeusi 9/4/2015 9/4/2015
6 Wiwin Sumiati 0000462221572 Cipacing 9/7/2015 9/8/2015
7 Inda 0000461382445 Hegarmanah 9/11/2015 9/12/2015
8 Siti Saropah 0000462294112 Hegarmanah 9/14/2015 9/14/2015
9 Dina Nurhayati 0001133861332 Jatiroke 9/14/2015 9/15/2015

10 Tina Sudiana 0001855428153 Sayang 9/15/2015 9/16/2015
11 Aneng Nita 0001515437245 Sayang 9/15/2015 9/16/2015
12 Yati 0000462919454 9/18/2015 9/19/2015

Jatiroke
13 Mulyani 0000462818518 Cileles 9/20/2015 9/21/2015
14 Juju Jubaedah 0001314371259 Hegarmanah 9/22/2015 9/22/2015
15 Dede Hayati 0001807821279 Hegarmanah 9/23/2015 9/24/2015
16 Emil 0000461810968 Jatiroke 9/29/2015 9/30/2015
Jumlah
Terbilang : Delapan Juta Empat Ratus Tujuh Puluh Lima Ribu Rupia
Mengetahui

NIP.19641030.200212.1.002
susulan juni

Bulan : Juni (Susulan )
Pelayanan : RITP
Tanggal Pelayanan
1 Popon 0000461939293 Cileles 6/21/2015 6/22/2015
2 Mariah Mariani 0001803383188 Cipacing 6/23/2015 6/24/2015
3 Lala Nurlaelawati 0000462566136 Sayang 6/27/2015 6/28/2015
4 Dariri 0001008250391 Cipacing 6/28/2015 6/28/2015
Jumlah
Terbilang : Dua Juta Lima Ratus Lima Puluh Ribu Rupiah
Mengetahui

NIP.19641030.200212.1.002

Bulan : October 2015
Pelayanan : RITP
Tanggal Pelayanan
1 Mismawati 0000462462579 Cipacing 10/3/2015 9/1/2015
2 Rita Nurfarida 0001515447246 Sayang 10/4/2015 10/5/2015
3 Nita Nuraeni 0001661841213 Cintamulya 10/8/2015 10/10/2015
4 Rika Novianti 0001175816193 Cileles 10/11/2015 10/11/2015
5 Nina Sulastri 0001876685758 Cikeruh 10/11/2015 10/12/2015
6 Wardiningsih 0000462773619 Cileles 10/16/2015 10/17/2015

7 Ai Suryati 0000462459089 Cilayung 10/17/2015 10/18/2015
8 Sumiyati 0001660749175 Cipacing 10/18/2015 10/19/2015
9 Erlin 0001013277846 Ujung Berung 10/18/2015 10/18/2015
10 Sri Herlina 000185812501 Sayang 10/19/2015 10/19/2015
11 Tita Rosita 0001522055755 Hegarmanah 10/19/2015 10/20/2015
12 Fera Nurhayati 0001267533235 10/20/2015 10/20/2015

Jatiroke
13 Nuri E 0000462772765 Cilayung 10/20/2015 10/20/2015
14 Imas Sulastri 0001885707099 Jatiroke 10/21/2015 10/21/2015
15 Tikah Sartika 0001660108465 Sayang 10/21/2015 10/22/2015
16 Siti Nurjanah 0001892838969 Cibeusi 10/22/2015 10/22/2015
17 Tita Rosita 0001843324018 Cibeusi 10/23/2015 10/23/2015
18 Shinta bella 0001883381163 Hegarmanah 10/29/2015 10/30/2015
19 Muji Rahayu 00011362615575 Cipacing 10/30/2015 10/30/2015
Jumlah
Terbilang : Tujuh Juta Sembilan Ratus Lima Puluh Ribu Rupiah
Mengetahui

NIP.19641030.200212.1.002

Bulan : November 2015
Pelayanan : RITP
Tanggal Pelayanan
1 Hidayah W 0001884694667 Cimahi 10/31/2015 11/1/2015
2 Elin Hertiyanti 0000462616839 11/3/2015 11/3/2015

Cileles
3 Juhaeli 0001663047786 Hegarmanah 11/3/2015 11/4/2015
4 Yuli Yuara 0000462015483 Cilayung 11/4/2015 11/4/2015
5 Neng Deti Haryati 0001886595276 Sayang 11/5/2015 11/6/2015
6 Aneng 0000462499683 Jatiroke 11/8/2015 11/8/2015
7 Ai Nurhayati 0001008297494 Cilayung 11/8/2015 11/8/2015
8 Neni 0000462499863 Cilayung 11/9/2015 11/9/2015
9 Nenden Rohaeni 0001008279268 Hegarmanah 11/9/2015 11/10/2015
10 Rosami 0000462396802 Jatimukti 11/9/2015 11/10/2015
11 Titin Kartini 0000463296227 Cilayung 11/10/2015 11/11/2015
0001873126056 11/11/2015 11/12/2015

12 Elin Karlina Buah dua
0001797890512 Cileunyi 11/14/2015 11/15/2015
13 Teti Rohaeti
0001859714019 Rancaekek 11/14/2015 11/15/2015
14 Saleha
15 Ela laela sari 0000462323722 Kutamandiri 11/19/2015 11/20/2015
16 Nani Suryani 0000462207396 Cipacing 11/20/2015 11/20/2015
17 Ina 0000461982216 Cileles 11/22/2015 11/22/2015
18 Sugianti 0000460010373 Hegarmanah 11/24/2015 11/25/2015
19 Mimin Mainah 0000461857397 Cipacing 11/25/2015 11/25/2015
20 Dewi Astriyani 0001522053281 Cipacing 11/26/2015 11/27/2015
21 Sofi Siti Aisyah 0001664261864 Cikeruh 11/27/2015 11/28/2015
22 Rosmawati 0000462003974 Cilayung 11/28/2015 11/29/2015
23 Ani Mulyani 0001894436695 Cibeusi 11/28/2015 11/29/2015
Jumlah
Terbilang : Sepuluh Juta Tujuh Ratus Tujuh Puluh Lima Ribu Rupiah
Mengetahui

NIP.19641030.200212.1.002
Bulan : December 2015
Pelayanan : RITP
Tanggal Pelayanan
Tanggal
1 Rani 0000462622454 Sayang 12/2/2015 12/3/2015
2 Rosmini 0000462192085 12/7/2015 12/7/2015

Cipacing
3 Rodiah 0000462758501 Cilayung 12/7/2015 12/8/2015
4 Nurhayati Saadah 0001847188034 Hegarmanah 12/10/2015 12/10/2015
5 Cicih Kurniasih 0001523680953 Kramat Mulya 12/11/2015 12/12/2015
6 Heni N 0001107370282 Cikembar 12/13/2015 12/14/2015
7 Ratih Hasanah 0001522054631 Cileles 12/16/2015 12/17/2015
8 Nia Kurniasih 0000461840321 Jatiroke 12/18/2015 12/19/2015
9 Jejeh 0000463493439 Cilayung 12/20/2015 12/21/2015
10 Epi 0000462866883 Cilayung 12/25/2015 12/26/2015
11 Susi Susilawati 0000461800348 Hegarmanah 12/27/2015 12/28/2015
0000053204242 12/28/2015 12/29/2015

12 Surtini Hegarmanah
0000462722679 Cileles 12/28/2015 12/29/2015
13 Irna
Jumlah
Terbilang : Delapan Juta Tiga Ratus Lima Puluh Ribu Rupiah

Mengetahui

NIP.19641030.200212.1.002

Bulan : January 2016
Pelayanan : RITP
Tanggal Pelayanan
1 Rosnaeni 0000461857127 Jatimukti 1/6/2016 1/7/2016
2 Cucum 0001522838496 Cipacing 1/7/2016 1/7/2016
3 Amanah 0001522851175 Cileles 1/13/2016 1/14/2016
4 Dini 0000463289668 Cilayung 1/14/2016 1/15/2016
5 Laelasari 0000462456764 Hegarmanah 1/15/2016 1/16/2016
6 Eneng Entin 0000462866815 Tanjung Sari 1/16/2016 1/16/2016
7 Laela Eliana 0001008269223 Cisempur 1/18/2016 1/19/2016
8 Ai Rosmawati 0001522839172 Cileles 1/18/2016 1/19/2016
9 Yuli Yani 0001807025319 Cilayung 1/21/2016 1/21/2016

10 Nia Handayani 0001150588989 Cipacing 1/24/2016 1/25/2016
11 Ayu Siti Islami 0001655802516 Cipacing 1/26/2016 1/27/2016
12 Kulvia Serreri 0001184220775 Cipacing 1/28/2016 1/29/2016
13 Mia Oktaviani 0000461733974 Cibeusi 1/29/2016 1/30/2016
14 Ida Nurlaela 0001478229693 Cileles 1/29/2016 1/30/2016
15 Santi Susanti 0001857608954 Cibeusi 1/30/2016 1/30/2016
Jumlah
Terbilang : Tujuh Juta Dua Ratus Lima Puluh Ribu Rupiah

Mengetahui

NIP.19641030.200212.1.002

Bulan : February 2016
Pelayanan : RITP
Tanggal Pelayanan
1 Dewi Sumarni 0001882464836 Cipacing 2/1/2016 2/1/2016
2 Iis Kurniawati 0000462357292 2/2/2016 2/2/2016

Sayang
3 Eni Rohaeni 0000461727617 Hegarmanah 2/4/2016 2/4/2016

4 Lina 0000460003296 Hegarmanah 2/6/2016 2/6/2016
5 Erni Rosidah 0001522054203 Jatiroke 2/10/2016 2/10/2016
6 Diana Nursaadah 0000462754078 Cipacing 2/11/2016 2/12/2016
7 Eti Rohaeti 0000462045734 Cilayung 2/13/2016 2/13/2016
8 Risma Yanti 0000462379937 Sayang 2/15/2016 2/15/2016
9 Surya Purnamasari 0000459987221 Hegarmanah 2/15/2016 2/16/2016
10 Elis Lisnawati 0000461437312 Cileles 2/15/2016 2/16/2016
11 Erni Rohaeni 0001719265937 Cipacing 2/16/2016 2/17/2016
12 Nining Maida 0001278202994 Cipacing 2/16/2016 2/17/2016
13 Lina Herlina 0000462535907 2/17/2016 2/17/2016

Cileles
14 Rini Mulyani 0000462836975 Hegarmanah 2/23/2016 2/23/2016
15 Rosminar 0001003484441 Cikeruh 2/24/2016 2/24/2016
16 Wiwi Widaningsih 0001792139297 Cinta mulya 2/25/2016 2/26/2016
17 Diah 0001008276219 Cilayung 2/25/2016 2/29/2016
18 Euis 0000058118624 Jatiroke 2/26/2016 2/26/2016
19 Hermawati 0001517903763 Hegarmanah 2/26/2016 2/27/2016
20 Erosmini 0000462066524 Cipacing 2/27/2016 2/27/2016
21 Ilmayasari 0000461718235 Sukasari 2/28/2016 2/28/2016
22 Sri Kiky Limawan 0001660150192 Cileles 2/28/2016 2/29/2016
23 Diana 0001008251436 Cipacing 2/27/2016 2/27/2016
24 Alni Marlinda 0001008279663 Hegarmanah 2/29/2016 2/29/2016
Jumlah
Terbilang : Sepuluh juta Tujuh Puluh Lima Ribu Rupiah
Mengetahui

NIP.19641030.200212.1.002

Bulan : March 2016
Pelayanan : RITP
Tanggal Pelayanan
1 Erni S 0000064872865 Sayang 3/1/2016 3/2/2016
2 Nining 0000462599695 Cileles 3/2/2016 3/2/2016
3 Ai Widiyani 0000462859817 Cileles 3/3/2016 3/4/2016
4 Della Dwi A 0001277129171 Cipacing 3/4/2016 3/4/2016
5 Kety Agianti 0001522847092 Jatiroke 3/6/2016 3/7/2016
6 Eti Sumiati 0000462427931 Cintamulya 3/10/2016 3/10/2016
7 Ade Partini 0000463196305 Cipacing 3/10/2016 3/10/2016
8 Mia Kusmiati 0001907817118 Cilayung 3/15/2016 3/16/2016
9 Aah 0000461395451 Cilayung 3/16/2016 3/17/2016
10 Siti Julaeha 0000462631847 Cileles 3/16/2016 3/17/2016
11 Dewi Purnamasari 0001008280102 Hegarmanah 3/16/2016 3/17/2016
12 Nena 0001969748583 Hegarmanah 3/21/2016 3/21/2016
13 Siti Amelia Y 0000462928689 Hegarmanah 3/25/2016 3/26/2016

14 Teti Herawati 0001147483181 Hegarmanah 3/25/2016 3/26/2016
15 Nani Sumarni 0001964571603 Cileles 3/28/2016 3/29/2016
16 Hindun K 0002041290415 Hegarmanah 3/30/2016 3/31/2016
Jumlah
Terbilang : Tujuh juta Tiga Ratus Tujuh Puluh Lima Ribu Rupiah
Mengetahui

NIP.19641030.200212.1.002

Bulan : Desember 2015 (Susulan)
Pelayanan : RITP
Tanggal Pelayanan
Tanggal
1 Risma Dewi 0000065476282 Cikeruh 12/30/2015 1/1/2016
2 Oneng R 0001515438044 12/31/2015 1/1/2016

Cipacing
Jumlah
Terbilang : Satu Juta Dua Ratus Ribu Rupiah
Mengetahui

NIP.19641030.200212.1.002
REKAPITULASI KLAIM KEBIDANAN DAN NEONATAL JAMINAN KESEHATAN NASION
Bulan : April 2016
Pelayanan : RITP
Tanggal Pelayanan
Pulang
1 Siska 0000461967096 Cibeusi 4/3/2016 4/4/2016
2 Neng Susi 0001666739248 Cileles 4/5/2016 4/5/2016
3 Siti Murni 0000164687736 Cileles 4/6/2016 4/6/2016
4 Tuti Widiastuti 0000462640329 Cibeusi 4/7/2016 4/7/2016
5 Putri Ayu Nimgsih 0000462759142 Cikeruh 4/8/2016 4/9/2016
6 Yulianti 0002045335454 Cibeusi 4/10/2016 4/11/2016
7 Leni 0000462368193 Sayang 4/12/2016 4/12/2016
8 Lia Susilawati 0000462006628 Cileles 4/12/2016 4/13/2016
9 Nining 0000462799078 Cileles 4/12/2016 4/13/2016
10 Neng Kartini 0002033823892 Cintamulya 4/13/2016 4/13/2016
11 Nunung 0000462442836 Hegarmanah 4/13/2016 4/14/2016

12 Yanti Sukamto 0001286905004 Jatiroke 4/18/2016 4/19/2016
13 Suryani 0001008257657 Sayang 4/19/2016 4/19/2016
14 Mita A 0001006279156 Hegarmanah 4/19/2016 4/19/2016
15 Euis Wawang 0000462631779 Cileles 4/19/2016 4/20/2016
16 Ipah 0000462615052 Cileles 4/20/2016 4/21/2016
17 Lina Maryani 0000462950188 Jatimukti 4/21/2016 4/22/2016
18 Erosmini 0000462066524 Cipacing 4/22/2016 4/22/2016
19 Ecin 0000460105187 Hegarmanah 4/25/2016 4/25/2016
Jumlah
Terbilang : Delapan Juta Lima Puluh Ribu Rupiah
Mengetahui

NIP.19641030.200212.1.002

Bulan : May 2016
Pelayanan : RITP
Tanggal Pelayanan
Pulang
1 Jujun 0000461810711 Cilayung 5/3/2016 5/2/2016
2 Nuraisyah 0001426193324 Cipacing 5/5/2016 5/5/2016
3 Siti 0000462440171 Hegarmanah 5/6/2016 5/7/2016
4 Waryati 0000462665878 Jatiroke 5/10/2016 5/10/2016
5 Omah Romlah 0001389100634 Hegarmanah 5/12/2016 5/13/2016
6 Cucu Kurnia 0000461737697 Cibeusi 5/13/2016 5/14/2016
7 Rika 0000462866038 Cileles 5/14/2016 5/15/2016
8 Anis 0000461834897 Cilayung 5/15/2016 5/16/2016
9 Dade Widiawati 0001664657616 Tanjung sari 5/16/2016 5/17/2016
10 Resi D 0002050592602 Cileunyi 5/17/2016 5/17/2016
11 Ika Kartika 0001523632667 Sayang 5/17/2016 5/18/2016
12 Maryani 0000462609641 Sayang 5/19/2016 5/20/2016
13 Ita Apriyanti 0001666339964 Sayang 5/21/2016 5/22/2016
14 Lela H 0001521422346 Cikeruh 5/23/2016 5/24/2016
15 Ajijah 0000461863146 Mekargalih 5/24/2016 5/25/2016
16 Rina A 000166394926 Cipacing 5/24/2016 5/24/2016
17 Susi S 0001650248572 Sukasari 5/25/2016 5/26/2016
18 Nurhaeti 0000462634931 Cileles 5/27/2016 5/27/2016
19 Cahyati 0000462598846 Cileles 5/26/2016 5/28/2016
20 Eri Koriah 0000418480244 Cileunyi 5/28/2016 5/29/2016
21 Raisa 0000065650566 Cileles 5/28/2016 5/29/2016
22 Een 0000462404687 Hegarmanah 5/28/2016 5/29/2016
23 Nina Marlina 0001667153981 Cintamulya 5/29/2016 5/30/2016
24 Denis 0001664666381 Cipacing 5/30/2016 5/30/2016

25 Nunung 0001662565623 Cipacing 5/30/2016 5/31/2016
Jumlah
Terbilang : Lima Belas Juta Seratus Dua Puluh Lima Ribu Rupiah
Mengetahui

NIP.19641030.200212.1.002

Bulan : June 2016
Pelayanan : RITP
Tanggal Pelayanan
Pulang
1 Tuti 0001008250839 Cipacing 6/1/2016 6/2/2016
2 Tita Puspita 0001895154693 Cipacing 6/2/2016 6/3/2016
3 Uun Rostati 0001522342236 Sayang 6/3/2016 6/3/2016
4 Fitri 0000461356784 Hegarmanah 6/3/2016 6/3/2016
5 Enah Supianah 0000461943077 Cibeusi 6/4/2016 6/4/2016
6 Yeyen Asriani 0001441609885 Sindang Sari 09/06/20169 6/10/2016
7 Yati 0000462442667 Cileles 6/10/2016 6/10/2016
8 Aat Gina 0002057514928 Cileles 6/10/2016 6/10/2016
9 Siska Meilani 0002053435792 Jatiroke 6/11/2016 6/11/2016
10 Widia Kamelia 0000462672933 Cibeusi 6/12/2016 6/12/2016
11 Suci Alawiyah 0001515164242 Cihampelas 6/13/2016 6/14/2016

12 Rina 0000462136329 Jatiroke 6/13/2016 6/14/2016
13 Komalasari 0001721246725 Cibeusi 6/14/2016 6/15/2016
14 Rita Gustiana 0000462243172 Cipacing 6/14/2016 6/15/2016
15 Rati 0000462011984 Cisempur 6/15/2016 6/15/2016
16 Ade Julaeha 0001008283059 Hegarmanah 6/15/2016 6/16/2016
17 Ida Ningsih 0002059135784 Cipacing 6/16/2016 6/16/2016
18 Wina Setiawati 0001798832259 Hegarmanah 6/17/2016 6/18/2016
19 Cucu Sumiati 0001008283048 Hegarmanah 6/19/2016 6/19/2016
20 Iyah supianah 0000462725302 Cipacing 6/25/2016 6/25/2016
21 Oot 0000461814142 Cilayung 6/27/2016 6/27/2016
22 Maemunah 000050097066 Jatiroke 6/28/2016 6/28/2016
23 Lilis 0001666066511 Jatimukti 6/30/2016 7/1/2016
Jumlah
Terbilang : Sembilan Juta Tiga Ratus Lima Puluh Ribu Rupiah

Mengetahui

NIP.19641030.200212.1.002

Bulan : July 2016
Pelayanan : RITP
Tanggal Pelayanan
Tanggal Masuk
Pulang
1 Iyah Sobariah 0000461759139 Cibeusi 7/2/2016 7/3/2016
2 Fitri 0002064430956 Cipacing 7/2/2016 7/3/2016
3 Teni 0000461980539 Cilayung 7/4/2016 7/4/2016
4 Sri Sukoweni 0001669098385 Cibeusi 7/5/2016 7/5/2016

5 Nita Purnamasari 0001766001723 Cipacing 7/7/2016 7/8/2016
6 Desy Mulyanti 0000148114629 Hegarmanah 7/11/2016 7/12/2016
7 Yati Juarsih 0001008257398 Sayang 7/12/2016 7/13/2016
8 Mira Supriyati 0000463807034 Cilayung 7/16/2016 7/16/2016
9 Yuli Yuliasari 0001008257602 Sayang 7/21/2016 7/22/2016
10 Entin Suartini 0001523669927 Jatiroke 7/21/2016 7/22/2016
11 Siti 0000461685339 Cipacing 7/22/2016 7/23/2016
12 Sari Lestari 0000461898494 Cileles 7/24/2016 7/24/2016
13 Awang Suhayati 0001519383699 Cikeruh 7/25/2016 7/25/2016
14 Ruri Rosmawati 0001008269943 Cisempur 7/25/2016 7/26/2016
15 Irni Nuraeni 0001405492659 Hegarmanah 7/30/2016 7/31/2016
Jumlah
Terbilang : Tujuh Juta Tujuh Ratus Dua Puluh Lima Ribu Rupiah
Mengetahui

