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DAFTAR TAGIHAN KLAIM RAWAT JALAN JAMKESMAS DALAM DAN LUAR GEDUNG

PROPINSI : Sumatera Selatan BULAN : Januari TAHUN : 2013


KAB/KOTA : OKU/ BATURAJA PUSKESMAS : Karya Mukt

Kepada Yth
kepala Dinas Kesehatan Kab/Kota OKU/ Baturaja
di- Tempat
Bersama ini Kami ajukan tagihan Klaim Pelayanan Kesehatan Umum Rawat Jalan Peserta Jamkesmas

Pelayanan Kes dan Besaran tarif sesuai dengan PERDA(Rp*0


No. PESERTA UMUR JENIS TANGGAL Pemeriksaan Pemberian
NO NAMA PASIEN DIAGNOSA TOTAL BIAYA
Poli Umum IGD/Medis
JAMKESMAS (Thn) KUNJUNGAN Tindakan Poli Gigi Obat
KELAMIN Penunjangan Poli KIA/KB
(L/P) **)
1 2 3 4 5 6 7 8 9 10 11 12 13 (8+9+10+11+12+13)
1 mist 0000706416568 54 P 2/1/2013 Imlant Rp. 3,000 Rp. 4,500 - - Rp. 45,000 - Rp. 52,500
2 Adi Fest W 0000706415275 15 P 2/1/2013 ispa Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
3 Hermawat 0000707072613 37 P 2/1/2013 asma Rp. 3,000 Rp. 154,500 - - - Rp. 3,000 Rp. 160,500
4 Mujiat 0000706415455 41 P 2/1/2013 kb Rp. 3,000 - - - Rp. 15,000 - Rp. 18,000
5 Fera Dilla 0000706416489 23 P 2/1/2013 ispa Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
6 Supart 0000706418818 25 P 2/1/2013 kb Rp. 3,000 - - - Rp. 15,000 - Rp. 18,000
7 Sapinatul.K 0000707073467 11 P 5/1/2013 diare Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
8 Merri 0000707073434 37 P 7/1/2013 kb Rp. 3,000 - - - Rp. 15,000 - Rp. 18,000
9 Adi Fest W 0000706415275 15 P 7/1/2013 Dermatts Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
10 Kartni 0000706416603 113 P 8/1/2013 hypertensi Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
11 Rusdi 0000707072556 48 L 8/1/2013 rematoid Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
12 Kardi 0000706415387 86 L 10/1/2013 hypertensi Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
13 Ridwan 0000707072624 20 L 12/1/2013 diare Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
14 Edi Susanto 0000707073006 39 L 12/1/2013 kcl Rp. 3,000 Rp. 51,500 - - - Rp. 3,000 Rp. 57,500
15 Suroso 0000706415196 113 L 12/1/2013 diare Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
16 Ngatfa 0000706415308 66 P 14/1/2013 luka sayat Rp. 3,000 Rp. 12,000 - - - Rp. 3,000 Rp. 18,000
17 Supri 0000706995505 73 L 17/1/2013 Gastrits Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
18 Dariyono 0000706997349 39 L 17/1/2013 Fibris Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
19 Bayu 0000706416838 21 L 17/1/2013 diare Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
20 Bella Imelda 0000706418875 8 P 19/1/2013 luka kena pancing Rp. 3,000 Rp. 20,000 - - - Rp. 3,000 Rp. 26,000
21 Pent 0000706416849 17 P 19/1/2013 Fibris Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
22 santoso 0000706996135 52 L 19/1/2013 asma Rp. 3,000 Rp. 154,500 - - - Rp. 3,000 Rp. 160,500
23 Mustofa 0000707072602 39 L 21/1/2013 Dermatts Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500

24 Sit Saudah 0000706416682 48 P 22/1/2013 kb Rp. 3,000 - - - Rp. 15,000 - Rp. 18,000
25 Yani. W 0000706997709 36 P 22/1/2013 kb Rp. 3,000 - - - Rp. 15,000 - Rp. 18,000
26 Suyatning 0000706416928 70 P 22/1/2013 Hypertensi Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
27 Kuswan 0000706416917 75 L 23/1/2013 bisul Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
28 Wiyono 0000706416939 36 L 23/1/2013 ispa Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
29 Dwi Trimo 0000706418831 42 L 23/1/2013 diare Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
30 Sriani 0000707073445 43 P 25/1/2013 kb Rp. 3,000 - - - Rp. 15,000 - Rp. 18,000
31 tuham 0000707000073 65 L 2/1/2013 R.A Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
32 budi 0000707000252 8 L 5/1/2013 Ispa Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
33 sumardi 0000706407153 32 L 10/1/2013 diare Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
34 wahyu 0000706409291 46 L 12/1/2013 Gastrits Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
35 rosit 0000706409245 37 L 15/1/2013 dermatts infeksi Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
36 syukur 0000706405634 40 L 19/1/2013 Hypertensi Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
37 rukiman 0000707072387 65 L 3/1/2013 Gastrits Rp. 3,000 Rp. 4,500 - - Rp. 3,000 Rp. 10,500
38 junai 0000706997654 17 L 5/1/1900 vc Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
39 Riduan.f 0000706995955 20 L 5/1/2013 alergi Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
40 rahman 0000706996124 13 L 9/1/2013 Gastrits Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
41 edi siswanto 0000706416153 26 L 9/1/2013 ispa Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
42 adidana 0000706419472 18 L 9/1/2013 Gastrits Rp. 3,000 Rp. 4,500 - - Rp. 3,000 Rp. 10,500
43 mukamat 0000706997103 17 L 10/1/2013 asma Rp. 3,000 Rp. 154,500 - - - Rp. 3,000 Rp. 160,500
44 imam.R 0000706996686 13 L 12/1/2013 GE Rp. 3,000 Rp. 4,500 - - Rp. 3,000 Rp. 10,500
45 sayat 0000706996653 45 P 15/1/2013 remathoid Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
46 sit.k 0000706997147 36 P 16/1/2013 Hypertensi Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
47 tukiyo 0000707072442 40 L 16/1/2013 remathoid Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
48 yandi 0000707073366 14 L 16/1/2013 VC Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
49 sarnit 0000706995988 40 P 21/1/2013 remathoid Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
50 m.guntur 0000305434563 1,5 L 2/1/2013 batuk Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
51 tono 0000706412542 43 L 1/31/1900 alergi Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
52 soikah 00007064112719 82 P 5/1/2013 Hypertensi Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
53 rizki.a 0000305434462 12 L 7/1/2013 demam Rp. 3,000 - - - Rp. 3,000 Rp. 6,000
54 asih rahayu 0000305433917 29 P 9/1/2013 Gastrits Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
55 soetopo 00030551515160 62 L 12/1/2013 Hypertensi Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
56 muhajir 0000306354273 45 L 13/7/2013 ispa Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
57 jakori 0000306355072 48 L 13/1/2013 arthrits Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
58 tono 0000706412542 43 L 10/1/2013 hypertensi Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
59 muhanis 0000306355173 39 P 11/1/2013 ispa Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
60 hamdani 0000306352001 22 L 12/1/2013 batuk Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
61 nikmah 0000306352045 21 P 14/1/2013 kb Rp. 3,000 - - - Rp. 15,000 - Rp. 18,000
62 rizky 0000306352078 2 L 14/1/2013 demam Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
63 kusdhy hariyanto 0000306352462 37 P 15/1/2013 gastrits Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
64 asih rahayu 0000305433977 29 P 17/1/2013 kb Rp. 3,000 - - - Rp. 15,000 - Rp. 18,000
65 rath 0000305521997 29 P 2/1/2013 sariawan Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
66 suhandi 0000305411962 43 L 4/1/2013 demam Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
67 angga m.f 0000305460562 9 L 4/1/2013 alergi Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
68 winart 0000305460516 35 P 5/1/2013 reumatk Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
69 viki.r 0000305461292 3 L 5/1/2013 obs ispa Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
70 ade ayu 0000305454846 8 L 7/1/2013 sakit gigi Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
71 kasdiono 0000305460325 40 L 9/1/2013 demam Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
72 dewi larasat 0000305515636 4 P 9/1/2013 influenza Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
73 nanda 0000305511558 8 P 10/1/2013 demam Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
74 poniyah 0000305513968 46 P 10/1/2013 reumatk Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
75 yunita 0000305436183 25 P 11/1/2013 panas,batuk Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
76 sukram 0000305345788 50 L 11/1/2013 reumatk Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
77 darto 0000305308451 34 L 12/1/2013 sakit gigi Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
78 tumirah 0000305306932 28 P 12/1/2013 demam Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
79 turino 0000305477717 25 L 14/1/2013 batuk Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
80 zawiyah 0000305455814 25 P 14/1/2013 reumatk Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
81 sit zenab 0000305496459 20 P 15/1/2013 alergi Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
82 ardi 0000305520849 43 L 16/1/2013 alergi Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
Jumlah Rp. 1,379,500