NIP.19641030.200212.1.002
Bulan : August 2016
Pelayanan : RITP
Tanggal Pelayanan
Pulang
1 Iis Kurniawati 0000462357297 Sayang 8/1/2016 8/2/2016
2 Iis Hasanah 0001522850589 Hegarmanah 8/2/2016 8/3/2016
3 Nita Novianti 0002061738584 Cileles 8/6/2016 8/7/2016
4 Tuti Aisah 0002049760877 Pasigaran 8/7/2016 8/8/2016
5 Reni Sri Juliani 0001008256408 Sayang 8/8/2016 8/9/2016
6 Selvi 0001997603469 Cileles 8/8/2016 8/9/2016
7 Enden Yulianti 0001008258309 Sayang 8/8/2016 8/9/2016
8 Rienova Dheanty 0001665815308 Cinanjung 8/10/2016 8/11/2016
9 Meli Fitria 0002038782284 Cibeusi 8/11/2016 8/12/2016
10 Ida Farida 0000462306306 Hegarmanah 8/12/2016 8/13/2016
11 Yuni Ambarwati 0002065994335 Pagaden 8/13/2016 8/14/2016
12 Andalis 0002072146105 Cipacing 8/15/2016 8/16/2016
13 Santika 0000462187405 Cipacing 8/21/2016 8/23/2016

14 Sentri damiyati 0001008283454 Sayang 8/21/2016 8/22/2016
15 Rupita Heryani 0000462529326 Sayang 8/22/2016 8/23/2016
16 Dahlia 0001787583969 Cipacing 8/24/2016 8/25/2016
17 Nia Kurniawati 0002053960918 Hegarmanah 8/24/2016 8/24/2016
18 Fitria Anggraeni 0000462840524 Cileles 8/25/2016 8/26/2016
19 Epi Hari Septiani 0001514873799 Cipacing 8/26/2016 8/27/2016
20 Eni Rohaeni 0001153514878 Cipacing 8/27/2016 8/28/2016
21 Ani 0000462083815 Cilayung 8/30/2016 8/31/2016
22 Nia Karniati 0000463314161 Cilayung 8/31/2016 8/31/2016
Jumlah
Terbilang : Dua Belas Juta Tujuh Ratus Ribu Rupiah

Mengetahui

NIP.19641030.200212.1.002
Pelayanan : RITP
Tanggal Pelayanan
Pulang
1 Yunengsih 0000462757239 Cilayung 9/3/2016 9/3/2016
2 Ade Sri Dianti 0000462052304 Cilayung 9/3/2016 9/4/2016
3 Eti Sumiati 000046182695 Hegarmanah 9/4/2016 9/5/2016
4 Lina Yulianti 0001997450897 Hegarmanah 9/5/2016 9/6/2016
5 Puja Mayang sari 0000462743436 Cipacing 9/8/2016 9/8/2016

6 Imas Kartika 0000461917585 Hegarmanah 9/9/2016 9/10/2016
7 Nina Herlina 0000504216099 Cileles 9/10/2016 9/11/2016
8 Dewi Widiawati 0001857617515 Cipacing 9/10/2016 9/11/2016
9 Dwi Pratiwi A 0002071447716 Cikeruh 9/11/2016 9/12/2016
10 Santi 0000462816573 Cileles 9/14/2016 9/14/2016
11 Ika Kartika 0002060127898 Hegarmanah 9/14/2016 9/14/2016
12 Tika Rahayu 0001669412158 Cilayung 9/15/2016 9/16/2016
13 Siti Aisyah 0000461781584 Cilayung 9/18/2016 9/19/2016
14 Nunung 000046284417 Cileles 9/18/2016 9/19/2016
15 Lilik S 0001008294309 Cileles 9/20/2016 9/21/2016
16 Devi Nurlaelasari 0001008294761 Cilayung 9/21/2016 9/21/2016
17 Ina 0000461962484 Cikeruh 9/21/2016 9/22/2016
18 Irma Triana 0000461903444 Cikeruh 9/23/2016 9/24/2016
19 Siti Nuraisyah 0000461917361 Cileles 9/24/2016 9/24/2016
20 Dewi M 0001723207476 Cikeruh 9/24/2016 9/25/2016
21 Ela Herawati 0001771143726 Cipacing 9/26/2016 9/27/2016
Jumlah
Terbilang : Sembilan Juta Tujuh Lima Puluh Ribu Rupiah

Mengetahui

NIP.19641030.200212.1.002
Bulan N
: October 2016
o
Pelayanan :P RITP
e Tanggal
No Nama Pasien Alamat No Hp.
s Pelayanan
e
r Tanggal Masuk Tanggal
t Pulang
a
1 Wili Mega A 0002057339687 Cilayung 10/1/2016 10/2/2016
2 Lisna 0002076922326 Cileles 10/6/2016 10/6/2016
3 Parini 0001669413047 Cicalengka 10/8/2016 10/8/2016
4 Susi 0000462563638 Sayang 10/10/2016 10/10/2016
5 Erni Susanti 0001008280629 Hegarmanah 10/12/2016 10/13/2016
6 Shinta Maelina 0001450515508 Cikeruh 10/14/2016 10/15/2016
7 Neng Sri 0002071024277 Cipacing 10/14/2016 10/15/2016
8 Ratna 0000461730701 Cipacing 10/17/2016 10/17/2016
9 Yeni anggraeni 0001522055575 Cileunyi 10/20/2016 10/20/2016
10 Juju 000046063172 Cilayung 10/21/2016 10/21/2016
11 Mimin 0000461701585 Cipacing 10/21/2016 10/21/2016
12 Siti Saniah 0000462825887 Cileles 10/21/2016 10/22/2016
13 Omah 0000463839941 Cileles 10/24/2016 10/24/2016
14 Leni Rosliani 0001316630709 Cipacing 10/24/2016 10/25/2016
15 Yeyet 0001522838711 Cilayung 10/24/2016 10/25/2016
16 Nurkhasanah 0002085203362 Hegarmanah 10/24/2016 10/25/2016
17 Nina 0001661393924 Cileles 10/26/2016 10/27/2016

18 suranti 0002093286464 Cipacing 10/28/2016 10/28/2016
19 Mirawati 0000461910082 Cibeusi 10/29/2016 10/30/2016
20 Oka Meriana 0001392947302 Sayang 10/30/2016 10/31/2016
Jumlah
Terbilang : Sepuluh Juta Delapan Ratus Lima Puluh Ribu Rupiah

Mengetahui
uskesmas DTP Jatinangor
Haris Fatah Kristofa

641030.200212.1.002
Bulan N
: October 2016
o
Pelayanan :P RITP
e Tanggal
No Nama Pasien Alamat No Hp.
s Pelayanan
e
r Tanggal Masuk Tanggal
t Pulang
a
1 Wili Mega A 0002057339687 Cilayung 10/1/2016 10/2/2016
2 Lisna 0002076922326 Cileles 10/6/2016 10/6/2016
3 Parini 0001669413047 Cicalengka 10/8/2016 10/8/2016
4 Susi 0000462563638 Sayang 10/10/2016 10/10/2016
5 Erni Susanti 0001008280629 Hegarmanah 10/12/2016 10/13/2016
6 Shinta Maelina 0001450515508 Cikeruh 10/14/2016 10/15/2016
7 Neng Sri 0002071024277 Cipacing 10/14/2016 10/15/2016
8 Ratna 0000461730701 Cipacing 10/17/2016 10/17/2016
9 Yeni anggraeni 0001522055575 Cileunyi 10/20/2016 10/20/2016

10 Juju 000046063172 Cilayung 10/21/2016 10/21/2016
11 Mimin 0000461701585 Cipacing 10/21/2016 10/21/2016
12 Siti Saniah 0000462825887 Cileles 10/21/2016 10/22/2016
13 Omah 0000463839941 Cileles 10/24/2016 10/24/2016
14 Leni Rosliani 0001316630709 Cipacing 10/24/2016 10/25/2016
15 Yeyet 0001522838711 Cilayung 10/24/2016 10/25/2016
16 Nurkhasanah 0002085203362 Hegarmanah 10/24/2016 10/25/2016
Jumlah
Terbilang : Delapan Juta Tujuh Ratus Tujuh Puluh Lima Ribu Rupia
Mengetahui
Haris Fatah Kristofa

641030.200212.1.002
UNTUK OKTOBER SISA
NOPEMBER DIBAWAH
Pelayanan : RITP
Tanggal Pelayanan
Tanggal Masuk
Pulang
1 Cucu 0000462724929 Cileles 1-Nov-2016 2-Aug-2016
2 Junaripah 0001522340008 Jatimukti 2-Nov-2016 3-Nov-2016
3 Anti Sunarti 0000461644277 Cibeusi 3-Nov-2016 3-Nov-2016
4 Yulianti 0000462826034 Jatiroke 4-Nov-2016 5-Nov-2016
5 Yayah 0000461616129 Cilayung 5-Nov-2016 5-Nov-2016

6 Siti Nurjanah 0000463378116 Cilayung 5-Nov-2016 6-Nov-2016
7 Mira Maria Ulfah 0000462375707 Hegarmanah 6-Nov-2016 7-Nov-2016
8 Sri Monita 0000461962304 Cibeusi 9-Nov-2016 10-Nov-2016
9 Sona Soniasih 0000459987399 Hegarmanah 9-Nov-2016 10-Nov-2016
10 Siti Nurhasanah 0001803919432 CilelesH 14-Nov-2016 14-Nov-2016
11 Rini Yulyaningsih 0001997563678 Hegarmanah 16-Nov-16 17-Nov-16
12 Anggi 0002086490147 Cileles 16-Nov-16 17-Nov-16
13 Mimin 0001008298989 Cilayung 17-Nov-16 18-Nov-16
14 Yani 0000462736405 Cipacing 19-Nov-16 20-Nov-16
15 Ira 0001852601769 Cikeruh 19-Nov-16 21-Nov-16
16 Intan 0001670525638 Cikeruh 23-Nov-16 24-Nov-16
17 Euis Santika 0002064918914 Cisempur 23-Nov-16 24-Nov-16
18 Amanah 0000462067828 Cilayung 29-Nov-16 29-Nov-16
Jumlah
Terbilang : Delapan Juta Lima Ratus Tujuh Puluh Lima Ribu Rupiah
Mengetahui

NIP.19641030.200212.1.002
Pelayanan : RITP
Tanggal Pelayanan
Pulang
1 Tita 0000462443444 Cilayung 2/12/2016 3/12/2016
2 Siti Nurhaeni 0001666061684 Cileles 5/12/2016 6/12/2016
3 Ika Kartika 0000462868525 Jatiroke 6/12/2016 6/12/2016
4 Sri Rohmah 0000461975264 Cipacing 7/12/2016 7/12/2016
5 Komala 0000461859985 Cilayung 8/12/2016 9/12/2016
6 Ihat 0000461761661 Cilayung 11/12/2016 12/12/2016
7 Imas Mulyani 0001008286029 Cibeusi 11/12/2016 12/12/2016
8 Jubaedah 0000462073296 Cilayung 13/12/2016 14/12/2016
9 Rahmawati 0001008251021 Cipacing 17/12/2016 18/12/2016
10 Ernawati 0002202291707 Cilayung 17/12/2016 18/12/2016
11 Rita 0000462011409 Jatiroke 18/12/2016 18/12/2016
12 oon Rini 0001997550099 Hegarmanah 20/12/2016 21/12/2016
13 Tia Sintia 0001008261674 Mekargalih 23/12/2016 23/12/2016
14 Susan Kristina 0001997168297 Sayang 24/12/2016 25/12/2016
15 Rika santika 0001008295378 Cilayung 25/12/2016 26/12/2016
16 Rini Encaswati 0001008298912 Cilayung 26/12/2016 27/12/2016
17 Ineu Mulyaharti 0001008287335 Cibeusi 27/12/2016 27/12/2016

18 Ilah Karmilah 0000065444365 Cileles 28/12/2016 29/12/2016
19 Lela Suryamah 0000461861065 Hegarmanah 29/12/2016 29/12/2016
20 Een 0002196171213 Hegarmanah 30/12/2016 30/12/2016
Jumlah
Terbilang : Sembilan JutaTujuh Ratus Tujuh Puluh Lima Ribu Rupia

Mengetahui

NIP.19641030.200212.1.002
9 Yati Suryati 0001631504902Cipacing 14/12/2016
tahun 2017
Pelayanan : RITP
Tanggal Pelayanan
Pulang
1 Epi Supini 0001997445442 Hegarmanah 1/1/2017 1/1/2017
2 Sri Mulyasari 0001522831419 Cipacing 1/1/2017 2/1/2017
3 Sri Kurniati 0001670728151 Cileles 3/1/2017 3/1/2017
4 Dede Wawang 0000461482075 Cileles 3/1/2017 4/1/2017
5 Sri Suciyati 0002207957692 Hegarmanah 6/1/2017 7/1/2017

6 Lina Riswanti 0002211385612 Hegarmanah 6/1/2017 7/1/2017
7 Fitri Wulansari 0002198833964 Cikeruh 11/1/2017 11/1/2017
8 Rini Fitriyani 0000419432297 Cileles 11/1/2017 12/1/2017
9 Nurul Hotimah 0000462821016 Cilayung 15/1/2017 16/1/2017
10 Sayati 0000461681695 Cilayung 16/1/2017 17/1/2017
11 Nuri E 0000462772765 Cilayung 16/1/2017 17/1/2017
12 Nurhayati S 0001286906894 Hegarmanah 17/1/2017 18/1/2017
13 Rosita 0000462378205 jatimukti 18/1/2017 18/1/2017
14 Kokom Komala 0000463587208 Sayang 18/1/2017 19/1/2017
15 dewi Herliana S 0001155408074 Cipacing 20/1/2017 21/1/2017
16 Lilis Muslimawati 0002194853703 Cilayung 20/1/2017 21/1/2017
17 Yani Maryani 00001523674574 Cilayung 21/1/2017 22/1/2017
18 Rini Mulyani 0000462836979 Hegarmanah 22/1/2017 23/1/2017
19 Irma Sari 0000462666521 Cileles 23/1/2017 23/1/2017
20 Lina Rusliana 0001473827185 jatimukti 23/1/2017 24/1/2017
21 Dewi Mulyani 0000461756878 Cileles 26/1/2017 27/1/2017
22 Cicih Nursari 0001666248333 Cikeruh 28/1/2017 29/1/2017
23 Aliah 0000461874668 Cintamulya 31/1/2017 31/1/2017
20 Yani Siti M 0000461358505 Hegarmanah 31/1/2017 1/2/2017

Jumlah
Terbilang : Tiga Belas Juta Delapan Ratus Lima Puluh Ribu Rupiah
Mengetahui

NIP.19641030.200212.1.002
Pelayanan : RITP
Tanggal Pelayanan
Pulang
1 Susi Winarti 002199688224 Cipacing 31/1/2017 1/2/2017
2 Susanti 0001997619028 Hegarmanah 3/2/2017 3/2/2017

3 Fitri Wijayanti 0001405492075 Cipacing 3/2/2017 4/2/2017
4 Mirna Juliani 0000462190353 Cipacing 5/2/2017 5/2/2017
5 Suryati 0001997368358 Jatiroke 6/2/2017 6/2/2017
6 Santi Januaristi 0001522845257 Cibeusi 9/2/2017 9/2/2017
7 Selli Pebriati 0001008288022 Cileles 13/2/2017 14/2/2017
8 Rina 0000461734323 Hegarmanah 16/2/2017 18/2/2017
9 Rohimah 0002085956065 Cileles 17/2/2017 18/2/2017
10 Herlina 0000462083679 Cilayung 20/2/2017 20/2/2017
11 Ade Mariah 0001008295705 Cilayung 20/2/2017 21/2/2017
12 Tarmilah 0000461861831 Cilayung 23/2/2017 24/2/2017
13 Aan Siti Fatimah 0000462556596 Jatiroke 27/2/2017 28/2/2017
Jumlah
Terbilang : Lima Juta sembilan Ratus Ribu Rupiah

Mengetahui

NIP.19641030.200212.1.002
Bulan : March 2017
Pelayanan : RITP
Tanggal Pelayanan
Tanggal Masuk
Pulang
1 Nia kurnia 0000461907369 Mekargalih 2/3/2017 3/3/2017
2 Desi 0000504655582 Hegarmanah 4/3/2017 4/3/2017
3 kokom 0000461799437 Hegarmanah 8/3/2017 8/3/2017
4 Tuti Jamilah 0000461687883 Cileles 9/3/2017 9/3/2017
5 Dewi Purnama 0000461459632 Cileles 9/3/2017 9/3/2017
6 Rusdiana 0001008281204 Hegarmanah 13/3/2017 13/3/2017
7 Wiwi kartiwi 0000462544863 Sayang 13/3/2017 14/3/2017
8 Irma 0000428811041 Cilayung 16/3/2017 16/3/2017
9 El mariani Purba 0002219947582 Cinta Mulya 18/3/2017 19/3/2017
10 Irah 0000461991475 Cipacing 24/3/2017 24/3/2017
11 Evi novianti 0000462847476 Cikeruh 24/3/2017 24/3/2017
12 Rita anggraeni 0001279415924 Cipacing 24/3/2017 24/3/2017

13 Leni 0001287202803 Cileles 24/3/2017 25/3/2017
14 Lilis setiawati 000064989369 Cisempur 25/3/2017 25/3/2017
15 Sari 0000461981608 Cipacing 26/3/2017 27/3/2017
16 Ima srie R 0000458818233 Cikeruh 29/3/2017 29/3/2017
17 Sri 0001147826031 Solokan Jeruk 29/3/2017 29/3/2017
18 Lia 0000462038141 Cikeruh 29/3/2017 30/3/2017
19 Ani 0001008290878 Cikeruh 29/3/2017 30/3/2017
20 Dinaryani 0000461345409 Hegarmanah 29/3/2017 30/3/2017
Jumlah
Terbilang : Delapan Juta Dua Ratus Ribu Rupiah
Mengetahui

NIP.19641030.200212.1.002

Bulan : April
Pelayanan : RITP
Tanggal Pelayanan

Pulang
1 Sri Wahyuni 0002225890721 Cileles 2/4/2017 2/4/2017
2 Lilis Kusmawati 0000208426487 Cileles 3/4/2017 4/4/2017
3 Enur 0000431881828 Sukabakti 4/4/2017 5/4/2017
4 Euis Tita Mulyati 000046259987 Cileles 4/4/2017 4/4/2017
5 Nena Rosmayati 0002229128954 Mekargalih 4/4/2017 4/4/2017
6 Yati Suryati 0000462496105 Hegarmanah 5/4/2017 6/4/2017
7 Ening Rostini 0001981970807 Sayang 7/4/2017 8/4/2017

8 Karlina P 0001397589704 Cileles 7/4/2017 7/4/2017
9 Sri Mulyani 0000461345409 Hegarmanah 7/4/2017 9/4/2017
10 Erni Anggraeni 0000462266875 Hegarmanah 8/4/2017 8/4/2017
11 Wiwin Widiawati 0000462667961 Sayang 9/4/2017 9/4/2017
12 Ai Jariah 0000462355525 Jatimukti 10/4/2017 11/4/2017
13 Arti Indriani 0000415003252 Cipacing 11/4/2017 12/4/2017
14 Ratna 0000461926383 Cipacing 11/4/2017 12/4/2017
15 Teti Rosmini 0000462291524 Hegarmanah 12/4/2017 12/4/2017
16 Hernawati 0001515439427 Cipacing 12/4/2017 12/4/2017
17 Casrini 0001283940369 Cinta Mulya 16/4/2017 16/4/2017
18 Ente Sunarti 0001008284005 Cikeruh 16/4/2017 16/4/2017
19 Kokom Komasih 0000461799437 Hegarmanah 16/4/2017 16/4/2017
20 Teti Rohaeti 0001635127165 Cipacing 17/4/2017 17/4/2017
21 Dede Irmala 0000461790606 Cipacing 18/4/2017 18/4/2017
22 Eli Megawati 0001522055283 Cileles 19/4/2017 19/4/2017
23 Dedah 0000462407422 Jatimukti 19/4/2017 20/4/2017
24 Iip Latipah 0000463561604 Cileles 24/4/2017 25/4/2017

25 Siti Rohayati 0001008291734 Cileles 27/4/2017 28/4/2017
26 Iin Lisna M 0001520832576 Cipacing 27/4/2017 27/4/2017
27 Wawa Solihat 0000462382042 Cileles 29/4/2017 29/4/2017
Jumlah
Terbilang : Tiga Belas Juta Seratus Lima Puluh Ribu Rupiah

Mengetahui

NIP.19641030.200212.1.002

Bulan : MEI 2017
Pelayanan : RITP
Tanggal Pelayanan
Tanggal Masuk
Pulang
1 Santi 0000462262961 Mekargalih 2/5/2017 2/5/2017
2 Tati R 0002214327903 Cisempur 3/5/2017 3/5/2017
3 Nurlaelasari 0000463065941 Margajaya 3/5/2017 4/5/2017
4 Ai Hasanah 0001776306982 Hegarmanah 5/5/2017 6/5/2017
5 Enur Supriyati 0000462807077 Cikeruh 5/5/2017 6/5/2017
6 Eri Herdiati 0000461733445 Hegarmanah 5/5/2017 6/5/2017
7 Idah Paridah 0000463579751 Sayang 6/5/2017 7/5/2017
8 Dede Maemunah 0001443516311 Mekargalih 7/5/2017 7/5/2017

9 Devi R 0000065151573 Hegarmanah 7/5/2017 8/5/2017
10 Lilis Sumiati 0000461961156 Cikeruh 8/5/2017 9/5/2017
11 Dhewi Handayani 0002205703271 Cimanggung 10/5/2017 11/5/2017
12 Siti Annisa 0000463405926 Cilayung 13/5/2017 13/5/2017
13 Ika Rohimah 0000463337583 Cilayung 15/5/2017 15/5/2017
14 Nurhasarah 0001777839208 Cilayung 19/5/2017 20/5/2017
15 Winda Oktavia 0000058012075 Cileles 19/5/2017 19/5/2017
16 Dian Kusmiati 0001663047731 Cinta Mulya 21/5/2017 21/5/2017
17 Yayah Rokayah 0000461755449 Cibeusi 21/5/2017 21/5/2017
18 Arti Juhana 0001008255025 Cipacing 21/5/2017 22/5/2017
19 Srina 0000462037498 Cisempur 23/5/2017 23/5/2017
20 Sriyani 0000462083578 Cilayung 23/5/2017 23/5/2017
21 Vovi Sopiah 0000462137332 Cipacing 24/5/2017 25/5/2017
22 Nani Handayani 000166409769 Mekargalih 26/5/2017 26/5/2017
23 Toinah Ningsih 0002217186639 Cisempur 27/5/2017 28/5/2017
24 Susanti 0000461671288 Cibeusi 29/5/2017 31/5/2017
25 Juju Juariah 0001997568246 Cisempur 31/5/2017 30/5/2017
Jumlah
Terbilang : Tiga Belas Juta Tujuh Ratus Dua Puluh Lima Ribu Rupia
Mengetahui
Kepala Puskesmas Rawat Inap Jatinangor

NIP.19641030.200212.1.002

Bulan : MEI 2017 (SUSULAN )
Pelayanan : RITP
Tanggal Pelayanan
Tanggal Masuk
Pulang
1 Dewi Pujawati 0002242637425 Cibeusi 13/5/2017 14/5/2017
Jumlah
Terbilang : Tujuh Ratus Ribu Rupiah

Mengetahui

NIP.19641030.200212.1.002

Bulan : JUNI 2017
Pelayanan : RITP
Tanggal Pelayanan
Tanggal Masuk
Pulang
1 Dede Wahyuni 0000462019252 Cileles 2/6/2017 2/6/2017
2 Ita Rosita 0002242747912 Cibeusi 3/6/2017 3/6/2017
3 Ernawati 0000462440654 Cinta Mulya 6/6/2017 7/6/2017
4 Tuti Patmawati 0000461764269 Cilayung 8/6/2017 8/6/2017

5 Eni Mulyani 0000463542074 Cibeusi 11/6/2017 11/6/2017
6 Elis Saripah 0002242733859 Sindang Sari 11/6/2017 12/6/2017
7 Teti Mulyati 0001008272518 Cisempur 11/6/2017 12/6/2017
8 Asmarini 0000461644334 Cibeusi 12/6/2017 12/6/2017
9 Wati Kartini 0000460049444 Hegarmanah 14/6/2017 14/6/2017
10 Yuliana 0000461145341 Cilayung 14/6/2017 14/6/2017
11 Listiana Dewi 0001435675656 Cipacing 14/6/2017 15/6/2017
12 Ai Devi 0002250709896 Cilayung 17/6/2017 17/6/2017
13 Devi G 0000462773439 Cilayung 17/6/2017 17/6/2017
14 Wulandari 0001865623263 Cileunyi 18/6/2017 18/6/2017
15 Pungky Sudarmini 000162254379 Jatimukti 19/6/2017 20/6/2017
16 Nurhasanah 0000462500548 Cinta Mulya 19/6/2017 19/6/2017
17 Rahmayati 0002244415443 Jatimukti 21/6/2017 21/6/2017
18 Rina Rohayati 0000462661029 Cileles 22/6/2017 23/6/2017
19 Dini Melani 0001997167757 Hegarmanah 22/6/2017 23/6/2017
20 Tati Noviyanti 0000462225745 Mekargalih 23/6/2017 23/6/2017
21 Triyani A 0001666295019 Jatiroke 23/6/2017 24/6/2017
22 Retno Wulandari 0002241319228 Hegarmanah 24/6/2017 25/6/2017
23 Tita 0000463433163 Cilayung 29/6/2017 30/6/2017
24 Heni 0000462031514 Cilayung 29/6/2017 30/6/2017
25 Iceu 0001654867247 Jatisari 29/6/2017 30/6/2017
Jumlah
Terbilang : Sepuluh Juta Enam Ratus Ribu Rupiah

Mengetahui
dr Haris Fatah Kristofa JULI 2017

NIP.19641030.200212.1.002
Bulan : JULI 2017
Pelayanan : RITP
Tanggal Pelayanan
Tanggal Masuk
Pulang
1 Ai Hasanah 0001725330824 Cileles 1/7/2017 1/7/2017
2 Dewi Aprianti 0001997608915 Jatimukti 1/7/2017 1/7/2017
3 Jubaedah 0001522826212 Hegarmanah 1/7/2017 2/7/2017
4 Lia 0000461892453 Hegarmanah 2/7/2017 2/7/2017
5 Delfy Cylvia 0000507239662 Cilayung 2/7/2017 3/7/2017
6 Elysa 0002057357349 Cikeruh 4/7/2017 5/7/2017
7 Melli Meldiani 0001340562442 Hegarmanah 4/7/2017 6/7/2017
8 Rani Haerunisa 0001008286727 Cibeusi 5/7/2017 5/7/2017
9 Vivin Mulyatin 0002242683652 Cileles 7/7/2017 8/7/2017
10 Diani 0000461863776 Hegarmanah 8/7/2017 9/7/2017
11 Yeyen 0000429090489 Cisempur 8/7/2017 8/7/2017
12 Nia Komalasari 0002255689989 Cileles 8/7/2017 8/7/2017
13 Anita 0001997523944 Hegarmanah 9/7/2017 10/7/2017
14 Dewi Triani 0001008283149 Hegarmanah 10/7/2017 11/7/2017
15 Maya Mustika 0000460015852 Hegarmanah 13/7/2017 14/7/2017

16 Wiwin Sumiati 0000462221572 Cipacing 13/7/2017 13/7/2017
17 Yayah 0002251208979 Hegarmanah 13/7/2017 14/7/2017
18 Ai Milah 0000461811611 Jatiroke 17/7/2017 17/7/2017
19 Sri Ajeng R 0000463299456 Cilayung 17/7/2017 18/7/2017
20 Rina Anggelina 0000461950378 Cileles 20/7/2017 20/7/2017
21 Euis Komariyah 000224348838 Cipacing 21/7/2017 22/7/2017
22 Dhewi P 0001866411977 Cibeusi 22/7/2017 23/7/2017
23 Eka Nurjanah 0000463246593 Cikeruh 24/7/2017 25/7/2017
24 Sera Selina 0000461716514 Cikeruh 25/7/2017 26/7/2017
25 Ani Supriyani 0001475259579 Cipacing 26/7/2017 26/7/2017
26 Entin 0002202676154 Cibeusi 27/7/2017 28/7/2017
27 Siska Mustika 0000461810046 Cipacing 27/7/2017 28/7/2017
28 Atik Mariam 0000462019724 Cileles 28/7/2017 29/7/2017
29 Ira Laelasari 0002054008686 Hegarmanah 29/7/2017 30/7/2017
30 Leli Nurhayati 0001666333192 Sukasari 30/7/2017 30/7/2017
31 Novi Juwita 0001901206495 Hegarmanah 30/7/2017 30/7/2017
32 Nopiana 0001981508218 Jatiroke 31/7/2017 31/7/2017
33 Sinta Wulan R 0000462281016 Hegarmanah 31/7/2017 31/7/2017
Jumlah
Terbilang : Sembilan Belas Juta Enam Ratus Lima Puluh Ribu Rupia
Mengetahui
Kepala UPT Puskesmas DTP Jatinangor
drg.Amie.Fitriah.M.H.Kes
NIP.19721111.200604.2.017
AGUSTUS 2017

Bulan : AGUSTUS 2017
Pelayanan : RITP
Tanggal Pelayanan
Pulang
1 Sindi Pendari 0001008275556 Jatiroke 2/8/2017 2/8/2017
2 Iis Maesaroh 0000462551095 Jatiroke 5/8/2017 5/8/2017
3 Siti Sarah 0000463349698 Cilayung 5/8/2017 5/8/2017
4 Dahlia 0000482837723 Sayang 7/8/2017 8/8/2017
5 Titin Rohmatin 0001666242876 Cipacing 9/8/2017 10/8/2017
6 Pipit Pitriani 0000461891957 Mekargalih 10/8/2017 10/8/2017
7 Een Sumiati 0000461473029 Cileles 10/8/2017 10/8/2017
8 Susan Febriyani 0002265575861 Sindangsari 10/8/2017 11/8/2017
9 Yayan Taryani 0000460088122 Hegarmanah 12/8/2017 12/8/2017
10 Faridatun Nida 0001693968319 Sayang 12/8/2017 12/8/2017
11 Dianna M 0000462398545 Mekargalih 12/8/2017 12/8/2017
12 Ai Nuraeni 0000462151787 Cinumbang 13/8/2017 14/8/2017
13 Siti Maemunah 0001982174872 Jatiroke 14/8/2017 14/8/2017

14 Tamia Rahayu 00001405493188 Cipacing 14/8/2017 15/8/2017
15 Siti Aisah 0000462876715 Cibeusi 14/8/2017 15/8/2017
16 Epa 0000461810902 Cilayung 15/8/2017 16/8/2017
17 Tita Najiah 0000461466382 Cileles 15/8/2017 15/8/2017
18 Mia Susilawati 0000427977753 Cipacing 15/8/2017 15/8/2017
19 Ai Aminah 0000462624974 Sayang 16/8/2017 16/8/2017
20 Elis Lisnawati 0002224990495 Hegarmanah 16/8/2017 17/8/2017
21 Erni Yuningsih 0001008290619 Cileles 20/8/2017 20/8/2017
22 Popon Komariah 0001777830772 Cipacing 23/8/2017 24/8/2017
23 Tati Maryati 0001778000635 Hegarmanah 24/8/2017 24/8/2017
24 Cucun Sumiarsih 0001008257095 Sayang 24/8/2017 24/8/2017
25 Popon Sopiah 0002261650904 Cikeruh 25/8/2017 25/8/2017
26 Lala Nurlaela 0001793708818 Cilayung 29/8/2017 29/8/2017
27 Yuli Syti A 0002234356604 Cinta Mulya 29/8/2017 30/8/2017
28 Siti Hasanah 0001008272979 Hegarmanah 30/8/2017 30/8/2017
29 Eti Nurhayati 0000419918332 Hegarmanah 30/8/2017 30/8/2017
Jumlah
Terbilang : Tiga Belas Juta Rupiah
Mengetahui
NIP.19721111.200604.2.017
SEPT

Bulan : SEPTEMBER
Pelayanan : RITP
Tanggal Pelayanan
Tanggal Masuk
Pulang
1 Yuyun Y 000222842385 Cilayung 1/9/2017 2/9/2017
2 Ela Suryaningsih 0000462724435 Mekar Galih 1/9/2017 1/9/2017
2 Eli Rayani 000280593124 Cipacing 2/9/2017 3/9/2017
3 sinta 0000350069703 Sayang 3/9/2017 4/9/2017
4 Dewi Kurniawati 0002269480397 Cibeusi 4/9/2017 4/9/2017
5 Lara Satifah 0000461763742 Cilayung 6/9/2017 7/9/2017
6 Lela Nurlia 0000462516243 Sayang 6/9/2017 7/9/2017
7 Nani Yuningsih 0000461980765 Cipacing 7/9/2017 8/9/2017
8 Yuli Sity Aliyah 0002223435660 Cinta Mulya 8/9/2017 8/9/2017
9 Dedeh W 0001997145933 Cinta Mulya 8/9/2017 9/9/2017
10 Ipah Saripah 0000462239954 Cipacing 9/9/2017 10/9/2017
11 Rini 0000461412448 Cileles 9/9/2017 10/9/2017

12 Ai Popon R 0002261979685 Hegarmanah 9/9/2017 11/9/2017
13 Parni 0002263843563 Cileles 11/9/2017 11/9/2017
14 Siti Aminah 00001008263452 Mekar Galih 12/9/2017 12/9/2017
15 Nita Juwita 0002196478809 Cileles 12/9/2017 12/9/2017
16 Tuti Susanti 00022270839408 Jati Mukti 12/9/2017 13/9/2017
17 Ecin Kuraesin 0000462103661 Cilayung 17/9/2017 18/9/2017
18 Nani Suryani 0001522848352 Hegarmanah 19/9/2017 19/9/2017
19 Sri Wahyuni 0000461754685 Cilayung 20/9/2017 21/9/2017
20 Lisda Pujianti 000019586433 Tanjung Sari 22/9/2017 22/9/2017
21 Eli Yulianti 0000462386373 Sayang 27/9/2017 27/9/2017
22 Irmawati 0000462493462 Sayang 27/9/2017 28/9/2017
23 Yayang Siti S 00001729292319 Cikeruh 30/9/2017 30/9/2017
Jumlah
Terbilang : Tiga Belas Juta Lima Ratus Dua Puluh Lima Ribu Rupiah
Mengetahui
NIP.19721111.200604.2.017

Bulan : OKTOBER
Pelayanan : RITP
Tanggal Pelayanan
Pulang
1 0000462724435 Cilayung 1/10/2017
2 0000462724435 Mekar Galih
2 0000462724435 Cipacing
3 0000462724435 Sayang
4 0000462724435 Cibeusi
5 0000462724435 Cilayung
6 0000462724435 Sayang
7 0000462724435 Cipacing
8 0000462724435 Cinta Mulya
9 0000462724435 Cinta Mulya
10 0000462724435 Cipacing
11 0000462724435 Cileles
12 0000462724435 Hegarmanah
13 0000462724435 Cileles
14 0000462724435 Mekar Galih
15 0000462724435 Cileles
16 0000462724435 Jati Mukti
17 0000462724435 Cilayung
18 0000462724435 Hegarmanah
19 0000462724435 Cilayung
20 0000462724435 Tanjung Sari
21 0000462724435 Sayang
22 0000462724435 Sayang
23 0000462724435 Cikeruh
Jumlah
Terbilang : Tiga Belas Juta Lima Ratus Dua Puluh Lima Ribu Rupiah
Mengetahui
NIP.19721111.200604.2.017

Bulan : NOPEMBER
Pelayanan : RITP
Tanggal Pelayanan
Pulang
1 Puput Melati 0001008250781 Sayang 3/11/2017 4/11/2017
2 Nopi Nurbayanti 0002231936032 Jati Mukti 7/11/2017 8/11/2017
3 Nia Kurnia 0000461840321 Jatiroke 7/11/2017 8/11/2017
4 Widanengsih 0001008258783 Sayang 7/11/2017 8/11/2017
5 Nurhayati 0000461386168 Hegarmanah 8/11/2017 8/11/2017
6 Wati Mulyawati 0001661820336 Hegarmanah 8/11/2017 9/11/2017
7 Yuni Maelani 001781296626 Hegarmanah 9/11/2017 9/11/2017
8 Riska Yulianti 0001664655783 Cileles 13/11/2017 13/11/2017
9 Nining Wahyuni 0001666287123 Hegarmanah 17/11/2017 17/11/2017
10 Veny Indriani 02033012136 Sayang 17/11/2017 18/11/2017
11 Nuri Nurcahya 0001776912164 Cileles 21/11/2017 22/11/2017

12 Rita Rosita 001664689724 Cikeruh 22/11/2017 22/11/2017
13 Cucu Nurlaela 001668795006 Rancaekek 22/11/2017 23/11/2017
14 Etin 0001008292048 Cileles 23/11/2017 24/11/2017
15 Nani Hayati 0000462634086 Cileles 23/11/2017 24/11/2017
16 Euis Winda W 0000064974159 Cilayung 27/11/2017 28/11/2017
Cici Kamelia 0001771035748 Jatiroke 29/11/2017 30/11/2017
17
Jumlah
Terbilang : Dua Belas Juta Enam Ratus Lima Puluh Ribu Rupiah
Mengetahui
NIP.19721111.200604.2.017

Bulan : NOPEMBER
Pelayanan : RITP
Tanggal Pelayanan
Tanggal Masuk
Pulang
1 Dina Mulyani 0002285379988 Cimanggung 2/11/2017 2/11/2017
2 Maya Maida 0000462224722 Mekargalih 3/11/2017 3/11/2017
3 Siti Aisyah 0002282442884 Cipacing 8/11/2017 8/11/2017
4 Nani Widarti 0000462558262 Sayang 9/11/2017 9/11/2017
5 Iis Mulyaningsih 0001514775947 Cipacing 9/11/2017 9/11/2017
6 Eti Rohaeti 0000461797953 Cipacing 12/11/2017 12/11/2017
7 Sri Hanipah 0001901303829 Jatimukti 14/11/2017 5/11/2017
8 Cicih Kadarsih 0000462019127 Cileles 15/11/2017 15/11/2017
9 Elis Cimanggung 17/11/2017 18/11/2017

000043162825
10 Fitriawati Cileles 20/11/2017 20/11/2017

0000461925178
11 Dede Rosita 0001522819956 Hegarmanah 24/11/2017 24/11/2017
12 Hani Apriyani 0000462956857 Cipacing 25/11/2017 25/11/2017
Rismayanti Jatiroke 29/11/2017 30/11/2017

13 000046943652
Jumlah
Terbilang : Satu Juta Enam Ratus Dua Puluh Lima Ribu Rupiah
Mengetahui
NIP.19721111.200604.2.017
AMINAN KESEHATAN NASIONAL (JKN)
belum lengkap
sudah format lama
Jenis Pelayanan
Tarif [Rp ]
Pra Rujukan Persalinan Normal Persalinan Penyulit
P1A0 Partus Normal 600,000
G2P1A0 dgn KPD 125,000

P1A01Partus Normal 600,000
P2A0 dgn Manual
Placenta 750,000
G5P4A0Part Aterm kl I
125,000
125,000
125,000
7,250,000
us Lima Puluh Ribu Rupiah
Bendahara FKTP
Puskesmas DTP Jatinangor
Rina Mariani AMK

NIP.19701221.199803.2.003

Jenis Pelayanan
Tarif [Rp ]
G1P0A0 Parturient Aterm 125,000

Kala I fase laten dgn Anemia

Kala I fase laten dgn H D K
G1P0A0 grav 42-43 mg dgn 125,000
Anemia & Primi Tua
G2P1A0 Parturient Aterm

Kala I fase laten dgn KPD & 125,000
Susp CPD

Kala I fase aktif dgn Fetal 125,000
Distress
3,625,000
G4P2A01Parturient Aterm
Kala I fase laten dgn letak 125,000
Sungsang

Kala I fase aktif dgn PER

sungsang &preeclampsia
P1A0 dgn Perdarahan 750,000


Kala I fase laten dgn KPD
7,875,000
s Tujuh Puluh Lima Ribu Rupiah
Bendahara FKTP
Rina Mariani AMK

NIP.19701221.199803.2.003
Jenis Pelayanan
Tarif [Rp ]

Kala I fase laten dgn Anemia
P1A0 Partus dgn 750,000

Lilitan tali Pusat
Kala I fase aktif dgn Anemia 125,000
dan KPD
Kala I fase laten dgn Anemia 125,000
sedang
Kala I fase laten dgn Anemia 125,000
sedang & KPD


Perdarahan
3,325,000
P3A1 Partus dgn

Perdarahan&lilitan tali 750,000
pusat

Perdarahan


Kala I fase aktif dgn Anemia 125,000
dan PER
G3P1A1 gravida 39-40 mg 125,000

dgn letak lintang

Perdarahan
5,025,000
8,950,000
Ratus Lima Puluh Ribu Rupiah
Bendahara FKTP
Rina Mariani AMK

NIP.19701221.199803.2.003
Jenis Pelayanan
Tarif [Rp ]


Kala I dgn PEB
4,450,000

Perdarahan

Kala I fase laten dgn 125,000
Hypertensi Kronis dan
riwayat SC 1 Thn yg lalu
P1A0 Partus dgn

Lilitan tali Pusat 750,000
8,475,000
us Tujuh Puluh Lima Ribu Rupiah
Bendahara FKTP
Rina Mariani AMK

NIP.19701221.199803.2.003

Jenis Pelayanan
Tarif [Rp ]
P5A0 Partus Re Plac 750,000
2,550,000
Bendahara FKTP
Rina Mariani AMK

NIP.19701221.199803.2.003
Jenis Pelayanan
Tarif [Rp ]
G2P1A0 38 mg dgn KPD 125,000
P2 A1 dgn RePlac 750,000

P4 A0 dgn RePlac 750,000
G3P2A0 gravida 41-42 mg 125,000

dgn anemi dan post SC

Kala I fase laten dgn anami 125,000
dan Riwayat Asma
P3 A0 Post Partum dgn 175,000
Perdarahan
G3P2A0 gravida 24 mg dgn
Placenta previa dan susp 125,000
IUFD
G4P2A1 gravida 36 mg dgn 125,000

PER
G3P2A0 gravida 37-38 mg 125,000
dgn preeclampsi
G1P0A0 Serotinus Dgn

Letak sungsang dan Primi 125,000
Tua
7,950,000
atus Lima Puluh Ribu Rupiah

Bendahara FKTP
Rina Mariani AMK

NIP.19701221.199803.2.003
Jenis Pelayanan
Tarif [Rp ]
PUD dan Anemia gravis 125,000

Kala I fase laten dgn KPD 125,000
& PER

Anemi

dgn KPD
P3A0 Partus dgn PER 750,000
& Lilitan tali Pusat
4,850,000

G3P2A0 gravida 36 mg - 37 125,000

mg dgn PEB dan asma
riwayat SC
P2A0 dgn PER 750,000
&Anemi
Anemi
10,775,000
Bendahara FKTP
Rina Mariani AMK