Mengetahui,
Kepala UPTD Puskesmas Karya Mukt Karya Mukt, Januari 2013
pj. Pelayanan puskesmas
HASYMI, SKM Try Koesminingsih, SST
NIP. 195804151983031010 NIP. 19870712 201101 2005
rita W
Rp. 772,000

srimurtni
Rp. 49,500

resmita.m
Rp. 277,500
ismawat h
Rp. 118,500

140257660
rokhila
Rp. 162,000
DAFTAR TAGIHAN KLAIM RAWAT JALAN JAMKESMAS DALAM DAN LUAR GEDUNG
PROPINSI : Sumatera Selatan BULAN :Pebruari TAHUN : 2013
KAB/KOTA : OKU/ BATURAJA PUSKESMAS : Karya Mukt

Kepada Yth
kepala Dinas Kesehatan Kab/Kota OKU/ Baturaja
di- Tempat
Bersama ini Kami ajukan tagihan Klaim Pelayanan Kesehatan Umum Rawat Jalan Peserta Jamkesmas

Pelayanan Kes dan Besaran tarif sesuai dengan PERDA(Rp*0


No. PESERTA UMUR TANGGAL IGD/ Pemberian
NO NAMA PASIEN JENIS DIAGNOSA Pemeriksaan TOTAL BIAYA
JAMKESMAS (Thn) KUNJUNGAN Poli Umum Tindakan Poli Gigi Obat
KELAMIN Penunjangan **) Poli KIA/KB
(L/P) Medis
1 2 3 4 5 6 7 8 9 10 11 12 13 (8+9+10+11+12+13)
1 Sukarno 0000305514415 13 L 1/2/2013 Ispa Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
2 Nurjanah 0000305505281 23 P 1/2/2013 Demam Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
3 Muhrodim 0000305504987 29 L 4/2/2013 Sakit gigi Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
4 Nasrul. W 0000308455915 19 L 5/2/2013 Demam Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
5 Galib.M 0000305456006 7 L 5/5/1900 Demam Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
6 Tarmo 0000305518378 70 L 6/2/2013 Demam Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
7 Ayu wulandari 0000305517161 5 P 9/2/2013 Ispa Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
8 puji lestari 0000305516066 22 P 11/2/2013 Demam Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
9 M .Lukman 0000305516125 29 L 12/2/2013 Demam Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
10 Rohiman.H 0000305480169 22 P 14/2/2013 Pusing Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
11 purwadi 0000305479135 19 L 15/2/2013 Demam Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
12 Kasman 0000305524012 60 L 20/2/2013 Reuatk Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
13 Dodi Noprizal 0000305522853 6 L 20/2/2013 Panas Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
14 Barokah 0000305504875 8 P 22/2/2013 Batuk Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
15 Surip Apriyana 0000305522741 30 L 22/2/2013 Kembung Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
16 Ajok Laharjo 0000305540302 55 L 4/2/2013 febris Rp. 3,000 - - - Rp. 3,000 Rp. 6,000
17 Lutvi Malfarid 0000305536329 14 L 4/2/2013 Diare Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
18 Ratmini 0000305541134 50 P 5/2/2013 Hypertensi Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
19 Indi. S 0000305549998 20 P 8/2/2013 Cepalgia Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
20 Feri Amorta 0000305536421 15 P 8/2/2013 Diare Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
21 Rusmaidi 0000305536329 13 L 9/2/2013 febris Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
22 M.Komarudin 0000305537332 60 L 11/2/2013 Gastrits Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
23 Nurjanah 0000305554588 37 P 11/2/2013 CC Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
24 Solehatun 0000305545421 35 P 12/2/2013 ISK Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
25 Rodiah 0000305546488 38 P 14/2/2013 Gastrits Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
26 Ana Maryana 0000305545476 30 P 14/2/2013 Cepalgia Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
27 Suparman 0000305556377 48 L 15/2/2013 CC Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000 xxxxx
28 Wardi 0000305534294 45 L 16/5/1900 Rematk Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
29 Sinta, F 0000305576122 10 P 16/2/2013 Fibris Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
30 Ahmadiono 0000305556998 58 L 16/2/2013 Gastrits Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
31 Sobari 0000305578675 65 L 20/2/2013 Hypertensi Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
32 sugito 0000305582512 28 L 22/2/2013 Gastrits Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
33 Kasiani 0000305562082 23 P 22/2/2013 ISK Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
34 A.Kamim 0000305572983 39 L 23/2/1900 V.Lakarutum Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
35 Pratwi 0000306215919 29 P 1/1/2013 Rematoid Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
36 Miyem 0000306215998 35 P 1/2/2013 Gastrits Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
37 Slamet ,R 000036215954 40 L 4/2/2013 VC Rp. 3,000 Rp. 24,500 - - - Rp. 3,000 Rp. 30,500
38 Purwanto 0000306216003 27 L 5/2/2013 ISK Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
39 Budi 0000306219813 18 L 6/2/2013 GE Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
40 Sri Murniat 0000306219778 28 P 6/2/2013 KB Rp. 3,000 - - - Rp. 15,000 - Rp. 18,000
41 Samidi 0000306213366 25 L 12/2/2013 asma Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
42 Herningsih 0000306216555 19 P 12/2/2013 Gastrits Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
43 Billa 0000306222412 10 P 13/2/2013 Ispa Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
44 Iis Fatmah 0000306217539 15 P 15/2/2013 Alergi Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
45 Firman 0000306217462 41 L 16/2/2013 VC Rp. 3,000 Rp. 27,500 - - - Rp. 3,000 Rp. 33,500
46 Jasmini 0000306222478 50 P 16/2/2013 Hypertensi Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
47 Abdul, R 0000306222557 20 L 19/2/2013 Konjungtvits Rp. 3,000 4500 - - - Rp. 3,000 Rp. 10,500
48 Kusnul 0000306213423 38 P 22/2/2013 Keputhan Rp. 3,000 4500 - - - Rp. 3,000 Rp. 10,500
49 Wahyu 0000306219734 40 P 22/2/2013 Lepas imlan Rp. 3,000 4500 - - Rp. 35,000 Rp. 3,000 Rp. 45,500
50 lutvi Maifarid 0000305550551 30 L 3/2/2013 R.A Rp. 3,000 4500 - - - Rp. 3,000 Rp. 10,500
51 Arman Setawan 0000305590544 25 L 4/2/2013 Fibris Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
52 Sobari 0000305578675 50 L 5/2/2013 Hypertensi Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
53 Andi sanjaya 0000305548784 20 L 7/2/2013 Dematts alergi Rp. 3,000 4500 - - - Rp. 3,000 Rp. 10,500
54 Ana Maryana 0000305545476 32 P 14/2/2013 Ispa Rp. 3,000 4500 - - - Rp. 3,000 Rp. 10,500
55 Suhartni 0000305564051 40 P 18/2/2013 Dematts alergi Rp. 3,000 4500 - - - Rp. 3,000 Rp. 10,500
56 Karto prawiro 0000305564995 34 L 18/2/2013 Typoid Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
57 Ernawat 0000305573321 17 P 20/2/2013 Diare Rp. 3,000 4500 - - - Rp. 3,000 Rp. 10,500
58 Sit Aisah 0000305538153 35 P 11/2/2013 R.A Rp. 3,000 4500 - - - Rp. 3,000 Rp. 10,500
59 Sugimin 0000305563566 40 L 23/2/2013 R.A Rp. 3,000 4500 - - - Rp. 3,000 Rp. 10,500