NIP.19701221.199803.2.003
Jenis Pelayanan
Tarif [Rp ]


P3A0 Partus dgn

perdarahan dan 750,000
manual placenta
G3P0A0 Perpanjangan fase

aktif & PER 125,000
5,800,000
1,200,000
8,350,000
tus Lima Puluh Ribu Rupiah

Bendahara FKTP
Rina Mariani AMK

NIP.19701221.199803.2.003
tahun 2016
Jenis Pelayanan
Tarif [Rp ]

Kala II dgn Hypertensi

Kala I fase aktif dgn 125,000
Hypertensi & Anemi Berat
P3A0 Partus dgn PER 750,000

Anemi
4,125,000

+PER+Anemi+Susp Bayi
Besar
7,250,000
Bendahara FKTP
Rina Mariani AMK

NIP.19701221.199803.2.003
Jenis Pelayanan
Tarif [Rp ]
dgn KPD
G2P1A0 grav 10-11 mg dgn 125,000
Ab Incipien
Kala I fase aktif dgn anemi 125,000
&riwayat Epilepsi
dgn KPD &Anemi
Kala I fase aktif dgn letak 125,000
kaki
Partus dgn Retensio 750,000

placenta
G1P0A0 grav 35-36 mg dgn 125,000
KPSW & Anemi

4,500,000

Kala I fase laten dgn riwayat 125,000
SC
G1P0A0 11 mg dgn Susp 125,000
Abbortus
RePlac &BBLR
Distosia Bahu
Anemia
dgn Febris& Anemi&Fetal 125,000
Distress
P3A0 Partus 750,000
Perdarahan
G3P2A0 grav 30 mg dgn 125,000

Susp Placenta letak rendah
G1P0A0 dgn KPD 125,000
P1A0 Partus dgn lilitan 750,000

tali pusat
10,075,000
h Puluh Lima Ribu Rupiah
Bendahara FKTP
Rina Mariani AMK

NIP.19701221.199803.2.003
Jenis Pelayanan
Tarif [Rp ]
G5P4A0 Parturient Aterm Kala

I fase aktif dgn KPSW 125,000
&PEB&Riwayat Perdarahan


Kala I fase aktif dgn PER

Kala II dgn Partus Lama
4,825,000

P1A0 Partus dgn lilitan 750,000
tali pusat
7,375,000
Tujuh Puluh Lima Ribu Rupiah
Bendahara FKTP
Rina Mariani AMK

NIP.19701221.199803.2.003
Jenis Pelayanan
Tarif [Rp ]

1,200,000
a Ratus Ribu Rupiah
Bendahara FKTP
Rina Mariani AMK

NIP.19701221.199803.2.003
ATAL JAMINAN KESEHATAN NASIONAL (JKN)
Jenis Pelayanan Tarif [Rp ]

RePlac

Kala II dgn PER &Anemi

RePlac

Kala II dgn Partus lama & 125,000
anemi


5,600,000

I fase aktif dgn KPD &PEB& 125,000
Susp Bayi besar


RePlac

I dgn Placenta Letak rendah 125,000

Kala I fase laten dgn PER
8,050,000
ima Puluh Ribu Rupiah
Bendahara FKTP
Rina Mariani AMK

NIP.19701221.199803.2.003


Kala I Fasa Laten dgn letak 125,000
lintang
P6A0 Partus dgn PEB 750,000

RePlac
7,025,000

RePlac

RePlac

15,125,000
s Dua Puluh Lima Ribu Rupiah
Bendahara FKTP
Rina Mariani AMK

NIP.19701221.199803.2.003

RePlac

Kala I fase laten dgn PER
Kala II dgn Partus lama
Kala II dgn Partus lama


Kala II dgn KPD
3,775,000
P120 Partus Normal 600,000

P120 Partus Normal 600,000
G4P2A1 dgn Abb 125,000

Incomplete
Kala I fase laten dgn PEB 125,000
dan riwayat SC

G5P3A0 HDK dgn letak
obligue dan Placenta letak 125,000
rendah
RePlac
9,350,000
atus Lima Puluh Ribu Rupiah
Bendahara FKTP
Rina Mariani AMK

NIP.19701221.199803.2.003


RePlac
Kala I dgn Partus Lama

Kala I dgn KPD
6,400,000

Kala I dgn KPD
7,725,000
s Dua Puluh Lima Ribu Rupiah
Bendahara FKTP
Rina Mariani AMK

NIP.19701221.199803.2.003
P1A0 Partus Dgn 750,000

lilitan Tali Pusat
6,150,000

Perdarahan
G1P0A0 dgn Anemi Berat 125,000

Kala I fase laten dgn IUFD

Perdarahan
12,700,000
ujuh Ratus Ribu Rupiah
Bendahara FKTP
Rina Mariani AMK

NIP.19701221.199803.2.003

G1P0A0 Preterm Kala I fase 125,000

aktif
4,450,000

Kala I dgn placenta previa 125,000
&anemi
G2P1A0 dgn letak sungsang 125,000


9,750,000
h Lima Puluh Ribu Rupiah
Bendahara FKTP
Rina Mariani AMK

NIP.19701221.199803.2.003



Perdarahan
G2P0A0 dgn Abortus 125,000
Incomplit

RePlac
5,475,000

lilitan Tali Pusat
RePlac

RePlac PERUBAHAN TARIF
Hypertensi
10,850,000
Bendahara FKTP
Rina Mariani AMK

NIP.19701221.199803.2.003
KLAIM OKT S.D TGL 25/11/2016
MULAI TGL 26 TARIF BARU




Perdarahan
G2P0A0 dgn Abortus 125,000
Incomplit

RePlac
5,475,000

lilitan Tali Pusat
RePlac
8,775,000
Bendahara FKTP
Rina Mariani AMK

NIP.19701221.199803.2.003
TGL 26/11/2016 &SETERUSNYA BELUM DIKLAIM


Kala I fase laten dgn KPD tarif lama

sungsang


Perdarahan

Kala I dgn Panggul Sempit
4,250,000
G1P0A0 dgn Perpanjangan 125,000

fase aktif
8,575,000
Bendahara FKTP
Rina Mariani AMK

NIP.19701221.199803.2.003
6,000,000
G4P2A1 dgn Abb 125,000

Incomplete

Kala I fase aktif dgn P E R
G4P2A1 gravida 38 mg dgn

KPD &Hypertensi Kronis 125,000
15
RePlac
1
G1P0A0 37-38 mg dgn 125,000
KPSW 5
riwayat SC
9,775,000
Bendahara FKTP
Rina Mariani AMK

NIP.19701221.199803.2.003
15/12/2016 P2A0 Partus Normal 600,000 tdk aktif

Kala I fase aktif dgn sakit 125,000
Asma & riwayat Re Plac
G2P1A0 gravida 36-37 mg 125,000

dgn P E B


Kala I fase aktif dgn KPD

RePlac
5,525,000

Kala I fase laten dgn P E R
P2A0 Partus dgn letak 950,000

sungsang
G32A0 Parturient Aterm 125,000

Kala I fase aktif dgn PEB

Kala I fase aktif dgn Partus 125,000
Lama
13,150,000

13,850,000
Bendahara FKTP
Rina Mariani AMK

NIP.19701221.199803.2.003

540000


G2P1A0 grav 37 mg dgn 125,000
susp placenta letak rendah

dgn letak sungsang
4,100,000
5,900,000
lan Ratus Ribu Rupiah
Bendahara FKTP
Rina Mariani AMK

NIP.19701221.199803.2.003

kala I dgn Perpanjangan 125,000
fase aktif
G3P1A1 gravida 25-26 mg

dgn Susp Placenta Previa 125,000
dan Perdarahan

dg serotin ,post SC dan 125,000
Partus Lama


placenta letak rendah
3,625,000

dgn PEB


Kala I faselaten dgn KPD

Kala II dgn Partus Lama
8,200,000
Dua Ratus Ribu Rupiah
Bendahara FKTP
Rina Mariani AMK

NIP.19701221.199803.2.003

Kala I dgn tali pusat 125,000
menumbung
G1P0A0 gravida 34 mg dgn 125,000

KPD
Kala I fase aktif dgn partus 125,000
lama

Kala I dgn riwayat sakit 125,000
jantung
4,700,000

placenta previa

Kala I fase laten dgn PEB 125,000
,Letak Sungsang & PEB
G4P3A0 Parturient Preterm 125,000

dgn Leukeumia
125,000
125,000
125,000
11,050,000
13,150,000
Bendahara FKTP
Rina Mariani AMK

NIP.19701221.199803.2.003

I dgn KPD 125,000
G3P2A0 Parturient Aterm dgn

perpanjangan fase aktif 125,000

RePlac


I fase aktif dgn Gemelli 125,000
8,325,000

I dgn Riwayat SC +KPD 125,000

I fase aktif dgn Letak 125,000
Sungsang

I fase aktif dgn KPD & 125,000
Preeklamsi

I fase aktif dgn KPD + HDK 125,000
13,725,000
us Dua Puluh Lima Ribu Rupiah
Bendahara FKTP
Rina Mariani AMK

NIP.19701221.199803.2.003

700,000
tus Ribu Rupiah
Bendahara FKTP
Rina Mariani AMK

NIP.19701221.199803.2.003

KPD 125,000
G3P1A1 Parturient Aterm kala

I dgn KPD 125,000

KPD 125,000

perpanjangan fase aktif 125,000

PEB 125,000

Gemelli 125,000
G1P0A0 grav 38-39 mg dgn

PER 125,000

Eclampsi 125,000
5,200,000

KPD 125,000
G2P1A0 Parturient Aterm kala 125,000

I dgn Partus Lama

I dgn Perpanjangan fase aktif 125,000

I fase laten dgn KPSW 8 jam 125,000
10,600,000
nam Ratus Ribu Rupiah

Bendahara FKTP
Rina Mariani AMK

NIP.19701221.199803.2.003

I fase laten dgn KPD 125,000

II dgn partus lama 125,000

KPD dan letak sungsang 125,000

I fase laten dgn Placenta 125,000
previa
7,500,000


Perpanjangan fase aktif & KPD 125,000

16,150,000
19,650,000
m Ratus Lima Puluh Ribu Rupiah
Bendahara BLUD
Rina Mariani AMK

NIP.19701221.199803.2.003

KPD dan Anemi 125,000

Perpanjangan Fase Aktif & KPD 125,000

I fase laten dgn PEB 125,000
P1A0 dengan letak 950,000

Sungsang

I fase laten dgn letak 125,000
Sungsang

Susp Placenta Previa 125,000
G1P0A0 Parturient Preterm
kala I fase Aktif 125,000

G2P1A0 grav 5 mg dgn
Abbortus Incomplete 125,000
4,750,000
Manual Placenta

I dgn Partus Lama 125,000

I fase laten dgn PEB 125,000

Manual Placenta
G2P1A0 grav 31 - 32 mg dgn

KPD &Gemeli 125,000
G2P1A0 grav 34 - 35 mg dgn

Prematur Kontraksi 125,000
G2P0A1 grav 8 mg dgn Susp

KET 125,000
12,875,000
G1P0A0 dgn Serotin 125,000
13,000,000
as Juta Rupiah
Bendahara BLUD
Rina Mariani AMK
NIP.19701221.199803.2.003
Pra Rujukan Persalinan Normal Persalinan Penyulit bdn

Perdarahan Yanti S
Wiwi W
Yanti S
Dewi Siswati
G2P1A0 dgn Serotinus dan
riwayat SC 125,000
Wiwi W
Wiwi W
Anissa
Sri Rahayu
G1P0A0 grav 34-35mg dgn
Sri Rahayu
Yanti S
Anissa
Anissa
P4A1 Partus dgn
Perdarahan dan 950,000
manual Placenta
Wiwi W
G3P2A0 dgn Susp Placenta
Previa 125,000

I fase laten dgn P E B 125,000
Sri Rahayu
G3P1A1 Gravida 40 mg dgn
KPD 125,000
Wiwi W
Yanti S
Anissa
Tetih
Perdarahan Dewi Siswati

I fase laten dgn letak lintang 125,000
Yanti S
Anissa
Yanti S
Dewi Siswati
13,525,000
tus Dua Puluh Lima Ribu Rupiah
Bendahara BLUD
Rina Mariani AMK

NIP.19701221.199803.2.003

Perdarahan
G2P1A0 dgn Serotinus dan

riwayat SC 125,000
G1P0A0 grav 34-35mg dgn


P4A1 Partus dgn
Perdarahan dan 950,000
manual Placenta
G3P2A0 dgn Susp Placenta
Previa 125,000

I fase laten dgn P E B 125,000
G3P1A1 Gravida 40 mg dgn

KPD 125,000

Perdarahan
I fase laten dgn letak lintang 125,000

13,525,000
tus Dua Puluh Lima Ribu Rupiah
Bendahara BLUD
Rina Mariani AMK

NIP.19701221.199803.2.003

Normal dan Penyulit
Dewi Sis P1A0 Partus Normal 700,000 Dewi Sis

Wiwi P3A0 Partus Normal 700,000 Wiwi
Yanti S P3A3 Partus Normal 700,000 Yanti S
Anisa P3A0 Partus Normal 700,000 Anisa
Retensio Placenta
Teth Teth
Replac & Anemi
Dewi Sis Dewi Sis
Sri RJ P3A0 Partus Normal 700,000 Sri RJ
Anisa P2A0 Partus Normal 700,000 Anisa
Yanti S P4A0 Partus Normal 700,000 Yanti S
Dewi Sis Perdarahan Dewi Sis
12,650,000
Bendahara BLUD
Rina Mariani AMK

NIP.19701221.199803.2.003

Pra Rujukan

I fase laten dgn letak 125,000
Sungsang Dewi Sis Dewi Sis

I fase laten dgn Hypertensi 125,000
Wiwi Wiwi
G53A1 Parturient Aterm Kala I
fase aktif dgn letak Sungsang 125,000
Sri Sri
I fase laten dgn Hypertensi & 125,000
KPD Dewi Sis Dewi Sis
G2P1A0Parturient Aterm Kala I

fase laten dgn KPD 125,000
Dewi Sis Dewi Sis
fase aktif dgn PEB & KPD 125,000
Anisa Anisa
Yanti Yanti
fase laten dgn riwayat SC 125,000
Sri Sri
G43A0Parturient Aterm Kala I
dgn Perpanjangan fase aktif 125,000
Dewi Sis Dewi Sis
I dgn Gemelli 125,000
Anisa Anisa
1,250,000

I fase laten dgn KPD & PEB 125,000
Yanti S Yanti S
I fase laten dgn Hypertensi 125,000
Tetih Tetih
I Perpanjangan fase aktif 125,000
Dewi Sis Dewi Sis
1,625,000
Dua Puluh Lima Ribu Rupiah
Bendahara BLUD
Rina Mariani AMK

NIP.19701221.199803.2.003
600000 9,000,000
750000 750,000
125000 625,000
10,375,000
REKAPITULASI KLAIM RAWAT INAP JAMINAN KESEHATAN NASIONAL (JK

Pelayanan : RITP
No Nama No Peserta Alamat Diagnosa
1 Yoyoh 0000054091956 Cipacing 3/9 S . Thypoid

2 Hani Fitriyah 0000461540485 Cintamulya 3/9 Gastritis
3 Osih 0002292443537 Cileunyi 1/9 Gastritis
4 Popon 0000462668218 Sukasari 5/7 S . Thypoid
5 Rula Milda 0000462547337 Cisempur 2/10 S. DHF
6 Triani Novita 0001008284951 Cikeruh 3/3 S . Thypoid
7 Juju Juhriah 0001008252819 Cipacing 6/7 GEA
8 Ajat 0000195482259 Cileles 1/5 S . Thypoid
9 Ati 0000418401099 Cimekar 5/27 S . Thypoid
10 Dedi Jaelani 0002285932037 Cintamulya 4/8 Gastritis
11 Dasuki 0001008294996 Cilayung 1/6 S . Thypoid
12 Silmi Safira 0001981367289 Cintamulya 8/3 Gastritis
13 Coom 0000461988718 Cileles 3/9 GEA
14 Rianto Wibowo 0000461940377 Cikeruh 4/4 GEA
15 Rio Hermansyah 0001105892976 Jatiroke 3/5 GEA
16 Fatan Mulyawan 0002181073419 Nanggerang 2/9 S . Thypoid
17 Nana Rukmana 0001291160902 Cileles 2/1 Gastritis
18 Yosep Rizal 0001008260638 Sukarasa 3/1 Gastritis
19 Ginar Maulana 0001284919413 Cintamulya Gastritis
20 Hadmi 0002042131331 Jatiroke 2/4 GEA
21 Warliyah 0000462792262 Selacau 5/3 GEA
22 Intan 0000461736549 Cilayung 1/7 S . Thypoid
23 Fitriana 000151712127 Cisempur 3/3 Gastritis
24 Cucu M 0000463159719 Cisempur 3/9 GEA
25 E. Karmilah 0000462767578 Cileles 1/9 Gastritis
26 Atay 0000461964611 W. Kalde GEA
27 Rizal 0001008265285 Mekargalih Gastritis
28 Usep Dodo 0001666339806 Dangder DM
29 Suparman 0001127549643 Cimekar S . Thypoid
30 Nenden Dewi K 0001008691345 Hegarmanah 2/6 S . Thypoid
31 Hendi Sutisna 0000462610776 Cileles S . Thypoid
32 Ekem 0000463859739 Nanggerang 3/9 HT+ Stroke
33 Juju Juhriah 0001008252819 Cipacing 6/7 Gastritis
34 Juju 0000463907575 Nanggerang 3/9 GEA
35 Anih 0000461940232 Jatimukti 2/7 Gastritis
36 Kartiman 0002326568332 Kutamandiri 1/3 Gastritis
37 Kartini 0001008296425 Cilayung 3/8 S. DHF
38 Icah 0000463428156 Banyuresmi 3/1 S. Broncopneumonia
39 Widia 0002320128821 Cilayung 3/8 S. Thypoid
40 Rohmat 0000463502654 Cilayung 1/2 Anemia
41 Abdul Alamin 0000064943853 Cikeruh 4/9 BRPN
42 Sutiono 0000461167031 Cilayung 1/3 CHF
43 Yohanah 0000065331573 Hegarmanah 2/7 HHD
JUMLAH
Terbilang " Sembilan Belas Juta Enam Ratus Ribu Rupiah"
Mengetahui Kepala

NIP: 10721111 200604 2 017
INAP JAMINAN KESEHATAN NASIONAL (JKN)
Biaya
Tgl Masuk Tgl Keluar Jumlah
HP UC/Hari
29/ 1/20 18 2/2/20 18 4 200,000 800,000
29/ 1/20 18 1/2/20 18 3 200,000 600,000
29/ 1/20 18 1/2/20 18 3 200,000 600,000
30/ 1/20 18 1/2/20 18 2 200,000 400,000
30/ 1/20 18 2/2/20 18 3 200,000 600,000
1/2/20 18 3/2/20 18 2 200,000 400,000
2/2/20 18 5/2/20 18 3 200,000 600,000
2/2/20 18 6/2/20 18 4 200,000 800,000
6/2/20 18 8/2/20 18 2 200,000 400,000
6/2/20 18 8/2/20 18 2 200,000 400,000
6/2/20 18 8/2/20 18 2 200,000 400,000
7/2/20 18 9/2/20 18 2 200,000 400,000
8/2/20 18 9/2/20 18 1 200,000 200,000
9/2/20 18 11/2/20 18 2 200,000 400,000
10/2/20 18 11/2/20 18 1 200,000 200,000
10/2/20 18 12/2/20 18 2 200,000 400,000
12/2/20 18 13/2/20 18 1 200,000 200,000
12/2/20 18 14/2/20 18 2 200,000 400,000
13/2/20 18 14/2/20 18 1 200,000 200,000
12/2/20 18 14/2/20 18 2 200,000 400,000
13/2/20 18 17/2/20 18 4 200,000 800,000
13/2/20 18 17/2/20 18 4 200,000 800,000
14/2/20 18 17/2/20 18 3 200,000 600,000
14/2/20 18 17/2/20 18 3 200,000 600,000
15/2/20 18 17/2/20 18 2 200,000 400,000
16/2/20 18 20/2/20 18 4 200,000 800,000
17/2/20 18 20/2/20 18 3 200,000 600,000
17/2/20 18 20/2/20 18 3 200,000 600,000
17/2/20 18 20/2/20 18 3 200,000 600,000
19/2/20 18 21/2/20 18 2 200,000 400,000
21/2/20 18 23/2/20 18 2 200,000 400,000
22/2/20 18 23/2/20 18 1 200,000 200,000
22/2/20 18 23/2/20 18 1 200,000 200,000
23/2/20 18 24/2/20 18 1 200,000 200,000
23/2/20 18 26/2/20 18 3 200,000 600,000
23/2/20 18 26/2/20 18 3 200,000 600,000
23/2/20 18 26/2/20 18 3 200,000 600,000
2/24/2018 26/2/20 18 2 200,000 400,000
2/24/2018 26/2/20 18 2 200,000 400,000
2/27/2018 2/28/2018 1 200,000 200,000
2/26/2018 2/28/2018 2 200,000 400,000
2/27/2018 2/28/2018 1 200,000 200,000
2/27/2018 1/28/2018 1 200,000 200,000
AH 19,600,000
Belas Juta Enam Ratus Ribu Rupiah"
Jatinangor, 2 Maret 2018

Rina Mariani AMK

NIP.19701221.199803.2.003
REKAPITULASI KLAIM RUJUKAN JAMINAN KESEHATAN NASIONAL (JKN)