60 Jaelani 0000706415422 23 L 1/2/2013 Dermatts Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
61 Mega suryana 0000706997722 12 P 1/2/2013 Caries gigi Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
62 Diyem 0000706415163 113 P 1/2/2013 Asma Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
63 Rika N.P. 0000706997711 18 P 4/2/2013 Gastrits Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
64 Sumain 0000706416715 59 L 6/2/2013 Asma Rp. 3,000 Rp. 154,500 - - - Rp. 3,000 Rp. 160,500
65 Wasiyo 0000706997902 73 L 6/2/2013 Rematoid Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
66 Nurwiat 0000706416502 17 P 6/2/2013 Febris Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
67 Yuliatn 0000706997992 92 P 6/2/2013 Diare Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
68 Edi suwandi 0000706418763 35 L 6/2/2013 Febris Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
69 Ana mukayana 0000706996888 37 P 6/2/2013 KB Rp. 3,000 - - - Rp. 15,000 - Rp. 18,000
70 Wiyono 0000706416939 36 L 7/2/2013 Obs.Malaria Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
71 Anisa A 0000706416491 19 P 7/2/2013 ISpa Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
72 Kaman 0000706416941 113 L 11/2/2013 Dermatts Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
73 Turam 0000706416557 58 L 11/2/2013 Luka kn air pns Rp. 3,000 Rp. 16,500 - - - Rp. 3,000 Rp. 22,500
74 Fikriyanto 0000706997698 47 L 11/2/2013 Caries gigi Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
75 Kuwat 0000706997968 67 L 12/2/2013 Kcl Rp. 3,000 Rp. 27,500 - - - Rp. 3,000 Rp. 33,500
76 Nopo 0000706416827 24 L 13/2/2013 Sakit mata Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
77 Ronik 0000707072567 24 P 18/2/2013 KB Rp. 3,000 - - - Rp. 15,000 - Rp. 18,000
78 Darso 0000706416614 113 L 18/5/1900 Febris Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
79 Diah Kurniat 0000706997362 14 P 18/2/2013 KB Rp. 3,000 - - - Rp. 15,000 - Rp. 18,000
80 Sit Nafiah 0000707073456 14 P 18/2/2013 Dermatts Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
81 Agus.s 0000706416704 22 L 18/2/2013 ISPA Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
82 Suyono 0000706415343 113 L 19/2/2013 Caries gigi Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
83 Astani 0000707072591 12 P 19/2/2013 Diare Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
84 Aminah 0000707072589 19 P 20/2/1900 KB Rp. 3,000 - - - Rp. 15,000 - Rp. 18,000
85 Rohadi 0000706996877 39 L 22/2/2013 ISPA Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
86 Sit Maimunah 0000706415253 25 P 22/2/2013 Lepas imlan Rp. 3,000 - - - Rp. 35,000 Rp. 3,000 Rp. 41,000
87 Mustofa 0000707072602 39 L 22/2/2013 Kcl Rp. 3,000 Rp. 27,500 - - - Rp. 3,000 Rp. 33,500
88 Agus Triono 0000706997496 15 L 22/2/2013 Kcl Rp. 3,000 Rp. 24,500 - - - Rp. 3,000 Rp. 30,500
89 Deni 0000706416783 314 L 23/2/2013 Febris Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
90 Dimas T 0000706415286 10 L 24/2/2013 ISPA Rp. 3,000 Rp. 4,500 - - - - Rp. 7,500
91 Supart 0000706418818 25 P 24/2/2013 KB Rp. 3,000 - - - Rp. 15,000 - Rp. 18,000
92 Pent 0000706416849 17 P 24/2/2013 ISPA Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
93 Suetopo 0000305515168 7 L 29/1/2013 Hypertensi Rp. 3,000 - Rp. 3,000 Rp. 6,000
94 Asih Rahayu 0000305433977 29 P Rp. 41,610 Gastrits Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
95 Fahri 0000305488629 2,5 L 13/2/2013 Batuk pilek Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000

96 Elik 0000305486943 37 P 13/2/2013 Sakit gigi Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
97 ine 0000305546859 6 P 13/2/2013 Febris Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
98 M.Guntur 0000305434563 2 L 13/2/2013 Febris Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
99 Endang Susant 0000305544813 27 P 13/2/2013 Febris Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
100 Kusuma .H 0000305486886 42 L 20/2/2013 Febris Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
101 Hartk 0000305566042 31 P 20/2/2013 Alergi Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
102 Elik 0000305486943 37 P 20/2/1900 Sakit gigi Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
103 Lasari 0000305554432 25 P 21/2/2013 Stk KB Rp. 3,000 - - - Rp. 15,000 - Rp. 18,000
104 Herlina 0000305564389 24 P 21/2/2013 Stk KB Rp. 3,000 - - - Rp. 15,000 - Rp. 18,000
105 Adelia .P 0000305545184 6 P 21/2/2013 Comead cdd Rp. 3,000 - - - Rp. 3,000 Rp. 6,000
106 Suminten 0000305546815 26 P 22/2/2013 Stk KB Rp. 3,000 - - - Rp. 15,000 - Rp. 18,000
107 Sujani 0000305546567 32 L 22/2/2013 Gastrits Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
108 Maulun 0000305565873 40 L 22/2/2013 Artrits Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
109 Surani 0000305563972 37 L 22/2/2013 Febris Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
110 Tohif 0000305545296 10 L 22/2/2013 Febris Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
111 Ngatnah 0000305556794 50 P 22/2/2013 Stk KB Rp. 3,000 - - - Rp. 15,000 - Rp. 18,000
112 Niman 0000305556761 60 L 22/2/2013 Varingits Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
113 Ine.P 0000305546859 6 P 22/2/2013 Vulnus Las. Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
114 Elis Setyowat 0000305554386 19 P 22/2/2013 Stk KB Rp. 3,000 - - - Rp. 15,000 - Rp. 18,000
115 M.Fauzan 0000305487448 13 L 22/2/2013 Febris Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
116 Fathur Munip 0000305499565 25 L 22/2/2013 Vertgo Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
117 Shoviyatus.S 0000305499766 3 P 23/2/2013 Febris Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
118 Citra 0000306937765 3 P 1/2/2013 Dermatts Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
119 Sindi NS 0000307226722 6 P 1/2/2013 Obs. Febris Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
120 M.Rizki 0000307176491 6,5 L 2/2/2013 Febris Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
121 Supiah 0000307188549 37 P 3/2/2013 CC Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
122 Ilham M 0000307193038 12 L 3/2/2013 Cacar air Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
123 Sit.M 0000307189664 10 P 3/2/2013 Obs. Febris Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
124 Syamsiyah 0000305539209 57 P 4/2/2013 Caries Dental Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
125 Sriyant 0000305568832 23 P 7/2/2013 Caries Dental Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
126 Rohmawat 0000306919653 23 P 7/2/2013 Gastrits Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
127 Dewi Karnat 0000306935032 40 P 9/2/2013 Spootng Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
128 Revan V 0000305567774 4 L 11/2/2013 CC Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
129 Rizki A 0000305552507 5 L 12/2/2013 CC Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
130 Sriyant 0000305568834 23 P 12/2/2013 CC Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
131 Lasmini 0000307171629 65 P 12/2/2013 CC Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500

132 Rohmah 0000306939958 30 P 13/2/2013 Hypertensi Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
133 Rrido nur S 0000306913015 3 L 13/2/2013 Diare Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
134 Mengku W 0000306926199 3 L 14/2/2013 CC Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
135 Marninah 0000305536048 55 P 15/2/2013 Hypertensi Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
136 Butarmi 0000305555444 60 P 15/2/2013 Hypertensi Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
137 Ust 0000305527882 56 P 17/2/2013 Gastrits Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
138 Arjaya 0000305527274 63 L 18/2/2013 Gastrits Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
139 Agatha S 0000305522188 11 P 18/2/2013 Obs Tipoid Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
140 Rika S 0000305559505 25 P 19/2/2013 KB Rp. 3,000 - - - Rp. 15,000 - Rp. 18,000
141 gnes S 0000307173633 35 P 19/2/2013 KB Rp. 3,000 - - - Rp. 15,000 - Rp. 18,000
142 Tri Heni 0000305559213 7 P 20/2/2013 CC Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
143 Rami 0000305523876 35 P 21/2/2013 ANC Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
144 Ilham M 0000307193038 12 L 23/2/2013 Vulnus Scisum Rp. 3,000 Rp. 51,500 - - - Rp. 3,000 Rp. 57,500
145 Sendy 0000305559944 6 L 24/2/2013 Diare Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
146 Ishanur 0000307170011 8 L 24/2/2013 Disentri Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
147 Malinda 0000305549245 3,5 P 24/2/2013 CC Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
Jumlah Rp. 1,765,000

Mengetahui,
Kepala UPTD Puskesmas Karya Mukt Karya Mukt, Pebruari 2013
pj. Pelayanan puskesmas

HASYMI, SKM Try Koesminingsih, SST


NIP. 195804151983031010 NIP. 19870712 201101 2005
rokhila
Rp. 130,500
berta edi wiranto
198004142007011023

123000

Resmita amkep
Rp. 238,500

srimurtni
Rp. 91,500

rita widartk
Rp. 639,500
Ismawat hanis
Rp. 246,000
novalia 197811072005012011
Rp. 296,000
DAFTAR TAGIHAN KLAIM RAWAT JALAN JAMKESMAS DALAM DAN LUAR GEDUNG
PROPINSI : Sumatera Selatan BULAN :Maret TAHUN : 2013
KAB/KOTA : OKU/ BATURAJA PUSKESMAS : Karya Mukt

Kepada Yth
kepala Dinas Kesehatan Kab/Kota OKU/ Baturaja
di- Tempat
Bersama ini Kami ajukan tagihan Klaim Pelayanan Kesehatan Umum Rawat Jalan Peserta Jamkesmas