Bulan : July 2015
Pelayanan : RITP
Tanggal Pelayanan
No Nama Pasien No Peserta Alamat No Hp. Tanggal Tanggal Tujuan
Masuk Pulang
1 Suryana 0000461954485 Cileles 7/2/2015 7/2/2015 R S U Sumedang
2 Nurasiah Ismail 0000461811227 Cilayung 7/3/2015 7/3/2015 R S U Sumedang
3 Desi Nurhandayani 0001854459652 Cileles 7/4/2015 7/4/2015 R S U Sumedang
4 Aning 0001008280089 Hegarmanah 7/4/2015 7/4/2015 R S U Sumedang
5 Esih 0000461914953 Cikeruh 7/7/2015 7/7/2015 R S U Sumedang
6 E.Sobandi 0000462381287 Cileles 7/9/2015 7/9/2015 R S U Sumedang
7 Iis Sugiarsih 0000462521305 Cipacing 7/10/2015 7/10/2015 R S U Sumedang
8 Ibah 00004662448416 Jatiroke 7/13/2015 7/13/2015 R S U Sumedang
9 Uju Junaedi 0000462352329 Jatimukti 7/28/2015 7/28/2015 R S U Sumedang
10 Dewi Permatasari 0000461781843 Cipacing 7/29/2015 7/29/2015 R S U Sumedang
11 Entis Sutisna 0001475738144 Cipacing 7/31/2015 7/31/2015 R S U Sumedang
12 Tuti 0000463100229 Jatimukti 7/31/2015 7/31/2015 R S U Sumedang
Jumlah
Terbilang : Dua Juta Sembilan Ratus Empat Puluh Ribu Rupiah
Mengetahui

NIP.19641030.200212.1.002

Bulan : August 2015
Pelayanan : RITP
Tanggal Pelayanan
Masuk Pulang
1 Yuyun Yuningsih 0000208403561 Bugel 8/4/2015 8/4/2015 R S Pakuwon
2 Mimin Sumarni 0000462486363 Cileles 8/5/2015 8/5/2015 R S U Sumedang
3 Yulia Anggraeni 0001810505935 Cibeusi 8/8/2015 8/8/2015 R S U Sumedang
4 Rifa Wulan Sari 0001852318282 Hegarmanah 8/8/2015 8/8/2015 R S U Sumedang
5 Dedah 0000462752954 Cileles 8/9/2015 8/9/2015 R S U Sumedang
6 Samsudin 0000462092735 Cilayung 8/12/2015 8/12/2015 R S U Sumedang
7 Duloh Suparman 0001832724224 Jatiroke 8/15/2015 8/15/2015 R S U Sumedang
8 Susilawati 0000411597843 Cilayung 8/23/2015 8/23/2015 R S U Sumedang
9 Lia Warliah 0000462893117 Cibeusi 8/28/2015 8/28/2015 R S U Sumedang
Jumlah
Terbilang : Dua Juta Dua Ratus Lima Ribu Rupiah
Mengetahui

NIP.19641030.200212.1.002

Bulan : September
Pelayanan : RITP
Tanggal Pelayanan
Masuk Pulang
1 Norma Yuniasari 0000463248562 Hegarmanah 9/1/2015 9/1/2015 R S U Sumedang
2 Siti Sondari 000046780133 Cibeusi 9/4/2015 9/4/2015 R S U Sumedang
3 Wahyu 0001008279843 Hegarmanah 9/14/2015 9/14/2015 R S U Sumedang
4 Juju Jubaedah 0001314371259 Hegarmanah 9/22/2015 9/22/2015 R S U Sumedang
Jumlah
Terbilang : Sembilan Ratus Delapan Puluh Ribu Rupiah
Mengetahui

NIP.19641030.200212.1.002

Bulan : Oktober
Pelayanan : RITP
No Nama Pasien No Peserta Alamat No Hp. Tanggal Tujuan

Pelayanan
Tanggal Tanggal
Masuk Pulang
1 Herni Komalasari 0001316230694 Mekargalih 10/3/2015 10/3/2015 R S U Sumedang
2 Rita Kustiawati 0000462190241 Cipacing 10/6/2015 10/6/2015 R S U Sumedang
3 Nuri 0000462772765 Cilayung 10/19/2015 10/19/2015 R S U Sumedang
4 Imas 0001885707099 Jatiroke 10/21/2015 10/21/2015 R S U Sumedang
5 Roat R 0000461830893 Cilayung 10/31/2015 10/31/2015 R S U Sumedang
Jumlah
Terbilang : Satu Juta Dua Ratus Dua Puluh Lima Ribu Rupiah
Mengetahui
Kepala Puskesmas DTP Jatinangor Bendaha
Puskesmas DT
dr Haris Fatah Kristofa Rina Mari

NIP.19641030.200212.1.002 NIP.19701221.1

Bulan : Nopember
Pelayanan : RITP
No Nama Pasien No Peserta Alamat No Hp. Tanggal Pelayanan Tujuan
Tanggal Tanggal
Masuk Pulang
1 Elin Hertiyanti 0000462616839 Cileles 11/3/2015 11/3/2015 R S U Sumedang
2 Isum Suminar 0000461796827 Cipacing 11/4/2015 11/4/2015 R S U Sumedang
3 Susani 0001894054094 Cipacing 11/5/2015 11/5/2015 R S U Sumedang
4 M Sabits Z 0000417848174 Cibeusi 11/7/2015 11/7/2015 R S U Sumedang
5 Ai Nurhayati 0001008297494 Cilayung 11/8/2015 11/8/2015 R S U Sumedang
6 Aneng 0000462499683 Jatiroke 11/8/2015 11/8/2015 R S U Sumedang
7 Neni 0000462499863 Cilayung 11/9/2015 11/9/2015 R S U Sumedang
8 Reni Nopianti 0000165877211 Hegarmanah 11/21/2015 11/21/2015 R S U Sumedang
9 Ina Rosmayanti 0000461982216 Cileles 11/22/2015 11/22/2015 R S U Sumedang
10 Rosita 0000462947141 Hegarmanah 11/24/2015 11/24/2015 R S U Sumedang
11 Mimin 0000461857397 Cipacing 11/24/2015 11/24/2015 R S U Sumedang
12 Idah m 0001830341136 Sayang 11/25/2015 11/25/2015 R S U Sumedang
Terbilang : Dua Juta Sembilan Ratus Empat Puluh Ribu Rupiah
Mengetahui
Puskesmas DT

NIP.19641030.200212.1.002 NIP.19701221.1
Nama UPTD : Puskesmas DTP Jatinangor tidak diklaim ,blangko dan nota bensin hilang
Pelayanan : RITP
Tanggal
No Nama Pasien No Peserta Alamat No Hp. Tujuan
Pelayanan
Tanggal Tanggal
Masuk Pulang
1 Pri Mulyati 0001008271607 Cisempur 1/3 11/16/2015 11/16/2015 R S U Sumedang
2 Mintarsih 0000462927047 Hegarmanah 2/13 11/18/2015 11/18/2015 R S U Sumedang
3 Dana Sujana 0000461750567 Cilayung 2/8 11/21/2015 11/21/2015 R S U Sumedang
4 Wawan Setiawan 0000462577061 Cisempur 2/2 11/23/2015 11/23/2015 R S U Sumedang
5 Epi Toharudin 0000462866883 Cilayung 4/9 11/25/2015 11/25/2015 R S U Sumedang
Jumlah
Mengetahui
Puskesmas DT

NIP.19641030.200212.1.002 NIP.19701221.1
tahun 2016
Pelayanan : RITP
Tanggal
Pelayanan
Tanggal Tanggal
Masuk Pulang
1 Yuliyani 0001807025319 Cilayung 1/21/2016 1/21/2016 R S U Sumedang
2 Santi 0001857608954 Cibeusi 1/30/2016 1/30/2016 R S U Sumedang
Jumlah
Terbilang : Lima Ratus Sepuluh Ribu Rupiah
Mengetahui
NIP.19641030.200212.1.002

Pelayanan : RITP
Tanggal
Pelayanan
Tanggal Tanggal
Masuk Pulang
1 Dewi Suminar 0001882464838 Cipacing 2/1/2016 2/1/2016 R S U Sumedang
2 Iis Kurniawati 0000462357292 Sayang 2/2/2016 2/2/2016 R S U Sumedang
3 Rini Mulyani 0000462836979 Hegarmanah 2/3/2016 2/3/2016 R S U Sumedang
4 Eni Rohaeni 0000461727617 Mekargalih 2/4/2016 2/4/2016 R S U Sumedang
5 Shafa Arrumaisha 0001718195398 Cipacing 2/10/2016 2/10/2016 R S U Sumedang
6 Rosid 00000506321864 Cileles 2/11/2016 2/11/2016 R S U Sumedang
7 Ussi 0000462011433 Cisempur 2/13/2016 2/13/2016 R S U Sumedang
8 Rosmayanti 0000462379937 Sayang 2/15/2016 2/15/2016 R S U Sumedang
9 Marlina 0000462019465 Cipacing 2/17/2016 2/17/2016 R S U Sumedang
10 Lina Herlina 0000462535907 Cileles 2/17/2016 2/17/2016 R S U Sumedang
11 Novi Afriyanto 0000462519099 Sayang 2/23/2016 2/23/2016 R S U Sumedang
12 Rosminar 0001003484441 Cikeruh 2/24/2016 2/24/2016 R S U Sumedang
13 Euis danengsih 0000058118624 Jatiroke 2/26/2016 2/26/2016 R S U Sumedang
14 Diah Lestari 0001008276219 Jatiroke 2/27/2016 2/27/2016 R S U Sumedang
15 Rosmini 0000462066524 Cipacing 2/27/2016 2/27/2016 R S U Sumedang
16 Ilmayasari 0001810700234 Sukasari 2/28/2016 2/28/2016 R S U Sumedang
Jumlah
Terbilang : Empat Juta Delapan puluh Ribu Rupiah
Mengetahui

NIP.19641030.200212.1.002

Bulan : March 2016
Pelayanan : RITP
Tanggal
Pelayanan
Tanggal Tanggal
Masuk Pulang
1 Rodyan 0000462482469 Cisempur 3/1/2016 3/1/2016 R S U Sumedang
2 Nurhayati 0001126226575 Hegarmanah 3/2/2016 3/2/2016 R S U Sumedang
3 Arip 0000462963497 Cisempur 3/5/2016 3/5/2016 R S U Sumedang
4 Ahmad Soleh 0000209832513 Cipacing 3/9/2016 3/9/2016 R S U Sumedang
5 Ade Partini 0000463196305 Cipacing 3/10/2016 3/10/2016 R S U Sumedang
6 Eti Sumiati 0000462427931 Cintamulya 3/10/2016 3/10/2016 R S U Sumedang
7 Nena 0001969748583 Hegarmanah 3/21/2016 3/21/2016 R S U Sumedang
8 Kartini 0001008296425 Cilayung 3/24/2016 3/24/2016 R S U Sumedang
Jumlah
Terbilang : Dua Juta Empat puluh Ribu Rupiah
Mengetahui

NIP.19641030.200212.1.002
Bulan : April 2016
Pelayanan : RJTP
Tanggal
Pelayanan
Tanggal Tanggal
Masuk Pulang
1 Anita Ermawati 0001666245789 Cipacing 4/3/2016 4/3/2016 R S U Sumedang
2 Enas 0002038687874 Sayang 4/3/2016 4/3/2016 R S U Sumedang
3 Siti Murni 0000164687736 Cileles 4/6/2016 4/6/2016 R S U Sumedang
4 Tuti Widiastuti 0000462640329 Cibeusi 4/7/2016 4/7/2016 R S U Sumedang
5 Entang Tarliah 0000462746935 Cibeusi 4/10/2016 4/10/2016 R S U Sumedang
6 Leni 0000462368193 Sayang 4/12/2016 4/12/2016 R S U Sumedang
7 Neng Kartini 0002033823892 Cintamulya 4/13/2016 4/13/2016 R S U Sumedang
8 Rini Setiani 0000461719866 Hegarmanah 4/15/2016 4/15/2016 R S U Sumedang
9 Mita Anggraeni 0001008279156 Hegarmanah 4/19/2016 4/19/2016 R S U Sumedang
10 Suryani 0001008257657 Sayang 4/19/2016 4/19/2016 R S U Sumedang
11 Ipah 0000462615052 Cileles 4/21/2016 4/21/2016 R S U Sumedang
12 Rosmini 00004626066524 Cipacing 4/22/2016 4/22/2016 R S U Sumedang
13 Maman Suherman 0000462505601 Cipacing 4/25/2016 4/25/2016 R S U Sumedang
14 Ecin 0000460105187 Hegarmanah 4/25/2016 4/25/2016 R S U Sumedang
15 Nene K 0000462134259 Cilayung 4/29/2016 4/29/2016 R S U Sumedang
Jumlah
Terbilang : Tiga Juta Delapan Ratus Dua Puluh Lima Ribu Rupiah
Mengetahui

NIP.19641030.200212.1.002
REKAPITULASI KLAIM RUJUKAN JAMINAN KESEHATAN NASIONAL (JKN) LUAR DA
Bulan : April 2016
Pelayanan : RJTP
Tanggal
Pelayanan
Tanggal Tanggal
Masuk Pulang
1 Herna 0001008296302 Cilayung 4/27/2016 4/27/2016 R S J Prop JABAR
Jumlah
Terbilang : Tujuh Ratus Sembilan Puluh Delapan Ribu Rupiah
Mengetahui

NIP.19641030.200212.1.002
Bulan : May 2016
Pelayanan : RJTP
Tanggal
Pelayanan
Tanggal Tanggal
Masuk Pulang
1 Sumiati 0001664664052 Mekargalih 5/3/2016 5/3/2016 RSUD Sumedang
2 Suvandi 0001425455627 Cimanggung 5/4/2016 5/4/2016 RSUD Sumedang
3 Waryati 000462665878 Jatiroke 5/10/2016 5/10/2016 RSUD Sumedang
4 Ahyo 0001299435827 Cisempur 5/11/2016 5/11/2016 RSUD Sumedang
5 Heni M 0000461731972 Cilayung 5/16/2016 5/16/2016 RSUD Sumedang
6 M.Fachri 0001008266387 Cinta Mulya 5/17/2016 5/17/2016 RSUD Sumedang
7 Dedi apendi 0001666362576 Sawah Dadap 5/18/2016 5/18/2016 RSUD Sumedang
8 Asep Yadi M 0001263643468 Cibeusi 5/23/2016 5/23/2016 RSUD Sumedang
9 Mimin 0001008261516 Mekargalih 5/27/2016 5/27/2016 RSUD Sumedang
10 Ika Kartika 0000462685395 Sayang 5/30/2016 5/30/2016 RSUD Sumedang
Jumlah
Terbilang : Dua Juta Lima Ratus Lima Puluh Ribu Rupiah
Mengetahui

NIP.19641030.200212.1.002

Bulan : June 2016
Pelayanan : RJTP
Tanggal
Pelayanan
Tanggal Tanggal
Masuk Pulang
1 Tita Puspita 0001895154693 Cipacing 6/3/2016 6/3/2016 R S U Sumedang
2 Enah Supianah 0000461943077 Cibeusi 6/4/2016 6/4/2016 R S U Sumedang
3 Rukmana 0000461894951 Hegarmanah 6/9/2016 6/9/2016 R S U Sumedang
4 Novianti 0000462565629 Cisempur 6/9/2016 6/9/2016 R S U Sumedang
5 Yanti 0000462442667 Cileles 6/10/2016 6/10/2016 R S U Sumedang
6 Yeyen Asriani 0001441609885 Sukasari 6/10/2016 6/10/2016 R S U Sumedang
7 Aldi Muhammad 0000462949244 Hegarmanah 6/11/2016 6/11/2016 R S U Sumedang
8 Siska Meilani 0002053435792 Jatiroke 6/11/2016 6/11/2016 R S U Sumedang
9 Saripudin 0000462882475 Cisempur 6/13/2016 6/13/2016 R S U Sumedang
10 Ika santika 0000464699384 Cintamulya 6/14/2016 6/14/2016 R S U Sumedang
11 Rati 0000462011984 Cisempur 6/15/2016 6/15/2016 R S U Sumedang
12 Ida Ningsih 0002059135784 Cipacing 6/16/2016 6/16/2016 R S U Sumedang
13 Idit Santika 0000462487004 Cipacing 6/17/2016 6/17/2016 R S U Sumedang
14 Cucu Sumiati 0001008283048 Hegarmanah 6/19/2016 6/19/2016 R S U Sumedang
15 Iyah Supinah 0000462725302 Cipacing 6/25/2016 6/25/2016 R S U Sumedang
16 Oot 0000460814142 Cilayung 6/27/2016 6/27/2016 R S U Sumedang
17 Maemunah 0000500970666 Jatiroke 6/28/2016 6/28/2016 R S U Sumedang
18 Nunung J 0000462580547 Cileles 6/30/2016 6/30/2016 R S U Sumedang
Jumlah
Terbilang : Empat Juta Lima Ratus Sembilan Puluh Ribu Rupiah
Mengetahui

NIP.19641030.200212.1.002

Bulan : July 2016
Pelayanan : RJTP
Tanggal
Pelayanan
Tanggal Tanggal
Masuk Pulang
1 Suharya 000462926632 Hegarmanah 7/4/2016 7/4/2016 RSUD Sumedang
2 Mira Supriyati 000463807034 Cilayung 7/16/2016 7/16/2016 RSUD Sumedang
3 Santi Susanti 000462816573 Cileles 7/17/2016 7/17/2016 RSUD Sumedang
4 Maman suherman 0001392947447 Cisempur 7/22/2016 7/22/2016 RSUD Sumedang
5 Sari Lestari 000461898494 Cileles 7/24/2016 7/24/2016 RSUD Sumedang
6 Awang Suhayati 0001519383699 Cikeruh 7/25/2016 7/25/2016 RSUD Sumedang
Jumlah
Terbilang : Satu Juta Lima Ratus Tiga Puluh Ribu Rupiah
Mengetahui

NIP.19641030.200212.1.002

Bulan : July 2016
Pelayanan : RJTP
Tanggal Pelayanan
Tanggal Tanggal
Masuk Pulang
1 Suharya 000462926632 Hegarmanah 7/4/2016 7/4/2016 RSUD Sumedang
2 Mira Supriyati 000463807034 Cilayung 7/16/2016 7/16/2016 RSUD Sumedang
4 Maman suherman 0001392947447 Cisempur 7/22/2016 7/22/2016 RSUD Sumedang
5 Sari Lestari 000461898494 Cileles 7/24/2016 7/24/2016 RSUD Sumedang
Jumlah
Terbilang : Satu Juta Dua Ratus Tujuh Puluh Lima Ribu Rupiah
Mengetahui

NIP.19641030.200212.1.002

Bulan : August 2016
Pelayanan : RJTP
Tanggal Pelayanan
Tanggal Tanggal
Masuk Pulang
1 Dedi 0001008281799 Hegarmanah 8/5/2016 8/5/2016 RSUD Sumedang
2 Rohayati 000462467788 Cipacing 8/6/2016 8/6/2016 RSUD Sumedang
3 Sariningsih 000462657161 Sayang 8/8/2016 8/8/2016 RSUD Sumedang
4 Ijah 0001008296605 Cilayung 8/9/2016 8/9/2016 RSUD Sumedang
5 Deva D 0001997553688 Hegarmanah 8/18/2016 8/18/2016 RSUD Sumedang
6 Didi S 0000462715975 Sawah Dadap 8/20/2016 8/20/2016 RSUD Sumedang
7 Suherman 0001288401423 Cileles 8/20/2016 8/20/2016 RSUD Sumedang
8 Sri Yulia 0000201129851 Cileles 8/20/2016 8/20/2016 RSUD Sumedang
9 Lia K 0002064739443 Jatiroke 8/21/2016 8/21/2016 RSUD Sumedang
10 Rupita 000462529326 Hegarmanah 8/22/2016 8/22/2016 RSUD Sumedang
11 Nia k 0002053960918 Hegarmanah 8/24/2016 8/24/2016 RSUD Sumedang
12 Santika 000462187405 Cipacing 8/26/2016 8/26/2016 RSUD Sumedang
Jumlah
Terbilang : Tiga Juta Enam Puluh Ribu Rupiah
Mengetahui

NIP.19641030.200212.1.002

Pelayanan : RJTP
Tanggal Pelayanan
Tanggal Tanggal
Masuk Pulang
2 Niah 000461786859 Hegarmanah RSUD Sumedang
3 Yunengsih 000462757239 Cilayung RSUD Sumedang
4 Titing 0001303186037 Jatiroke RSUD Sumedang
5 Iis Waliyah 000461906998 Cibeusi RSUD Sumedang
6 Ahya 000462868683 Sukasari RSUD Sumedang
7 Puja 000462743436 Cileles RSUD Sumedang
8 Santi 000462816573 Cileles RSUD Sumedang
9 Dedi 000462479578 Jatiroke RSUD Sumedang
10 Devi Nurlaelasari 0001008294761 Hegarmanah RSUD Sumedang
Jumlah
Mengetahui

NIP.19641030.200212.1.002
REKAPITULASI KLAIM RUJUKAN JAMINAN KESEHATAN NASIONAL (JKN) LUAR DA

Pelayanan : RJTP
Tanggal
Pelayanan
Tanggal Tanggal
Masuk Pulang
1 Niah 000461786859 Hegarmanah 4/27/2016 4/27/2016 R S J Prop JABAR
Jumlah
Terbilang : Tujuh Ratus Sembilan Puluh Delapan Ribu Rupiah
Mengetahui
NIP.19641030.200212.1.002