Pelayanan Kes dan Besaran tarif sesuai dengan PERDA(Rp*0


No. PESERTA UMUR TANGGAL IGD/ Pemeriksaan Pemberian
NO NAMA PASIEN JENIS DIAGNOSA TOTAL BIAYA
JAMKESMAS (Thn) KUNJUNGAN Poli Umum Tindakan Poli Gigi Penunjangan Poli KIA/KB Obat
KELAMIN
(L/P) Medis **)
1 2 3 4 5 6 7 8 9 10 11 12 13 (8+9+10+11+12+13)
1 Trianto, S 0000305433505 44 L 27/2/2013 astrits Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
2 Asih Rahayu 0000305433977 34 P 27/2/2013 Gastrits Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
3 M. Fauzi 0000305487775 10 L 28/2/2013 Aleri Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
4 Erna 0000305535723 27 P 1/3/2013 febris Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
5 Elik 0000305488629 38 P 5/3/2013 Sakit gigi Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
6 Fahri 0000305486943 2,5 L 5/3/2013 Batuk pilek Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
7 Solikah 0000706411719 80 P 7/3/2013 Hypertensi Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
8 M. Fauzan 0000305487448 16 L 7/3/2013 Batuk Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
9 M. Fahri 0000305488629 8,5 L 7/3/2013 Demam Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
10 Eik 0000305486943 38 P 7/3/2013 Batuk Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
11 Ahmada 0000305930891 2 L 9/3/2013 Diare Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
12 Asih Rahayu 0000305433977 29 P 9/3/2013 Diare Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
13 Ismawat 0000306353496 11 P 9/3/2013 Gastrits Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
14 Hartk 0000305566642 37 P 11/3/2013 Hypertensi Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
15 Angi 0000306347141 11 L 11/3/2013 Batuk pilek Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
16 Hartni 000030635241 29 P 14/3/2013 Batuk pilek Rp. 3,000 - - - Rp. 3,000 Rp. 6,000
17 Abdul Rozak 0000306353981 4 L 14/3/2013 Batuk pilek Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
18 M.Guntur 0000305434563 2 L 18/3/2013 Ispa Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
19 Nanda 0000306355742 2 P 21/3/2013 Ispa Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000 Ismawat hanis
20 Trianto. S 0000305433505 44 L 23/3/2013 Ispa Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500 147000
21 Andri Sanjaya 0000305548784 30 L 5/3/2013 RA Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
22 Nabila Agustn 0000305548931 35 P 6/3/2013 Gastrits Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
23 Dakumi 0000305578989 40 L 11/3/2013 RA Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
24 M.Komarudin 0000305537332 50 L 12/3/2013 Ispa Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
25 Amat Diono 0000305558898 55 L 15/3/2013 RA Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
26 Ahmad Kamim 0000305572983 35 L 16/3/2013 Diare Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
27 Wahyu 0000706409291 29 L 18/3/2013 Ispa Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
28 Sumardi 0000706407153 31 L 19/3/2013 Caries dents Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
29 Rosit 0000706409245 32 L 21/3/2013 Ispa Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
30 Tuham 0000707000073 35 L 22/3/2013 Faringits Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500 Srimurtni
31 Syukur 0000706405634 50 L 23/3/2013 Hypertensi Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000 106500
32 Kateni 0000306105603 47 P 2/3/2013 Obs Hypertensi Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
33 Kurna Arini 0000305820112 30 P 2/3/2013 Gastrits Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
34 Rita 0000305818209 28 P 4/3/2013 KB Rp. 3,000 - - - Rp. 15,000 - Rp. 18,000
35 Endang 0000306221106 39 P 6/3/2013 Imlant Rp. 3,000 - - - Rp. 45,000 - Rp. 48,000
36 Ahmad Taslim 0000306101553 65 L 7/3/2013 Febris Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
37 Saprak 0000306220882 52 L 20/3/2013 Luka Rp. 3,000 Rp. 27,500 - - - Rp. 3,000 Rp. 33,500
38 Suwardi 0000306219317 50 L 22/3/2013 Rematoid Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500 rita widartk
39 Ngatni 0000306224144 42 P 22/3/2013 Ispa Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500 152000
40 Sit Anggun 0000305816433 15 P 2/3/2013 Ispa Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
41 Mariyat 0000306216191 42 P 2/3/2013 GE Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
42 Aminah 0000306213399 35 P 5/3/2013 Keputhan Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
43 Kartni 0000306213456 29 P 6/3/2013 Vc Rp. 3,000 Rp. 24,500 - - - Rp. 3,000 Rp. 30,500
44 Nurhayat 0000305816589 26 P 6/3/2013 Ispa Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
45 Tuminah 0000306219069 37 L 8/3/2013 Rematoid Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
46 Riyanto 0000306216156 18 L 11/3/2013 Gastrits Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
47 Rohmat 0000306219104 17 L 13/3/2013 Vc Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
48 Triazi 0000306219699 40 P 13/3/2013 Rematoid Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
49 Ali 0000306219194 23 L 13/3/2013 Gastrits Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
50 Heni 0000305819291 37 P 14/3/1900 Hypertensi Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
51 Rohman.F 0000306102194 20 L 15/3/2013 Caries dents Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
52 Siswo 0000306101823 27 L 15/3/2013 GE Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
53 Ninik.H 0000306211601 9 P 16/3/2013 Skabies Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
54 Ahlun 0000305819201 21 P 16/3/2013 Asma Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
55 Serli 0000305819324 4 P 18/3/2013 Alergi Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
56 Yuyun 0000306211533 15 P 18/3/2013 Konjuntfits Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000 Resmita Meviarnaa
57 Halima 0000305217505 28 P 18/3/2013 KB Rp. 3,000 - - - Rp. 15,000 - Rp. 18,000 185000
58 Imam Seta budi 0000305453711 13 L 8/3/2013 Sakit gigi Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
59 Supriyadi 0000305492308 23 L 8/3/2013 Batuk pilek Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
60 Dwi haryat 0000305478371 24 P 9/3/2013 Alergi Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
61 Kasmiini 0000305492471 28 P 9/3/2013 Sakit gigi Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
62 Mia yyulia andini 0000305477087 27 P 11/3/2013 Demam Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
63 Paini 0000305434541 65 P 11/3/2013 Hypertensi Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
64 Tantri dana. S 0000305477054 12 P 13/3/2013 Demam Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
65 A. Sidik 0000305434078 10 L 13/3/2013 Batuk Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
66 Slamet Wibowo 0000305454295 8 L 14/3/2013 Batuk Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
67 Dian Sigit 0000305434271 8 L 15/3/2013 Demam Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
68 Binten Liana 0000305609253 39 P 16/3/2013 Batuk Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
69 Erlina 0000305516747 29 P 18/3/2013 Demam Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
70 Mugiyanto 000030551`3636 65 L 19/3/2013 Sakit mata Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
71 Kasiatun 0000305413637 32 P 20/3/2013 Pusing Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
72 sriwayat 0000305461991 28 P 21/3/2013 Kembung Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
73 Alwi Mur Sodik 0000305462812 38 L 22/3/2013 Gastrits Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500 140257660
74 Suwanda 0000305486005 29 L 23/3/2013 Batuk Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500 Rokhila
75 Nasiyem 0000305485569 36 P 25/3/2013 Pusing Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000 153000
Jumlah Rp. 743,500