Pelayanan : RJTP
Tanggal Pelayanan
Tanggal Tanggal
Masuk Pulang
1 Iin Susanti 0001522337769 Jatimukti 10/2/2016 10/2/2016 RSUD Sumedang
2 Lisna Lisnawati 0000462816578 Cileles 10/7/2016 10/7/2016 RSUD Sumedang
3 Susi 0000462563638 Cileles 10/10/2016 10/10/2016 RSUD Sumedang
4 Mamat Sumirat 0000460053325 Hegarmanah 10/22/2016 10/22/2016 RSUD Sumedang
5 Omah Halimah 0000463839941 Cileles 10/24/2016 10/24/2016 RSUD Sumedang
6 Suranti 0002093286464 Cipacing 10/28/2016 10/28/2016 RSUD Sumedang
Jumlah
Terbilang : Satu Juta Lima Ratus Tiga Puluh Ribu Rupiah
Mengetahui

NIP.19641030.200212.1.002

Pelayanan : RJTP
Tanggal Pelayanan
Tanggal Tanggal
Masuk Pulang
1 Cucu 00004627724929 Cileles 1/11/2016 1/11/2016 RSUD Sumedang
2 Anti Sunarti 0000461644277 Cibeusi 3/11/2016 3/11/2016 RSUD Sumedang
3 Yayah 0000461616129 Cilayung 5/11/2016 5/11/2016 RSUD Sumedang
4 Solehudin 0000461779975 Cibeusi 19/11/2016 19/11/2016 RSUD Sumedang
5 Siti Nurhasanah 0001803919432 Cileles 14/11/2016 14/11/2016 RSUD Sumedang
6 Ira Turniasih 0001852601692 Cikeruh 21/11/2016 21/11/2016 RSUD Sumedang
7 Cacah 0001912755159 Hegarmanah 21/11/2016 21/11/2016 RSUD Sumedang
8 Rizka rahmah 0000055619008 Cinanjung 24/11/2016 24/11/2016 RSU AMC
9 Nanah 0001008285625 Cibeusi 25/11/2016 25/11/2016 RSUD Sumedang
10 Yeyet 0000463335129 Cilayung 28/11/2016 28/11/2016 RSUD Sumedang
Jumlah
Terbilang : Tiga Juta s Tiga Puluh Ribu Rupiah
Mengetahui

NIP.19641030.200212.1.002

Bulan : Januari 2017
Pelayanan : RJTP
Tanggal Pelayanan
Tanggal Tanggal
Masuk Pulang
1 Rika Santika 0001008295378 Cilayung 2/1/2017 2/1/2017 RSUD Sumedang
2 Sri Kurniati 0001670728151 Cileles 4/1/2017 4/1/2017 RSUD Sumedang
3 Sri Laela 0001832104956 Hegarmanah 7/1/2017 7/1/2017 RSUD Sumedang
4 Ade Rohman 0000462219838 Cipacing 10/1/2017 10/1/2017 RSUD Sumedang
5 Fitri Wulan sari 0002198833964 Cikeruh 11/1/2017 11/1/2017 RSUD Sumedang
6 Anih 0000462791856 Cileles 13/1/2017 13/1/2017 RSUD Sumedang
7 Egi Agustin 0000461143124 Jatiroke 16/1/2017 16/1/2017 RSUD Sumedang
8 Rosita 0000462378205 Jatimukti 18/1/2017 18/1/2017 RSUD Sumedang
9 Rostiawati 0001008252641 Cipacing 21/1/2017 21/1/2017 RSUD Sumedang
10 Irma sari 0000462666521 Cileles 23/1/2017 23/1/2017 RSUD Sumedang
11 Aliah 0000461874688 Jatimukti 31/1/2017 31/1/2017 RSUD Sumedang
Jumlah
Terbilang : Dua Juta Delapan Ratus Lima Ribu Rupiah
Mengetahui

NIP.19641030.200212.1.002

Bulan : Pebruari 2017
Pelayanan : RJTP
Tanggal Pelayanan
Tanggal Tanggal
Masuk Pulang
1 Popon 0002000054002 Hegarmanah 1/2/2017 1/2/2017 RSUD Sumedang
2 Endang 0000462352926 Cintamulya 1/2/2017 1/2/2017 RSUD Sumedang
3 Onih 0000461822016 Mekar Asih 4/2/2017 4/2/2017 RSUD Sumedang
4 Mirna Julianni 0000462190363 Cipacing 5/2/2017 5/2/2017 RSUD Sumedang
5 Suryati 0001997368356 Jatiroke 7/2/2017 7/2/2017 RSUD Sumedang
6 Santi Januaristi 0001522845257 Cileles 9/2/2017 9/2/2017 RSUD Sumedang
7 Herlina 0000462083679 Cilayung 20/2/2017 20/2/2017 RSUD Sumedang
Jumlah
Terbilang : Satu Juta Tujuh RatusDelapan Puluh Lima Ribu Rupiah
Mengetahui

NIP.19641030.200212.1.002
Bulan : Maret 2017
Pelayanan : RJTP
Tanggal Pelayanan
Tanggal Tanggal
Masuk Pulang
1 Desi Andriani 0000504655582 Hegarmanah 4/3/2017 4/3/2017 RSUD Sumedang
2 Kokom 0000461799437 Hegarmanah 8/3/2017 8/3/2017 RSUD Sumedang
3 Dewi Purnama 0000461459632 Cileles 10/3/2017 10/3/2017 RSUD Sumedang
4 Rosdiana 0001008281204 Hegarmanah 13/3/2017 13/3/2017 RSUD Sumedang
5 Lina Susliawati 0000462259686 Cipacing 15/3/2017 15/3/2017 RSUD Sumedang
6 Evi Novianti 0000462847476 Cikeruh 24/3/2017 24/3/2017 RSUD Sumedang
7 Enip Ependi 0000056652456 Hegarmanah 25/3/2017 25/3/2017 RSUD Sumedang
8 Lilis Setiawati 0000064989369 Cisempur 25/3/2017 25/3/2017 RSUD Sumedang
9 Sri Kristiani 0001147826035 Solokan Jeruk 30/3/2017 30/3/2017 RSUD Sumedang
Jumlah
Terbilang : Dua Juta Dua Ratus Sembilan Puluh Lima Ribu Rupiah
Mengetahui

NIP.19641030.200212.1.002

Bulan : April 2017
Pelayanan : RJTP
Tanggal Pelayanan
Tanggal Tanggal
Masuk Pulang
1 Sri Wahyuni 0002225890721 Cileles 2/4/2017 2/4/2017 RSUD Sumedang
2 Risma 0000462725638 Cileles 3/4/2017 3/4/2017 RSUD Sumedang
3 Nena Rosmayati 0000462240448 Mekargalih 4/4/2017 4/4/2017 RSUD Sumedang
4 kokom Komariah 0000462084006 Cilayung 10/4/2017 10/4/2017 RSUD Sumedang
5 Hernawati 0001515439427 Cipacing 12/4/2017 12/4/2017 RSUD Sumedang
6 Tina Martina 0000418942787 Cileunyi 13/4/2017 13/4/2017 RSUD Sumedang
7 Kokom Komasih 0000461799437 Hegarmanah 16/4/2017 16/4/2017 RSUD Sumedang
8 Casrini 0001283940369 Cinta Mulya 16/4/2017 16/4/2017 RSUD Sumedang
9 Risa Roswati 0000462763912 Cileles 27/4/2017 27/4/2017 RSUD Sumedang
Jumlah
Terbilang : Dua Juta Dua Ratus Sembilan Puluh Lima Ribu Rupiah
Mengetahui

NIP.19641030.200212.1.002
mei 2017

Bulan : MEI 2017
Pelayanan : RJTP
Tanggal Pelayanan
Tanggal Tanggal
Masuk Pulang
1 Santi Rostiana 0000462262961 Mekargalih 2/5/2017 2/5/2017 RSUD Sumedang
2 Tati Rahmawati 0002214327903 Cisempur 3/5/2017 3/5/2017 RSUD Sumedang
3 Dayat Sudrajat 0001008282666 Hegarmanah 3/5/2017 3/5/2017 RSUD Sumedang
4 Iis Aisah 0001523269315 Hegarmanah 5/5/2017 5/5/2017 RSUD Sumedang
5 Siti Anisa 0000463406926 Cilayung 13/5/2017 13/5/2017 RSUD Sumedang
6 Dian Kusmiati 0001663047731 Cinta Mulya 21/5/2017 21/5/2017 RSUD Sumedang
7 Yayah Rokayah 0000461755449 Cibeusi 22/5/2017 22/5/2017 RSUD Sumedang
8 Isah 0001008251886 Cipacing 22/5/2017 22/5/2017 RSUD Sumedang
9 Srina 0000462037498 Cisempur 23/5/2017 23/5/2017 RSUD Sumedang
10 Tuti Setiawati 0001190293896 Cicalengka 26/5/2017 26/5/2017 RSUD Sumedang
11 Juju Juariah 0001997568246 cisempur 31/5/2017 31/5/2017 RSUD Sumedang
12 Adah 0000462516761 Cileles 31/5/2017 31/5/2017 RSUD Sumedang
13 Cici Wulandari 0000462294235 Sawah Dadap 31/5/2017 31/5/2017 RSUD Sumedang
Jumlah
Terbilang : Tiga Juta Tiga Ratus Lima Belas Ribu Rupiah
Mengetahui

NIP.19641030.200212.1.002
Bulan : JUNI 2017
Pelayanan : RJTP
Tanggal Pelayanan
Tanggal Tanggal
Masuk Pulang
1 Dede Wahyuni 0000462019252 Cileles 2/6/2017 2/6/2017 RSUD Sumedang
2 Ita Rosita 0002242747912 Cibeusi 4/6/2017 4/6/2017 RSUD Sumedang
3 Memeh 0000462320212 Hegarmanah 7/6/2017 7/6/2017 RSUD Sumedang
4 Tuti Fatmawati 0000461764269 Cilayung 8/6/2017 8/6/2017 RSUD Sumedang
5 Sari Nengsih 0001008272867 Cisempur 10/6/2017 10/6/2017 RSUD Sumedang
6 Elis saripah 0002242733859 Sukasari 12/6/2017 12/6/2017 RSUD Sumedang
7 Wati Kartini 0000460049444 Hegarmanah 14/6/2017 14/6/2017 RSUD Sumedang
8 Yuliana 0000461145341 Cilayung 14/6/2017 14/6/2017 RSUD Sumedang
9 Ai Devi kania 0002250709896 Cilayung 17/6/2017 17/6/2017 RSUD Sumedang
10 Devi Gustriani 0000462773439 Cilayung 17/6/2017 17/6/2017 RSUD Sumedang
11 Tika sartika 0000462038038 Cikeruh 20/6/2017 20/6/2017 RSUD Sumedang
12 Rahmayati 0002244415443 Jatimukti 21/6/2017 21/6/2017 RSUD Sumedang
13 Dini Mailani 0001997167757 Hegarmanah 23/6/2017 23/6/2017 RSUD Sumedang
14 Tati Noviyanti 0000462225745 Mekar Galih 23/6/2017 23/6/2017 RSUD Sumedang
Jumlah
Terbilang : Tiga Juta Lima Ratus Tujuh Puluh Ribu Rupiah
Mengetahui

NIP.19641030.200212.1.002
9 Ujang Tantan N 0001008266027 Cinta Mulya 16/6/2017 16/6/2017 RSUD Sumedang

Bulan : July 2017
Pelayanan : RJTP
Tanggal Pelayanan
Tanggal Tanggal
Masuk Pulang
1 Ai Hasanah 0001725330824 Cileles 1/7/2017 1/7/2017 RSUD Sumedang
2 Dewi Aprianti 0001997608915 Jatimukti 1/7/2017 1/7/2017 RSUD Sumedang
3 Lia Rosmiyati 0000461892453 Hegarmanah 2/7/2017 2/7/2017 RSUD Sumedang
4 Zaskia Agustina 0001796887179 Tanjungsari 6/7/2017 6/7/2017 RSUD Sumedang
5 Rani Hoerunissa 0001008266727 Cibeusi 6/7/2017 6/7/2017 RSUD Sumedang
6 Wiwin 0000462221572 Cipacing 13/7/2017 13/7/2017 RSUD Sumedang
7 Ecep Kosasih 0000462145184 Cilayung 15/7/2017 15/7/2017 RS Pakuwon
8 Euis Komariyah 0002243488318 Cipacing 22/7/2017 22/7/2017 RSUD Sumedang
Jumlah
Terbilang : Dua Juta Empat Puluh Ribu Rupiah
Mengetahui
NIP.19721111.200604.2.017

Bulan : August 2017
Pelayanan : RJTP
Tanggal Pelayanan
Tanggal Tanggal
Masuk Pulang
1 Siti Sarah 0000463349698 Cilayung W-T 5/8/2017 5/8/2017 RSUD Sumedang
2 Iis Maesaroh 0000462551095 Cisempur S-T 5/8/2017 5/8/2017 RSUD Sumedang
3 Erum 0000462192794 Sayang R-T 8/8/2017 8/8/2017 RSUD Sumedang
4 Een Sumiati 0000461473029 Cileles W-T 10/8/2017 10/8/2017 RSUD Sumedang
5 Suharya 0000462926632 Hegarmanah K-T 10/8/2017 10/8/2017 RSUD Sumedang
6 Pipit Pitriani 0000461891957 Mekargalih S-T 10/8/2017 10/8/2017 RSUD Sumedang
7 Dianna H 0000462398545 Mekargalih W-T 12/8/2017 12/8/2017 RSUD Sumedang
8 Faridatun 0001693968319 Sayang S-T 12/8/2017 12/8/2017 RSUD Sumedang
9 Yayan Taryani 0000460088122 Hegarmanah S-T 13/8/2017 13/8/2017 RSUD Sumedang
10 Ai Nuraeni 0000462151787 Cilayung W-T 14/8/2017 14/8/2017 RSUD Sumedang
11 Ai Aminah 0000462624974 Sayang S-T 17/8/2017 17/8/2017 RSUD Sumedang
12 Lala Nurlaela 0001793708818 Cilayung W-T 29/8/2017 29/8/2017 RSUD Sumedang
13 Siti Hasanah 0001008272979 Hegarmanah S-T 30/8/2017 30/8/2017 RSUD Sumedang
Jumlah
Mengetahui
NIP.19721111.200604.2.017

Pelayanan : RJTP
Tanggal Pelayanan
Tanggal Tanggal
Masuk Pulang
1 Ela Suryaningsih 0000462724435 Mekargalih 1/9/2017 1/9/2017 RSUD Sumedang
2 Yuli Sity Aliah 0002234366604 Cinta Mulya W-T 8/9/2017 8/9/2017 RSUD Sumedang
3 Agus 0000461715502 Cilayung S-T 9/9/2017 9/9/2017 RSUD Sumedang
4 Nita Junita 0002196478809 Cileles R-T 12/9/2017 12/9/2017 RSUD Sumedang
5 Parni 0002263843563 Cileles W-T 12/9/2017 12/9/2017 RSUD Sumedang
6 Siti Aminah 0001008263457 Mekargalih K-T 12/9/2017 12/9/2017 RSUD Sumedang
7 Odang 0000195864333 Suka Sari S-T 20/9/2017 20/9/2017 RSUD Sumedang
8 Lisda 0000195864333 Cinanjung W-T 22/9/2017 22/9/2017 RSUD Sumedang
9 Karyan 0000462549712 Jatiroke S-T 26/9/2017 26/9/2017 RSUD Sumedang
10 Lili Sahli 0000418365628 Bojong Soang S-T 27/9/2017 27/9/2017 RSUD Sumedang
11 Yayah 0000462792227 Cileles W-T 27/9/2017 27/9/2017 RSUD Sumedang
Jumlah
Mengetahui
NIP.19721111.200604.2.017

Pelayanan : RJTP
Tanggal Pelayanan
Tanggal Tanggal
Masuk Pulang
1 0000462724435 Mekargalih 1/10/2017 RSUD Sumedang
2 0000462724435 Cinta Mulya W-T RSUD Sumedang
3 0000462724435 Cilayung S-T RSUD Sumedang
4 0000462724435 Cileles R-T RSUD Sumedang
5 0000462724435 Cileles W-T RSUD Sumedang
6 0000462724435 Mekargalih K-T RSUD Sumedang
7 0000462724435 Suka Sari S-T RSUD Sumedang
8 0000462724435 Cinanjung W-T RSUD Sumedang
9 0000462724435 Jatiroke S-T RSUD Sumedang
10 0000462724435 RSUD Sumedang
12 0000462724435 Bojong Soang S-T RSUD Sumedang
Jumlah
Mengetahui
NIP.19721111.200604.2.017

Pelayanan : RJTP
Tanggal Pelayanan
Tanggal Tanggal
Masuk Pulang
1 0000462724435 Mekargalih 1/10/2017 RSUD Sumedang
2 0000462724435 Cinta Mulya W-T RSUD Sumedang
3 0000462724435 Cilayung S-T RSUD Sumedang
4 0000462724435 Cileles R-T RSUD Sumedang
6 0000462724435 Mekargalih K-T RSUD Sumedang
7 0000462724435 Suka Sari S-T RSUD Sumedang
8 0000462724435 Cinanjung W-T RSUD Sumedang
9 0000462724435 Jatiroke S-T RSUD Sumedang
12 0000462724435 Bojong Soang S-T RSUD Sumedang
Jumlah
Mengetahui
NIP.19721111.200604.2.017

Pelayanan : RJTP
Tanggal Pelayanan
Tanggal Tanggal
Masuk Pulang
1 Dina Mulyani 0002285379988 Cimanggung W-T 2/11/2017 2/11/2017 RSUD Sumedang
2 Maya Maida 0000462224722 Mekargalih S-T 3/11/2017 3/11/2017 RSUD Sumedang
3 Siti Aisyah 0002282442884 Cipacing S-T 8/11/2017 8/11/2017 RSUD Sumedang
4 Iis Mulyaningsih 0001514775947 Cipacing S-T 9/11/2017 9/11/2017 RSUD Sumedang
5 Dadang 0000462039491 Cilayung I-T 11/11/2017 11/11/2017 RSUD Sumedang
6 Sri Hanipah S 0001901303829 Jatimukti S-T 15/11/2017 15/11/2017 RSUD Sumedang
7 Elis 0000463162825 Cimanggung W-Opik 18/11/2017 18/11/2017 RSUD Sumedang
8 Veny Indriani 0002033012136 Sayang S-T 18/11/2017 18/11/2017 RSUD Sumedang
9 Fitriawati 0000461925178 Cileles W-T 20/11/2017 20/11/2017 RSUD Sumedang
10 Pandi 0000462841839 Cipacing Im-Opik 21/11/2017 21/11/2017 RSUD Sumedang
11 Dede Rosita 0001522819956 Hegarmanah S-T 24/11/2017 24/11/2017 RSUD Sumedang
12 Rismayanti 0000461943652 Cisempur S-T 30/11/2017 30/11/2017 RSUD Sumedang
Jumlah
Mengetahui
NIP.19721111.200604.2.017

Pelayanan : RJTP
Tanggal Pelayanan
Tanggal Tanggal
Masuk Pulang
1 Dina Mulyani 0002285379988 Cimanggung W-T 2/11/2017 2/11/2017 RSUD Sumedang
2 Maya Maida 0000462224722 Mekargalih S-T 3/11/2017 3/11/2017 RSUD Sumedang
3 Siti Aisyah 0002282442884 Cipacing S-T 8/11/2017 8/11/2017 RSUD Sumedang
4 Iis Mulyaningsih 0001514775947 Cipacing S-T 9/11/2017 9/11/2017 RSUD Sumedang
5 Dadang 0000462039491 Cilayung I-T 11/11/2017 11/11/2017 RSUD Sumedang
6 Sri Hanipah S 0001901303829 Jatimukti S-T 15/11/2017 15/11/2017 RSUD Sumedang
7 Elis 0000463162825 Cimanggung W-Opik 18/11/2017 18/11/2017 RSUD Sumedang
8 Veny Indriani 0002033012136 Sayang S-T 18/11/2017 18/11/2017 RSUD Sumedang
9 Fitriawati 0000461925178 Cileles W-T 20/11/2017 20/11/2017 RSUD Sumedang
10 Pandi 0000462841839 Cipacing Im-Opik 21/11/2017 21/11/2017 RSUD Sumedang
11 Dede Rosita 0001522819956 Hegarmanah S-T 24/11/2017 24/11/2017 RSUD Sumedang
12 Rismayanti 0000461943652 Cisempur S-T 30/11/2017 30/11/2017 RSUD Sumedang
Jumlah
Mengetahui
NIP.19721111.200604.2.017

Pelayanan : RJTP
Tanggal Pelayanan
Tanggal Tanggal
Masuk Pulang
1 Neng Elis Trisnawati 0001008296447 Cilayung k-t 6/12/2017 6/12/2017 RSUD Sumedang
2 Jakaria 0001008298124 Cilayung r-t 9/12/2017 9/12/2017 RSUD Sumedang