Mengetahui,
Kepala UPTD Puskesmas Karya Mukt Karya Mukt, Maret 2013
pj. Pelayanan puskesmas

HASYMI, SKM Try Koesminingsih, SST


NIP. 195804151983031010 NIP. 19870712 201101 2005
at hanis
a Meviarnaa
DAFTAR TAGIHAN KLAIM RAWAT JALAN JAMKESMAS DALAM DAN LUAR GEDUNG
PROPINSI : Sumatera Selatan BULAN : Mei TAHUN : 2013
KAB/KOTA : OKU/ BATURAJA PUSKESMAS : Karya Mukt

Kepada Yth
kepala Dinas Kesehatan Kab/Kota OKU/ Baturaja
di- Tempat
Bersama ini Kami ajukan tagihan Klaim Pelayanan Kesehatan Umum Rawat Jalan Peserta Jamkesmas

Pelayanan Kes dan Besaran tarif sesuai dengan PERDA(Rp*0


JENIS
No. PESERTA UMUR KELAMIN TANGGAL IGD/ Pemeriksaan Pemberian
NO NAMA PASIEN DIAGNOSA TOTAL BIAYA
JAMKESMAS (Thn) (L/P) KUNJUNGAN Poli Umum Tindakan Poli Gigi Penunjangan Poli KIA/KB Obat
Medis **)

1 2 3 4 5 6 7 8 9 10 11 12 13 (8+9+10+11+12+13)
1 Tiono 0000306110259 29 L 5/1/2013 Rematoid Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
2 Setu 0000306110485 49 L 5/4/2013 Gastrits Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
3 Marsih 0000306110507 19 P 5/6/2013 Alergi Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
4 Santo 0000306221973 35 L 5/8/2013 Gastrits Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
5 Muslih 0000306110913 50 L 5/8/2013 Konjungtfits Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
6 Herawat 0000306222592 29 P 5/9/2013 GE Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
7 Erika 0000306222513 10 P 5/10/2013 Ispa Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
8 Mioftahul.J 0000306222636 4 P 5/14/2013 Scabies Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
9 Sunardi 0000306222456 18 L 5/14/2013 Asma Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
10 Hermanto 0000306140123 2 L 5/15/2013 Ispa Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000 resmita meviarnaamkke
11 Ika 0000306140218 40 P 5/18/2013 VC Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500 111000
12 Asih Rahayu 0000305433977 30 P 4/26/2013 Gastrits Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
13 M. Guntur 0000305434563 3 L 4/27/2013 Ispa Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
14 Hoidayul 0000305500511 12 P 4/30/2013 Faringits Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
15 Ana Lestari 0000305564477 22 P 4/30/2013 Gastrits Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
16 Herlina 0000305564398 30 P 5/7/2013 Demam Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
17 Yastri 0000305564938 15 P 5/13/2013 Konstpasi Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
18 Ine.P 0000305546859 6 P 5/13/2013 Ispa Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
19 Asih Rahayu 0000305433977 30 P 5/14/2013 Gastrits Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
20 Kundari 0000305564984 38 P 5/14/2013 Gastrits Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
21 Suratni 0000305563977 34 P 5/18/2013 Hypertensi Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500 ismawat hanis amkeb
22 Edi Santoso 0000305563138 28 L 5/19/2013 Ispa Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500 93000
23 Muslim 0000989625159 35 L 5/1/2013 RA Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
24 Reza Pratama 0000989625172 40 L 5/2/2013 Dermatts Alergi Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
25 Sagadah 0000989625194 50 P 5/3/2013 Gastrits Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
26 Istnah 0000989625216 32 P 5/4/2013 Dermatts Alergi Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
27 Reni Aniza 0000989625161 10 P 5/7/2013 Ispa Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
28 Toha Yasin 0000989625183 30 L 5/9/2013 Gastrits Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
29 Saiful Rahman 0000989625205 32 L 5/10/2013 Febris Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
30 Farhan 0000989625227 40 L 5/13/2013 RA Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
31 Supriyanto 0000989625238 70 L 5/15/2013 RA Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
32 Agung Darmawan 0000989625251 30 L 5/15/2013 Caries dents Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
33 Sri Nuryat 0000989625273 25 P 5/16/2013 Hypertensi Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
34 Andi Prastya 0000989625295 20 L 5/18/2013 Febris Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
35 Nurlelawat 0000989625249 21 P 5/18/2013 Caries dents Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
36 Sunardi 0000989625262 40 L 5/20/2013 Dermatts Alergi Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
37 Febri Setawan 0000989625284 20 L 5/21/2013 Gastrits Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
38 Lia Agustn 0000989625306 10 P 5/21/2013 Febris Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
39 Kawi 0000989625317 45 L 5/22/2013 Hypertensi Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
40 Nur Kayat 0000989625339 27 L 5/22/2013 Ispa Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
41 Wisnu saputra 0000989625362 12 L 5/22/2013 Ispa Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500 srimurtni amkeb
42 Ngatnah 0000989625328 47 P 5/23/2013 Hypertensi Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000 178500
43 Rosmi 0000305820909 48 P 5/1/2013 Up imlant Rp. 3,000 Rp. 39,500 - - - Rp. 3,000 Rp. 45,500
44 Romanus Sukadi 0000305820876 52 L 5/1/2013 Remathoid Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
45 Redho 0000306218081 7 L 5/2/2013 Diare Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
46 Mesran 0000306219227 58 L 5/3/2013 Obs Hypertensi Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
47 Erwin 0000305818176 40 L 5/3/2013 Diare Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
48 Herman Efendi 0000306218013 31 L 5/4/2013 Kaki gatal Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
49 Kurna Arini 0000305820112 30 P 5/7/2013 KB Rp. 3,000 - - - Rp. 15,000 - Rp. 18,000
50 Siska 0000306221185 8 P 5/7/2013 Diare Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
51 Suwart 0000305820461 46 P 5/9/2013 Rematk+hypertensi Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
52 Warlianto 0000306101474 35 L 5/9/2013 Sakit mata Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
53 Aziz 0000306221049 27 L 5/10/2013 Gastrits Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
54 Roaini 0000306218057 33 P 5/13/2013 KB Rp. 3,000 - - - Rp. 15,000 - Rp. 18,000
55 Susi S 0000306216729 36 P 5/15/2013 Imlant Rp. 3,000 Rp. 4,500 - - Rp. 45,000 Rp. 3,000 Rp. 55,500
56 Kasman 0000306101158 65 L 5/16/2013 Hypertensi Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
57 Yohana 0000306216729 5 P 1/17/1900 Diare Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
58 Kumaludin 0000306221005 40 L 5/18/2013 Ispa Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
59 Imam Safi'i 0000989617871 31 L 5/20/2013 KCL Rp. 3,000 Rp. 27,500 - - - Rp. 3,000 Rp. 33,500
60 Suyetno 0000989617882 60 L 5/21/2013 KCL Rp. 3,000 Rp. 102,000 - - - Rp. 3,000 Rp. 108,000 Rp. 97,500
61 Het 0000989618005 28 P 5/22/2013 KB Rp. 3,000 Rp. 4,500 - - Rp. 15,000 - Rp. 22,500
62 Sutni 0000989617904 25 P 5/22/2013 Gastrits Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
63 Suharminto 0000989617948 31 L 5/23/2013 Hypotensi Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500 rita widartk Skm
64 Est 0000989617926 23 P 5/23/2013 KB Rp. 3,000 - - - Rp. 15,000 - Rp. 18,000 466000
65 Erniwat 0000989624103 38 P 5/1/2013 Pusing Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
66 Aas vitriana 0000989624114 14 P 5/1/2013 Pusing Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
67 Anis Wardani 0000989623528 12 P 5/3/2013 Kembung Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
68 Siswandi 0000989623697 29 L 5/3/2013 pusing,mual Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
69 Rasiman 0000989623484 50 L 5/3/2013 Sakit gigi Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
70 choirul huda 0000989623506 9 L 5/4/2013 Demam,pilek Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
71 Sri wahyuni 0000305493789 28 P 5/4/2013 Sakit pinggang Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
72 Imam aripin 0000305494277 16 L 5/6/2013 Sakit perut Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
73 muslimin 0000305456758 48 L 5/6/2013 Kembung Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
74 Samini 0000305457063 37 P 5/6/2013 Kembung Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
75 Sri erna 0000305457535 16 P 5/8/2013 Sakit gigi Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
76 M. Abdik rohman 0000305458733 45 L 5/8/2013 Demam,kembung Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
77 Yurleni S 0000305458031 15 P 5/8/2013 Demam Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
78 Mukson 0000305481912 43 L 5/10/2013 Sakit pinggang Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
79 Sumirah 0000305721764 30 P 1/12/1900 Reumatk Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
80 Abqori 0000305424731 75 L 5/13/2013 Alergi Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
81 Kartomo 0000303599433 37 L 5/15/2013 Kembung,mual Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
82 Purni 0000303091893 35 P 5/15/2013 Demam Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500 rokhila amkeb
83 Sinem 0000308523068 65 P 1/19/1900 Reumatk Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500 140257660
84 Sukur 0000305345586 45 L 5/23/2013 Hypotensi Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500 192000
Jumlah Rp. 1,040,500

Mengetahui,
Kepala UPTD Puskesmas Karya Mukt Karya Mukt, Mei 2013
pj. Pelayanan puskesmas
HASYMI, SKM Try Koesminingsih, SST
NIP. 195804151983031010 NIP. 19870712 201101 2005
meviarnaamkkep

t hanis amkeb
ni amkeb
artk Skm
DAFTAR TAGIHAN KLAIM RAWAT JALAN JAMKESMAS DALAM DAN LUAR GEDUNG
PROPINSI : Sumatera Selatan BULAN : April TAHUN : 2013
KAB/KOTA : OKU/ BATURAJA PUSKESMAS : Karya Mukt

Kepada Yth
kepala Dinas Kesehatan Kab/Kota OKU/ Baturaja
di- Tempat
Bersama ini Kami ajukan tagihan Klaim Pelayanan Kesehatan Umum Rawat Jalan Peserta Jamkesmas

Pelayanan Kes dan Besaran tarif sesuai dengan PERDA(Rp*0


JENIS
No. PESERTA UMUR KELAMIN TANGGAL IGD/ Pemeriksaan Pemberian
NO NAMA PASIEN DIAGNOSA TOTAL BIAYA
JAMKESMAS (Thn) (L/P) KUNJUNGAN Poli Umum Tindakan Poli Gigi Penunjangan Poli KIA/KB Obat
Medis **)

1 2 3 4 5 6 7 8 9 10 11 12 13 (8+9+10+11+12+13)
1 Yogi 0000306219857 9 L 1/4/2013 Gastrits Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
2 Acep 0000305819177 28 L 2/4/2013 VC Rp. 3,000 Rp. 50,500 - - - Rp. 3,000 Rp. 10,500
3 Andra 0000305819267 5 L 10/4/2013 Caries Dents Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
4 Sunart 0000306217697 2 P 10/4/2013 Ispa Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
5 Nasida 0000304621793 19 P 12/4/2013 Asma Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
6 Joko 0000306219159 40 L 15/4/2013 GE Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
7 Fajri 0000706217438 38 L 15/4/2013 Rematoid Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
8 Samsudin 0000306217361 50 L 15/4/2013 VC Rp. 3,000 Rp. 27,500 - - - Rp. 3,000 Rp. 33,500
9 Pusmawat 0000306211498 28 P 17/4/2013 KB Rp. 3,000 - - - Rp. 15,000 - Rp. 18,000
10 merina 0000305818885 29 P 17/4/2013 Rematoid Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
11 Novia 0000306217618 27 P 18/4/2013 KB Rp. 3,000 - - - Rp. 15,000 - Rp. 18,000
12 Mujiani 0000306102071 25 P 19/4/2013 Keputhan Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
13 Suci 0000306221523 60 P 20/4/2013 Hypertensi Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
14 Dian.A 0000306217978 32 P 20/4/2013 Sakit Telinga Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500 resmita.m
15 Rabun 0000306217899 49 L 20/4/2013 Konjungtfits Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500 195500
16 M. Alimin 0000305550314 45 L 1/4/2013 Vulnus Laceratum Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
17 M. Guntur 0000306434563 2 L 1/4/2013 Ispa Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
18 Sujani 0000305546562 35 L 4/4/2013 Hypotensi Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
19 Ine.P 0000305546859 5 P 4/4/2013 Ispa Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
20 M.Karinsyah 0000305505595 10 L 12/4/2013 Vulnus Laceratum Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
21 M.Al majid 0000305506293 8 L 12/4/2013 Vulnus Laceratum Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
22 Ma'rifat Al Karomah 0000305508925 7 P 12/4/2013 Vulnus Laceratum Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
23 Masnum.I 0000305504763 15 P 12/4/2013 Vulnus Laceratum Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000