3 Gunawan 0002053338849 Cicalengka R-T 12/12/2017 12/12/2017 RSUD Sumedang
4 Trias Ambar Dewi 000462183974 Sayang W-T 14/12/2017 14/12/2017 RSUD Sumedang
5 Tika Kartika 0001666408127 Mekargalih W-T 20/12/2017 20/12/2017 RSUD Sumedang
6 Odah Siti Saodah 000462759838 Cikeruh Sr-T 19/12/2017 19/12/2017 RSUD Sumedang
7 Tia Dwi Oktaviani 0001008290283 Cileles Sr-T 11/12/2017 11/12/2017 RSUD Sumedang
8 Eva Farida 0000462332823 Cintamulya w-t 3/12/2017 3/12/2017 RSUD Sumedang
9 Rusniawati 0000462149021 Cilayung w-opik 9/12/2017 9/12/2017 RSUD Sumedang
10 Fitri Yani 0000459996772 Hegarmanah W-T 17/12/2017 17/12/2017 RSUD Sumedang
11 Aas 0000462146747 Cilayung R-OPIK 25/12/2017 25/12/2017 RSUD Sumedang
12 Ratna Monika 0000462627448 Cimanggung W-T 27/12/2017 27/12/2017 RSUD Sumedang
Jumlah
Mengetahui
NIP.19721111.200604.2.017

Pelayanan : RJTP
Tanggal Pelayanan
Tanggal Tanggal
Masuk Pulang
1 Eva Farida 0000462332823 Cintamulya w-t 3/12/2017 3/12/2017 RSUD Sumedang
2 Neng Elis Trisnawati 0001008296447 Cilayung k-t 6/12/2017 6/12/2017 RSUD Sumedang
3 Jakaria 0001008298124 Cilayung r-t 9/12/2017 9/12/2017 RSUD Sumedang

4 Rusniawati 0000462149021 Cilayung w-opik 9/12/2017 9/12/2017 RSUD Sumedang
5 Tia Dwi Oktaviani 0001008290283 Cileles Sr-T 11/12/2017 11/12/2017 RSUD Sumedang
6 Gunawan 0002053338849 Cicalengka R-T 12/12/2017 12/12/2017 RSUD Sumedang
7 Trias Ambar Dewi 000462183974 Sayang W-T 14/12/2017 14/12/2017 RSUD Sumedang
8 Fitri Yani 0000459996772 Hegarmanah W-T 17/12/2017 17/12/2017 RSUD Sumedang
9 Odah Siti Saodah 000462759838 Cikeruh Sr-T 19/12/2017 19/12/2017 RSUD Sumedang
10 Tika Kartika 0001666408127 Mekargalih W-T 20/12/2017 20/12/2017 RSUD Sumedang
11 Aas 0000462146747 Cilayung R-OPIK 25/12/2017 25/12/2017 RSUD Sumedang
12 Ratna Monika 0000462627448 Cimanggung W-T 27/12/2017 27/12/2017 RSUD Sumedang
Jumlah
Mengetahui
NIP.19721111.200604.2.017

Bulan : Januari 2018
Pelayanan : RJTP
Tanggal Pelayanan
Tanggal Tanggal
Masuk Pulang
1 Yuliani 0000462801442 Cipacing Sr-Op 1/1/2018 1/1/2018 RSUD Sumedang
2 Waryati 0000462665878 Jatiroke Sr-Op 1/1/2018 1/1/2018 RSUD Sumedang
3 Isam 0001437830381 Jakarta barat w-t 1/1/2018 1/1/2018 RSUD Sumedang
4 Elti Fitriyani 0000462280115 Hegarmanah r-0p 2/1/2018 2/1/2018 RSUD Sumedang
Eghi Ramadhani 0000057994547 r-0p 2/1/2018 2/1/2018 RSUD Sumedang
5 Nining Komariah 0002294229328 Hegarmanah Sr-T 7/1/2018 7/1/2018 RSUD Sumedang
6 Lilis Jubaedah 0000461375166 Kota Kaler Sr-T 9/1/2018 9/1/2018 RSUD Sumedang
7 Kartiem 0000462129772 Jatisari R_T 11/1/2018 11/1/2018 RSUD Sumedang
8 Ayi Rohmiati 0002310289661 Hegarmanah Sr-T 12/1/2018 12/1/2018 RSUD Sumedang
9 Aman 0001008285906 Cibeusi R_T 12/1/2018 12/1/2018 RSUD Sumedang
10 Nani Sumarni 0002314863909 Cibeusi Sr-T 24/1/2018 24/1/2018 RSUD Sumedang
Jumlah
Mengetahui
NIP.19721111.200604.2.017

Pelayanan : RJTP
Tanggal Pelayanan
Tanggal Tanggal
Masuk Pulang
1 Popon 0000462668218 Sukasari kiki-tat 1/2/2018 1/2/2018 RSUD Sumedang
2 Rula milda sari 0000462547337 Lunjuk im-tat 2/2/2018 2/2/2018 RSUD Sumedang
3 Yayah Duriah 0002181351824 Sukasari wi-op 5/2/2018 5/2/2018 RSUD Sumedang
4 Fahri Muhammad 0000461431541 Mekarjaya kiki-tat 6/2/2018 6/2/2018 RSUD Sumedang
5 Ai Minah 0000461942842 Cikeruh Sri-op 24/2/2018 24/2/2018 RSUD Sumedang
6 Tasirah 0001089619121 Cintamulya Tetih-tat 25/2/2018 25/2/2018 RSUD Sumedang
7 Icah 0000463428156 Sukasari Sep-tat 26/2/2018 26/2/2018 RSUD Sumedang
8 Tuti Herlina 0001786071903 Cintamulya Sr-Op 28/2/2018 28/2/2018 RSUD Sumedang
9 Rahmat 0000463502654 Cilayung im-op 28/2/2018 28/2/2018 RS Harapan Keluarga
10 Sutiano 0000461167031 Cilayung im-op 28/2/2018 28/2/2018 RSUD Sumedang
Jumlah
Terbilang : Dua Juta Sembilan Ratus Lima Puluh Ribu Rupiah
Mengetahui
NIP.19721111.200604.2.017
Uang Harian
Bahan
Sewa Jumlah
Bakar Pendamping Sopir
25,000 50,000 100,000 70,000 245,000

25,000 50,000 100,000 70,000 245,000
25,000 50,000 100,000 70,000 245,000
25,000 50,000 100,000 70,000 245,000
25,000 50,000 100,000 70,000 245,000
25,000 50,000 100,000 70,000 245,000
25,000 50,000 100,000 70,000 245,000
25,000 50,000 100,000 70,000 245,000
25,000 50,000 100,000 70,000 245,000
25,000 50,000 100,000 70,000 245,000
25,000 50,000 100,000 70,000 245,000
25,000 50,000 100,000 70,000 245,000
300,000 600,000 1,200,000 840,000 2,940,000

Rupiah
Bendahara FKTP
Rina Mariani AMK

NIP.19701221.199803.2.003
Uang Harian
Bahan
Sewa Jumlah
25,000 50,000 100,000 70,000 245,000

25,000 50,000 100,000 70,000 245,000
25,000 50,000 100,000 70,000 245,000
25,000 50,000 100,000 70,000 245,000
25,000 50,000 100,000 70,000 245,000
25,000 50,000 100,000 70,000 245,000
25,000 50,000 100,000 70,000 245,000
25,000 50,000 100,000 70,000 245,000
25,000 50,000 100,000 70,000 245,000
225,000 450,000 900,000 630,000 2,205,000
Bendahara FKTP
Rina Mariani AMK

NIP.19701221.199803.2.003
Uang Harian
Bahan
Sewa Jumlah
25,000 50,000 100,000 70,000 245,000

25,000 50,000 100,000 70,000 245,000
25,000 50,000 100,000 70,000 245,000
25,000 50,000 100,000 70,000 245,000
100,000 200,000 400,000 280,000 980,000

ah
Bendahara FKTP
Rina Mariani AMK

NIP.19701221.199803.2.003
ONAL (JKN)
Sewa Bahan Uang Harian Jumlah

Bakar
Pendamping Sopir
25,000 50,000 100,000 70,000 245,000

25,000 50,000 100,000 70,000 245,000
25,000 50,000 100,000 70,000 245,000
25,000 50,000 100,000 70,000 245,000
25,000 50,000 100,000 70,000 245,000
125,000 250,000 500,000 350,000 1,225,000

upiah
Bendahara FKTP
Rina Mariani AMK

P.19701221.199803.2.003
ONAL (JKN)
Bahan
Sewa Uang Harian Jumlah
Bakar
Pendamping Sopir
25,000 50,000 100,000 70,000 245,000

25,000 50,000 100,000 70,000 245,000
25,000 50,000 100,000 70,000 245,000
25,000 50,000 100,000 70,000 245,000
25,000 50,000 100,000 70,000 245,000
25,000 50,000 100,000 70,000 245,000
25,000 50,000 100,000 70,000 245,000
25,000 50,000 100,000 70,000 245,000
25,000 50,000 100,000 70,000 245,000
25,000 50,000 100,000 70,000 245,000
25,000 50,000 100,000 70,000 245,000
25,000 50,000 100,000 70,000 245,000
300,000 600,000 1,200,000 840,000 2,940,000

Rupiah
Bendahara FKTP
Rina Mariani AMK

P.19701221.199803.2.003
bensin hilang
Bahan
Bakar
Pendamping Sopir
25,000 50,000 100,000 70,000 245,000

25,000 50,000 100,000 70,000 245,000
25,000 50,000 100,000 70,000 245,000
25,000 50,000 100,000 70,000 245,000
25,000 50,000 100,000 70,000 245,000
125,000 250,000 500,000 350,000 1,225,000
Bendahara FKTP
Rina Mariani AMK

P.19701221.199803.2.003
ONAL (JKN)
Bahan
Bakar
Pendamping Sopir
25,000 50,000 110,000 70,000 255,000

25,000 50,000 110,000 70,000 255,000
50,000 100,000 220,000 140,000 510,000
Bendahara FKTP
Rina Mariani AMK
NIP.19701221.199803.2.003
ONAL (JKN)
Bahan
Bakar
Pendamping Sopir
25,000 50,000 110,000 70,000 255,000

25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
400,000 800,000 1,760,000 1,120,000 4,080,000
Bendahara FKTP
Rina Mariani AMK

NIP.19701221.199803.2.003
ONAL (JKN)
Bahan
Bakar
Pendamping Sopir
25,000 50,000 110,000 70,000 255,000

25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
200,000 400,000 880,000 560,000 2,040,000
Bendahara FKTP
Rina Mariani AMK

NIP.19701221.199803.2.003
ONAL (JKN)
Bahan
Bakar
Pendamping Sopir
25,000 50,000 110,000 70,000 255,000

25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
375,000 750,000 1,650,000 1,050,000 3,825,000

Rupiah
Bendahara FKTP
Rina Mariani AMK

NIP.19701221.199803.2.003
KN) LUAR DAERAH
Bahan
Bakar
& Tol Pendamping Sopir
25,000 83,000 375,000 315,000 798,000
25,000 83,000 375,000 315,000 798,000

Rupiah
Bendahara FKTP
Rina Mariani AMK

NIP.19701221.199803.2.003
ONAL (JKN)
Bahan
Bakar
25,000 50,000 110,000 70,000 255,000

25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
250,000 500,000 1,100,000 700,000 2,550,000

iah
Bendahara FKTP
Rina Mariani AMK

NIP.19701221.199803.2.003
ONAL (JKN)
Bahan
Bakar
Pendamping Sopir
25,000 50,000 110,000 70,000 255,000

25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
450,000 900,000 1,980,000 1,260,000 4,590,000

Rupiah
Bendahara FKTP
Rina Mariani AMK

NIP.19701221.199803.2.003
ONAL (JKN)
Bahan
Bakar
25,000 50,000 110,000 70,000 255,000

25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
150,000 300,000 660,000 420,000 1,530,000

iah
Bendahara FKTP
Rina Mariani AMK

NIP.19701221.199803.2.003
ONAL (JKN)
Bahan Uang Harian

Bakar
Sewa Jumlah
25,000 50,000 110,000 70,000 255,000

25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
125,000 250,000 550,000 350,000 1,275,000

upiah
Bendahara FKTP
Rina Mariani AMK

NIP.19701221.199803.2.003
ONAL (JKN)
Bahan Uang Harian
Bakar
Sewa Jumlah
25,000 50,000 110,000 70,000 255,000

25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
300,000 600,000 1,320,000 840,000 3,060,000
Bendahara FKTP
Rina Mariani AMK

NIP.19701221.199803.2.003
ONAL (JKN)
Bahan Uang Harian

Bakar
Sewa Jumlah
25,000 50,000 110,000 70,000 255,000

25,000 50,000 110,000 70,000 255,000 TDK DI ACC BPJS
25,000 50,000 110,000 70,000 255,000 ALASAN TDK SINKRON
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
250,000 500,000 1,100,000 700,000 2,550,000
Bendahara FKTP
Rina Mariani AMK

NIP.19701221.199803.2.003
KN) LUAR DAERAH
Bahan
Bakar
25,000 83,000 375,000 315,000 798,000 TDK DI ACC BPJS

ALASAN TDK SINKRON
25,000 83,000 375,000 315,000 798,000

Rupiah
Bendahara FKTP
Rina Mariani AMK
NIP.19701221.199803.2.003
ONAL (JKN)
Bahan Uang Harian

Bakar
Sewa Jumlah
25,000 50,000 110,000 70,000 255,000

25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
150,000 300,000 660,000 420,000 1,530,000

piah
Bendahara FKTP
Rina Mariani AMK

NIP.19701221.199803.2.003
ONAL (JKN)
Bahan Uang Harian
Bakar
Sewa Jumlah
25,000 50,000 110,000 70,000 255,000

25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 20,000 375,000 315,000 735,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
250,000 470,000 1,365,000 945,000 3,030,000
Bendahara FKTP
Rina Mariani AMK

NIP.19701221.199803.2.003
ONAL (JKN)
Bahan Uang Harian

Bakar
Sewa Jumlah
25,000 50,000 110,000 70,000 255,000

25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
275,000 550,000 1,210,000 770,000 2,805,000

h
Bendahara FKTP
Rina Mariani AMK

NIP.19701221.199803.2.003
ONAL (JKN)
Bahan Uang Harian

Bakar
Sewa Jumlah
25,000 50,000 110,000 70,000 255,000

25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
175,000 350,000 770,000 490,000 1,785,000

Rupiah
Bendahara FKTP
Rina Mariani AMK

NIP.19701221.199803.2.003
ONAL (JKN)
Bahan Uang Harian

Bakar
Sewa Jumlah
25,000 50,000 110,000 70,000 255,000

25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
225,000 450,000 990,000 630,000 2,295,000
u Rupiah
Bendahara FKTP
Rina Mariani AMK

NIP.19701221.199803.2.003
ONAL (JKN)
Bahan Uang Harian

Bakar
Sewa Jumlah
25,000 50,000 110,000 70,000 255,000

25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
225,000 450,000 990,000 630,000 2,295,000
u Rupiah
Bendahara BLUD
Rina Mariani AMK

NIP.19701221.199803.2.003
ONAL (JKN)
Bahan Uang Harian

Bakar
Sewa Jumlah
25,000 50,000 110,000 70,000 255,000

25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
325,000 650,000 1,430,000 910,000 3,315,000
piah
Bendahara BLUD
Rina Mariani AMK

NIP.19701221.199803.2.003
ONAL (JKN)
Bahan Uang Harian

Bakar
Sewa Jumlah
25,000 50,000 110,000 70,000 255,000

25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
350,000 700,000 1,540,000 980,000 3,570,000
piah
Bendahara BLUD
Rina Mariani AMK

NIP.19701221.199803.2.003
25,000 50,000 110,000 70,000 255,000 tidak ada kis
ONAL (JKN)
Bahan Uang Harian
Bakar
Sewa Jumlah
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
200,000 400,000 880,000 560,000 2,040,000
Bendahara BLUD
Rina Mariani AMK

NIP.19701221.199803.2.003
ONAL (JKN)
Bahan Uang Harian

Bakar
Sewa Jumlah
25,000 50,000 110,000 70,000 255,000

25,000 50,000 110,000 70,000 255,000 W-T
25,000 50,000 110,000 70,000 255,000 S-T
25,000 50,000 110,000 70,000 255,000 R-T
25,000 50,000 110,000 70,000 255,000 W-T
25,000 50,000 110,000 70,000 255,000 K-T
25,000 50,000 110,000 70,000 255,000 S-T
25,000 50,000 110,000 70,000 255,000 W-T
25,000 50,000 110,000 70,000 255,000 S-T
25,000 50,000 110,000 70,000 255,000 S-T
25,000 50,000 110,000 70,000 255,000 W-T
25,000 50,000 110,000 70,000 255,000 S-T
25,000 50,000 110,000 70,000 255,000 W-T
325,000 650,000 1,430,000 910,000 3,315,000 S-T
piah
Bendahara BLUD
Rina Mariani AMK

NIP.19701221.199803.2.003
ONAL (JKN)
Bahan Uang Harian

Bakar pendamping dan Sopir
Sewa Jumlah
25,000 50,000 110,000 70,000 255,000 W-T

25,000 50,000 110,000 70,000 255,000 W-T
25,000 50,000 110,000 70,000 255,000 K-T
25,000 50,000 110,000 70,000 255,000 W-T
25,000 50,000 110,000 70,000 255,000 W-T
25,000 50,000 110,000 70,000 255,000 S-T
25,000 50,000 110,000 70,000 255,000 R-T
25,000 50,000 110,000 70,000 255,000 W-T
25,000 50,000 110,000 70,000 255,000 I- T
25,000 50,000 110,000 70,000 255,000 K-T
25,000 50,000 110,000 70,000 255,000 R-T
275,000 550,000 1,210,000 770,000 2,805,000
piah
Bendahara BLUD
Rina Mariani AMK

NIP.19701221.199803.2.003
ONAL (JKN)
Bahan Uang Harian

Bakar
Sewa Jumlah
25,000 50,000 110,000 70,000 255,000

25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
325,000 650,000 1,430,000 910,000 3,315,000
upiah
Bendahara BLUD
Rina Mariani AMK

NIP.19701221.199803.2.003
ONAL (JKN)
Bahan Uang Harian

Bakar
Sewa Jumlah
25,000 50,000 110,000 70,000 255,000

25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
325,000 650,000 1,430,000 910,000 3,315,000
upiah
Bendahara BLUD
Rina Mariani AMK

NIP.19701221.199803.2.003
ONAL (JKN)
Bahan Uang Harian
Bakar
Sewa Jumlah
25,000 50,000 110,000 70,000 255,000 W-T

25,000 50,000 110,000 70,000 255,000 W-T
25,000 50,000 110,000 70,000 255,000 S-T
25,000 50,000 110,000 70,000 255,000 R-T
25,000 50,000 110,000 70,000 255,000 W-T
25,000 50,000 110,000 70,000 255,000 K-T
25,000 50,000 110,000 70,000 255,000 S-T
25,000 50,000 110,000 70,000 255,000 W-T
25,000 50,000 110,000 70,000 255,000 S-T
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000 S-T
300,000 600,000 1,320,000 840,000 3,060,000
Bendahara BLUD
Rina Mariani AMK

NIP.19701221.199803.2.003
ONAL (JKN)
Bahan Uang Harian

Bakar
Sewa Jumlah
25,000 50,000 110,000 70,000 255,000

25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
300,000 600,000 1,320,000 840,000 3,060,000
Bendahara BLUD
Rina Mariani AMK

NIP.19701221.199803.2.003
ONAL (JKN)
Bahan Uang Harian

Bakar
Sewa Jumlah
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000

25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
300,000 600,000 1,320,000 840,000 3,060,000
Bendahara BLUD
Rina Mariani AMK

NIP.19701221.199803.2.003
ONAL (JKN)
Bahan Uang Harian

Bakar
Sewa Jumlah
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000

25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
300,000 600,000 1,320,000 840,000 3,060,000
Bendahara BLUD
Rina Mariani AMK

NIP.19701221.199803.2.003
ONAL (JKN)
Bahan Uang Harian
Bakar
Sewa Jumlah
25,000 50,000 110,000 70,000 255,000

25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
25,000 50,000 110,000 70,000 255,000
275,000 550,000 1,210,000 770,000 2,805,000
ah
Bendahara BLUD
Rina Mariani AMK

NIP.19701221.199803.2.003
ONAL (JKN)
Bahan Uang Harian

Bakar
Sewa Jumlah
25,000 50,000 140,000 80,000 295,000

25,000 50,000 140,000 80,000 295,000
25,000 50,000 140,000 80,000 295,000
25,000 50,000 140,000 80,000 295,000
25,000 50,000 140,000 80,000 295,000
25,000 50,000 140,000 80,000 295,000
25,000 50,000 140,000 80,000 295,000
25,000 50,000 140,000 80,000 295,000
25,000 50,000 140,000 80,000 295,000
25,000 50,000 140,000 80,000 295,000
250,000 500,000 1,400,000 800,000 2,950,000
Rupiah
Bendahara BLUD
Rina Mariani AMK

NIP.19701221.199803.2.003
REKAPITULASI KLAIM KB JAMINAN KESEHATAN NASIONAL (JKN)
Nama UPTD : Puskesmas ..............................

Bulan : Jun-15
Pelayanan : RJTP
Tanggal Jenis Tindakan KB

No Nama Pasien No Peserta Alamat No Hp. Tarif
Pelayanan Suntik IUD Implant
1 Nama Di Kartu Alamat Di Kartu di isi sama dgn Ceklis UP / PASANG UP / PASANG sesuai Tindakan
2 di Pcare
3
4
5
dst.
Jumlah
Terbilang : ....................................................................................................................................
Mengetahui
Kepala Puskesmas............ Bendahara FKTP
Puskesmas....................
............................. .............................
NIP. NIP.
REKAPITULASI KLAIM ANC JAMINAN KESEHATAN NASIONAL (JKN)

Bulan : Jun-15
Pelayanan : RJTP
No Nama Pasien No Peserta Alamat No Hp. Tanggal Pelayanan Diagnosa Tarif Jumlah
1 Nama Di Kartu Alamat Di Kartu di isi Trimester 1 G..P..A...
Trimester 2
Trimester 3
Trimester 3 ke dua
2 Nama Di Kartu Alamat Di Kartu di isi Trimester 1 G..P..A...
Trimester 2
Trimester 3
Trimester 3 ke dua
dst.
Jumlah
Terbilang : ....................................................................................................................................
Mengetahui
Puskesmas....................
............................. .............................
NIP. NIP.
REKAPITULASI KLAIM PNC JAMINAN KESEHATAN NASIONAL (JKN)

Bulan : Jun-15
Pelayanan : RJTP
Tanggal
No Nama Pasien No Peserta Alamat No Hp. PNC Tarif Jumlah
Pelayanan
1 Nama Di Kartu Alamat Di Kartu di isi sama dgn KF 1 dan KN 1 / sesuai Tindakan Berapa kali tindakan
2 di Pcare KF 2 dan KN 2 / satu pasien nya
3 KF 3 dan KN 3 /
4
5
dst.
Jumlah
Terbilang : ....................................................................................................................................
Mengetahui
Puskesmas....................
............................. .............................
NIP. NIP.
DINAS KESEHATAN KAB SUMEDANG DINAS KESEHATAN KAB SUMEDANG
PUSKESMAS DTP JATINANGOR PUSKESMAS DTP JATINANGOR
BON PENGELUARAN BON PENGELUARAN
TANGGAL : TANGGAL :
NAMA : NAMA :
KEPERLUAN : KEPERLUAN :
JUMLAH UANG : JUMLAH UANG :
MENGETAHUI MENGETAHUI
KA PKM JATINANGOR YG MENERIMA KA PKM JATINANGOR YG MENERIMA
DINAS KESEHATAN KAB SUMEDANG DINAS KESEHATAN KAB SUMEDANG

PUSKESMAS DTP JATINANGOR PUSKESMAS DTP JATINANGOR
BON PENGELUARAN BON PENGELUARAN
TANGGAL : TANGGAL :
NAMA : NAMA :
KEPERLUAN : KEPERLUAN :
JUMLAH UANG : JUMLAH UANG :

MENGETAHUI MENGETAHUI
KA PKM JATINANGOR YG MENERIMA KA PKM JATINANGOR YG MENERIMA

DATA PERSALINAN &PRA RUJUKAN DATA PERSALINAN &PRA RUJUKAN
PASIEN BPJS / JKN PASIEN BPJS / JKN
NO BPJS : NO BPJS :
NAMA : NAMA :
TGL MASUK : TGL MASUK :
TGL KELUAR : TGL KELUAR :
KELUHAN : KELUHAN :
TINGGI BADAN : TINGGI BADAN :

BERAT BADAN : BERAT BADAN :
TEKANAN DARAH : TEKANAN DARAH :
RESPIRASI : RESPIRASI :
NADI : NADI :
DIAGNOSA/KODE : DIAGNOSA/KODE :
TH/ORAL : TH/ORAL :
TH/CAIRAN : TH/CAIRAN :
TH/INJEKSI : TH/INJEKSI :
TINDAKAN : TINDAKAN :
LAB : LAB :
BIDAN : BIDAN :
DATA PERSALINAN &PRA RUJUKAN DATA PERSALINAN &PRA RUJUKAN

PASIEN BPJS / JKN PASIEN BPJS / JKN
NO BPJS : NO BPJS :
NAMA : NAMA :
TGL MASUK : TGL MASUK :
TGL KELUAR : TGL KELUAR :
KELUHAN : KELUHAN :
TINGGI BADAN : TINGGI BADAN :

BERAT BADAN : BERAT BADAN :
TEKANAN DARAH : TEKANAN DARAH :
RESPIRASI : RESPIRASI :
NADI : NADI :
DIAGNOSA/KODE : DIAGNOSA/KODE :
TH/ORAL : TH/ORAL :
TH/CAIRAN : TH/CAIRAN :
TH/INJEKSI : TH/INJEKSI :
TINDAKAN : TINDAKAN :
LAB : LAB :
BIDAN : BIDAN :
PAKAIAN DINAS DI LINGKUNGAN PEMERINTAH KABUPATEN SUMEDANG
SENIN & SELASA : P D H WARNA KHAKI
RABU : KEMEJA PUTIH /ROK (CELANA ) WARNA HITAM /GELAP
KAMIS : PAKAIAN BATIK KASUMEDANGAN
JUMAT : PAKAIAN BATIK.
SABTU : PAKAIAN OLAH RAGA
KEPALA PUSKESMAS DTP JATINANGOR
DR HARIS FATAH KRISTOFA
NIP: 19641030 200212 1 002

P2BPK
No Medrec :
Ruangan/No Bed :
Nama :
Umur :
Alamat :
Rt. Rw.
Pekerjaan :
Diagnosa Medis :
P2BPK
No Medrec :
Ruangan/No Bed :
Nama :
Umur :
Alamat :
Rt. Rw.
Pekerjaan :
Diagnosa Medis :
P2BPK
No Medrec :
Ruangan/No Bed :
Nama :
Umur :
Alamat :
Rt. Rw.
Pekerjaan :
Diagnosa Medis :
BAPA AS 085220104480
BAPA XL 085922890500
BAPA TRI 089530698450
MAMAH AS 081321772255
MAMAH TRI 0895320307870
A ISHAL 089622444911
A FARRAS 089613692936
FAUZAN 08977871233
AA MANDR 1320017769978
BR RINA 089001003517508
B AMA 0247524274
B ISHAL 0378093224
B FN S 0479837806
BN RINA 0445064015 - 211998
BN T T 0395076218
RC 0059390163001
LISTRIK 14214134802
LISTRIK SIMPONI 535510996386
PAJAK PKM 200054633446000

E PIN 565863
BJB 022 - 7781619
PT MANDIRI TUNAS FNC 1300004832831

NO KONTRAK 9021500315
HNF 081214513669
SYF 089666866145
BAPA AS 085220104480
BAPA XL 085922890500
BAPA TRI 089530698450
MAMAH AS 081321772255
MAMAH TRI 0895320307870
A ISHAL 089622444911
A FARRAS 089613692936
FAUZAN 08977871233
AA MANDR 1320017769978
BR RINA 089001003517508
B AMA 0247524274
B ISHAL 0378093224
BN RINA 0445064015 - 211998
BN T T 0395076218
RC 0059390163001
B FN S 0479837806
LISTRIK 14214134802
LISTRIK SIMPONI 535510996386
PAJAK PKM 200054633446000

E PIN 565863
BJB 022 - 7781619
PT MANDIRI TUNAS FNC 1300004832831

NO KONTRAK 9021500315
HNF 081214513669
SYF 089666866145
NO TANGGAL TERIMA PAJAK SISA KETERANGAN
FORMULIR TANDA TERIMA KLAIM
NAMA FKTP : PUSKESMAS RAWAT INAP JATINANGOR

TANGGAL PENYERAHAN :
NO JENIS KLAIM BULAN LAYAN BIAYA PADA FPK
Catatan :
Sumedang, 2017
Yang Menyerahkan Yang Menerima
( ) ( )


Catatan :
Sumedang, 2017
( ) ( )

Catatan :
Sumedang, 2017
( ) ( )


Catatan :
Sumedang, 2017
( ) ( )
DAFTAR PESERTA PROLANIS
PUSKESMAS RAWAT INAP JATINANGOR
NO NAMA ALAMAT NO PESERTA DIAGNOSA KETERANGAN
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
REKAPITULASI KLAIM IVA TEST JAMINAN KESEHATAN NASIONAL (JKN)
Nama UPTD : Puskesmas Rawat Inap Jatinangor

Pelayanan : RJTP
Tanggal Jenis Tindakan

No Nama Pasien No Peserta Alamat No Hp. Tarif
Pelayanan IVA TEST
1 Yeni Ernawati 0004536700323 Bandung 24/2/2018 V 25,000
2 Holipah 0000048870865 Cinunuk 24/2/2018 V 25,000
3 Ika Ari Puji A 0000048870887 Banten 24/2/2018 V 25,000
4 Tri Sutaryah 0000050367227 Cimahi 24/2/2018 V 25,000
5 Deti Suhaeti 0000052581756 Ciparay 24/2/2018 V 25,000
6 Hj Nia suniati 0000052582239 Bandung 24/2/2018 V 25,000
7 Nani 0000052608947 Bandung 24/2/2018 V 25,000
8 Erianti 0000052927367 Bandung 24/2/2018 V 25,000
9 Edeh Maemunah 0000053721606 Ciparay 24/2/2018 V 25,000
10 Holisoh 0000053907996 Rancakole 24/2/2018 V 25,000
11 Cucu 0000054130004 Cicalengka 24/2/2018 V 25,000
12 Hj Yeti Sumiati 0000054302916 Bandung 24/2/2018 V 25,000
13 Cucu Suryani 0000054303399 Cicalengka 24/2/2018 V 25,000
14 Siti Julaeha 0000054303579 Nagreg 24/2/2018 V 25,000
15 Ade Taswidah 00000555388665 Bandung 24/2/2018 V 25,000
16 Esih Juariah 0000055693708 Bandung 24/2/2018 V 25,000
17 Hermawati 0000055694902 Cileunyi 24/2/2018 V 25,000
18 Imas Maesaroh 0000055695947 Bandung 24/2/2018 V 25,000
19 Lilis Mulyati 0000055697501 Bandung 24/2/2018 V 25,000
20 Meizar 0000055698142 Cileunyi 24/2/2018 V 25,000
21 Yati Nurmayati 0000055706049 Bandung 24/2/2018 V 25,000
22 Yulia 0000055706455 Bandung 24/2/2018 V 25,000
23 Hj Rina Siti 0000055901957 Bandung 24/2/2018 V 25,000
24 Mamah Suryamah 0000055926112 Bandung 24/2/2018 V 25,000
25 Neneng 0000056017811 Nagreg 24/2/2018 V 25,000
26 S.Ratna 0000057682956 Bandung 24/2/2018 V 25,000
27 Revi H 0000057747971 Bandung 24/2/2018 V 25,000
28 Sri Kusrini 0000057888527 Cibeusi 24/2/2018 V 25,000
29 A Susilawati 0000057938297 Bandung 24/2/2018 V 25,000
30 Aci Nurkasih 0000058004368 Cibeusi 24/2/2018 V 25,000
31 Dedah Amaliah 0000058011535 jatiroke 24/2/2018 V 25,000
32 Laela Badriah 0000064941737 Bandung 24/2/2018 V 25,000
33 Dewi safitri 0000064944573 Cibeusi 24/2/2018 V 25,000
34 Eem Nurnawati 0000064945541 Tanjung sari 24/2/2018 V 25,000
35 Eneng sumiati 0000064946147 Alam sari 24/2/2018 V 25,000
36 Idah Hidayah 0000064947688 Cibeusi 24/2/2018 V 25,000
37 Ika Agustina 0000064947802 Sayang 24/2/2018 V 25,000
38 Nani M 0000064948601 Cilayung 24/2/2018 V 25,000
39 Lina marlina 0000064950221 Cipacing 24/2/2018 V 25,000
40 Momoh 0000064951435 Tanjung kerta 24/2/2018 V 25,000
41 Jumiati 0000064953685 Tanjung sari 24/2/2018 V 25,000
42 Popong Rodiah 0000064953854 Sumedang 24/2/2018 V 25,000
43 Riyan sulistyo 0000064954539 Bandung 24/2/2018 V 25,000
44 Siti Rohimah 0000064955913 Cibeusi 24/2/2018 V 25,000
45 Kadariah 0000065571096 Cipacing 24/2/2018 V 25,000
46 Yulianti Husen 0000133630863 Cibeusi 24/2/2018 V 25,000
47 Hj. Iyong 0000162583223 Cisempur 24/2/2018 V 25,000
48 Nunik Puspitasari 0000166672787 Cikutra 24/2/2018 V 25,000
49 Ruzkiali 0000200714837 Bandung 24/2/2018 V 25,000
50 Sri Rubianti 0000202248966 Bandung 24/2/2018 V 25,000
51 Ema Rohimatul 0001669451095 Cibeusi 24/2/2018 V 25,000
52 E. Setiawati 00004127878991 Ciseupang 24/2/2018 V 25,000
53 Gaidah 0000412875426 Cicalengka 24/2/2018 V 25,000
60 Puji Wuryani 0001003131055 Cicalengka 24/2/2018 V 25,000

61 Ai Halimah 0001003814383 Cileunyi 24/2/2018 V 25,000
62 Mintarsih 0001013303125 Bandung 24/2/2018 V 25,000
63 Yusi eva 0001080520201 Cibeusi 24/2/2018 V 25,000
64 Putriyanti 0001164930221 Bandung 24/2/2018 V 25,000
65 Yani Setiyani 0001175033531 Cipageran 24/2/2018 V 25,000
66 Ekawati 0001778321859 Tanjung sari 24/2/2018 V 25,000
67 Nuranjani 0001282727171 Cimahi 24/2/2018 V 25,000
68 Hildah 0001284988757 Cimaung 24/2/2018 V 25,000
69 Supinah 0001305573838 Cimahi 24/2/2018 V 25,000
70 Dini Nurjanah 0001339070872 Cicalengka 24/2/2018 V 25,000
71 Dedeh Jubaedah 0001387852389 Cicalengka 24/2/2018 V 25,000
72 Kristina Damyanti 0001390226747 Rancaekek 24/2/2018 V 25,000
73 Nurhalimah 0001397593067 Gede bage 24/2/2018 V 25,000
74 Siti Qoribah 0001398772326 Bandung 24/2/2018 V 25,000
75 Iyam Mariam 0001399891746 Bandung 24/2/2018 V 25,000
76 Wiwin 0001463221528 Purbasari 24/2/2018 V 25,000
77 Susilawati 0001469156411 Cimahi 24/2/2018 V 25,000
78 Yeti Purwantini 0001478596691 Nagreg 24/2/2018 V 25,000
79 Deniarti 0001514806749 Bandung 24/2/2018 V 25,000
80 Yani S 0001514953495 Sayang 24/2/2018 V 25,000
81 Hj. Sri Muntiana 0001515042404 Bojong Koneng 24/2/2018 V 25,000
82 Christin M 0001519300629 Bandung 24/2/2018 V 25,000
83 Reniyati 0001519698969 Bandung 24/2/2018 V 25,000
84 Dwi lestari 0001519834263 Cicalengka 24/2/2018 V 25,000
85 Tina Rosiana 0001521592345 Majalengka 24/2/2018 V 25,000
86 Wiwik Sri 0001654300912 Bandung 24/2/2018 V 25,000
87 Cecilia 0001659919599 Batujajar 24/2/2018 V 25,000
88 Imas Hayati 0001660757264 Permai Lestari 24/2/2018 V 25,000
89 Lilis Megawati 0001661795098 Sukamenak 24/2/2018 V 25,000
90 Rini Nur F. 0001664662678 Cimanggung 24/2/2018 V 25,000
91 Sri Rasmawati 0001666939263 Cileunyi 24/2/2018 V 25,000
92 Erna Murniawati 000166948902 Bandung 24/2/2018 V 25,000
93 Erna Febrianti 0000210410212 Caringin 24/2/2018 V 25,000
94 Tuti Wijayanti 0001723329674 Bandung 24/2/2018 V 25,000
95 Rita Susiati 0001728296717 Cicalengka 24/2/2018 V 25,000
96 Iya Wiarsih 0001788007768 Cileunyi 24/2/2018 V 25,000
97 Mamah Suryamah 0001852104082 Cibeunying 24/2/2018 V 25,000
98 Eli susanti 0001854683864 Cimahi 24/2/2018 V 25,000
99 Lilis Kholisoh 0001899161526 Ciseupang 24/2/2018 V 25,000
100 Nurhayati 0002058074019 Bandung 24/2/2018 V 25,000
101 Itang Atikah 0002074788685 Bandung 24/2/2018 V 25,000
102 Istiyanti T 0002082185673 Jatinangor 24/2/2018 V 25,000
103 Entin Suhartini 0002182701881 Bandung 24/2/2018 V 25,000
104 Ani maryani 0002242426588 Bandung 24/2/2018 V 25,000
105 Nenden Maya 0002300650345 Cileunyi 24/2/2018 V 25,000
106 Irma Rahma 0002431587183 Bandung 24/2/2018 V 25,000
107 Nina Heryani 0000504999911 Bandung 24/2/2018 V 25,000
Jumlah 2,675,000
Terbilang : Dua Juta Enam Ratus Tujuh Puluh Lima Ribu Rupiah
Mengetahui Kepala Bendahara BLUD

Puskesmas Rawat Inap Jatinangor Puskesmas Rawat Inap Jatinangor
drg. Amie Fitriah, M.H.Kes Rina Mariani AMK

NIP: 10721111 200604 2 017 NIP.19701221.199803.2.003
AJUAN IVA TEST PASIEN BPJS
PUSKESMAS RAWAT INAP JATINANGOR
BULAN PEBRUARI 2018

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REKAPITULASI KLAIM RAWAT INAP JAMINAN KESEHATAN NASIONAL (JKN)

Nama UPT Puskesmas Rawat Inap Jatinangor

No Nama No Peserta Alamat Diagnosa Tgl Masuk

1 Ujang Sutisna 0001892367786 H.Manah S . Thypoid 30/ 3/20 18

drg. Amie Fitiah, M.H.Kes

Jatinangor, 3 Mei 2018

Rina Mariani AMK

Nama UPT Puskesmas Rawat Inap Jatinangor

No Nama No Peserta Alamat Diagnosa

1 Yoyoh 0000054091956 Cipacing 3/9 S . Thypoid

drg. Amie Fitiah, M.H.Kes

Jatinangor, 2 Maret 2018

Rina Mariani AMK

1 Rahmawati 0000461976794 Cipacing 6/1/2015

2 Leni 0000461976794 Cileles 6/3/2015

3 Siti Nurjanah 0000461976794 Hegarmanah 6/1/2015

4 Roshayanti 0000461976794 Sayang 6/1/2015

5 Fitri RatnaSari 0000461976794 Cileunyi 6/1/2015

6 Elis Trisnawati 0000461976794 Cilayung 6/1/2015

7 Ela Siti Nurlela 0000461976794 Mekargalih 6/1/2015

8 Ina Kartina 0000461976794 Cikeruh 6/1/2015

9 Erna Suhaeni 0000461976794 Hegarmanah 6/1/2015

10 Romlah satori 0000461976794 Mekargalih 6/1/2015

11 Lusi Andriati 0000461976794 Sayang 6/1/2015

12 Tuti Hasanah 0000461976794 Hegarmanah 6/1/2015

13 Yanti Priyanti 0000461976794 Cintamulya 6/1/2015

14 Mia rahmi 0000461976794 Sayang 6/1/2015

15 Wartini 0000461976794 Jatimukti 6/1/2015

dr Haris Fatah Kristofa

REKAPITULASI KLAIM KEBIDANAN DAN NEONATAL JAMINAN KESEHATAN NASIONAL (J

1 Ai Sari 0000461707187 Cilayung 7/1/2015 7/1/2015

2 Dewi Suciyanti 0001060876944 Jatiroke 7/2/2015 7/2/2015

3 Nurasiah Ismail 0000461811227 Cilayung 7/3/2015 7/3/2015

4 Desi Nurhandayani 0001854459652 Cileles 7/4/2015 7/4/2015

5 Yepi Agustina 0001175055478 Cipacing 7/4/2015 7/5/2015

6 Kristina Clara 0000460042571 Hegarmanah 7/5/2015 7/6/2015

7 Yuyun Nurhayati 0001855814534 Cibeusi 7/5/2015 7/6/2015

8 Milah Jamilah 0001522053246 Cibeusi 7/8/2015 7/9/2015

9 Iis Sugiarsih 0000462521305 Cipacing 7/9/2015 7/9/2015

10 Fitriyani 0001008255688 Sayang 7/9/2015 7/9/2015

11 Dede Rohimah 0000463465337 Cilayung 7/9/2015 7/10/2015

12 Sumiati 0001838113749 Cileles 7/10/2015 7/10/2015

13 Yanti Permatasari 0000461739857 Hegarmanah 7/13/2015 7/13/2015

14 Ibah 0000462448416 Jatiroke 7/13/2015 7/13/2015

15 Nurul Khotimah 0001153453948 Cileunyi 7/17/2015 7/18/2015

16 Eli Pratiwi Dewi 0001519859711 Cibeusi 7/17/2015 7/18/2015

17 Asatika Intan 0001854072167 Mekargalih 7/20/2015 7/18/2015

18 Watini 0000462571299 Cileles 7/21/2015 7/22/2015

20 Tuti 0000463100229 Sayang 7/31/2015 7/31/2015

dr Haris Fatah Kristofa

1 Mimin 0000462486363 Cileles 8/5/2015 8/5/2015

2 Atik Sopiah 0001517921818 Hegarmanah 8/5/2015 8/6/2015

3 Reni 0000461673472 Cipacing 8/6/2015 8/6/2015

4 Rifa Wulan Sari 0001852318282 Hegarmanah 8/8/2015 8/8/2015

5 Yulia Anggraeni 0001810505935 Cibeusi 8/8/2015 8/8/2015

6 Dedah 0000462752954 Cileles 8/8/2015 8/8/2015

7 Nia Yuniarti 0001008262855 Mekargalih 8/8/2015 8/9/2015

8 Teni 0000462483415 Sayang 8/8/2015 8/9/2015

10 Neng Yeni 0001826325279 Cileles 8/15/2015 8/16/2015

11 Yuyun 0000461449675 Cileles 8/16/2015 8/17/2015

12 Sariamah 0001840332677 Cileles 8/16/2015 8/17/2015

13 Nurmala 0000201129748 Cileles 8/21/2015 8/22/2015