24 Guntur 0000306434563 2 L 12/4/1900 Ispa Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
25 Erna 0000305535723 27 P 16/4/2013 Vertgo Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
26 Ine.P 0000308595546 5 P 16/4/2013 Demam Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
27 Aan Ardianto 0000706355048 13 L 16/4/2013 Batuk Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
28 Hartk 0000705566042 37 P 16/4/2013 Anorexia Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
29 Deni.K 0000706354431 15 L 16/4/2013 Demam Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
30 Anggi 0000306347141 11 L 17/4/2013 Batuk Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
31 Revalina 0000305535971 6 P 17/4/2013 Ispa Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
32 Mustaji 0000305503492 50 L 18/4/2013 Arthrits.R Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
33 Darsono 0000305521727 51 L 19/4/2013 Gastrits Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
34 Srimani 0000305517644 37 P 20/4/2013 Batuk Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
35 A.Rizal 0000305504853 10 L 20/4/2013 Infesi kulit Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
36 Edi jhoni 0000305537286 45 L 20/4/2013 Vertgo Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
37 Sarmidi 0000305537679 11 L 22/4/2013 Tonsilits Rp. 3,000 Rp. 500 - - - Rp. 3,000 Rp. 6,500 ismawat hanis
38 Martni 0000305537106 47 P 22/4/2013 Alergi Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500 179000
39 Tiara Monalisa 0000305546398 11 p 4/4/2013 Caries dents Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
40 Lina Meliana 0000306940004 12 P 4/4/2013 CC Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
41 Supriat 0000301616841 28 P 6/4/2013 Obs Febris Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
42 Ririn Tamara 0000306940757 19 P 8/4/2013 Gastrits Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
43 Evi Yuliana 0000307232087 10 P 8/4/2013 Febris Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
44 Asep Andalas 0000306934435 35 L 9/4/2013 CC Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
45 Otarina 0000305533664 45 P 12/4/2013 CC Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
46 Enah 0000307232526 50 P 15/4/2013 CC Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
47 Jec yani ipang 0000306932077 39 P 15/4/2013 CC Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
48 Nilam Cahya 0000307220207 4 P 20/4/2013 CC Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
49 Danar Riyan T 0000306917548 22 L 20/4/2013 Gastrits Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
50 Maimin 0000307206235 32 L 20/4/2013 Alergie Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
51 Tobrani 0000306939767 45 L 22/4/2013 Diare Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
52 Fitri Istqomah 0000303157216 1 P 22/4/2013 CC Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
53 Puji lestari 0000307210522 16 P 4/22/2013 CC Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
54 Romen 0000306928956 41 L 4/23/2013 Vertgo Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
55 neneng Wangsih 0000305551855 33 P 4/23/2013 Gastrits Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
56 Tedi Setawan 0000305569359 12 L 4/24/2013 Obs Febris Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
57 yuliana 0000305532037 36 P 1/23/1900 CC Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
58 FidaniaUchiatul.h 0000306914646 2 P 4/25/2013 Febris Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
59 Agista Arisaul.u 0000306914602 14 P 4/25/2013 Alergi Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
60 Sulnah 0000307213558 29 P 4/26/2013 Gastrits Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
61 Tami 0000305539367 40 L 4/26/2013 Gastrits Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
62 Khoirul Anas 0000305536509 28 L 4/27/2013 Febris Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
63 Adi Iswantoro 0000305521536 19 L 4/27/2013 CC Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
64 Sri Yant 0000305568832 25 P 4/29/2013 Anemia Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000 novalia
65 Ilham Makbulin 0000307193038 3 L 4/29/2013 Alergi Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000 197811072005012011
66 Revan Valeri 0000305567774 6 L 4/30/2013 Diare Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000 249000
67 Ferlita. I 0000306306070 13 P 4/6/2013 Demam Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
68 Supriyanto 0000305461607 31 L 4/8/2013 Pusing,kembung Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
69 Maryanto 0000305287104 25 L 4/8/2013 Sakit gigi Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
70 Khoirul Umah 0000305482586 19 L 4/9/2013 Kembung,Muntah Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
71 Edi Susarwo 0000305453586 27 L 4/9/2013 Sakit gigi Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
72 Warsito 0000305313862 32 L 4/9/2013 Demam Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
73 Atminah 0000305319047 29 P 4/10/2013 Demam,Kembung Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
74 Laelatul Fitria 0000304308138 22 P 4/10/2013 Kembung Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
75 Rianto 0000308345374 27 L 4/11/2013 Sakit Mata Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
76 Hari Sudarsono 0000308808184 25 L 4/11/2013 Demam,Batuk Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
77 Amas 0000305346081 38 L 4/12/2013 Pusing,kembung Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
78 Samini 0000305346295 29 P 4/13/2013 Alergi Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
79 Tat Sumiat 0000305345103 20 P 4/15/2013 Pusing,kembung Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500 140257660
80 Indri Lukitasari 0000305345452 22 P 4/16/2013 Demam Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500 Rokhila
81 Sulasmi 0000305285286 42 P 4/18/2013 Alergi Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500 144000
82 0000306219699 40 /4/2013 Rp. 3,000 Rp. 4,500 - - - Rp. 3,000
83 Ali 0000306219194 23 L /4/2013 Gastrits Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
84 Heni 0000305819291 37 P /4/2013 Hypertensi Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
85 Rohman.F 0000306102194 20 L /4/2013 Caries dents Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
86 Siswo 0000306101823 27 L /4/2013 GE Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
87 Ninik.H 0000306211601 9 P /4/2013 Skabies Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
88 Ahlun 0000305819201 21 P /4/2013 Asma Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
89 Serli 0000305819324 4 P /4/2013 Alergi Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500 118
90 Yuyun 0000306211533 15 P /4/2013 Konjuntfits Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
91 Halima 0000305217505 28 P /4/2013 KB Rp. 3,000 - - - Rp. 15,000 - Rp. 18,000

24 M.Komarudin 0000305537332 50 L /4/2013 Ispa Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
25 Amat Diono 0000305558898 55 L /4/2013 RA Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
26 Ahmad Kamim 0000305572983 35 L /4/2013 Diare Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
27 Wahyu 0000706409291 29 L /4/2013 Ispa Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
28 Sumardi 0000706407153 31 L /4/2013 Caries dents Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
29 Rosit 0000706409245 32 L /4/2013 Ispa Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
30 Tuham 0000707000073 35 L /4/2013 Faringits Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
31 Syukur 0000706405634 50 L /4/2013 Hypertensi Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
32 Kateni 0000306105603 47 P /4/2013 Obs Hypertensi Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
33 Kurna Arini 0000305820112 30 P /4/2013 Gastrits Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
34 Rita 0000305818209 28 P /4/2013 KB Rp. 3,000 - - - Rp. 15,000 - Rp. 18,000
35 Endang 0000306221106 39 P /4/2013 Imlant Rp. 3,000 - - - Rp. 45,000 - Rp. 48,000
36 Ahmad Taslim 0000306101553 65 L /4/2013 Febris Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
37 Saprak 0000306220882 52 L /4/2013 Luka Rp. 3,000 Rp. 27,500 - - - Rp. 3,000 Rp. 33,500
38 Suwardi 0000306219317 50 L /4/2013 Rematoid Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
39 Ngatni 0000306224144 42 P /4/2013 Ispa Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
40 Sit Anggun 0000305816433 15 P /4/2013 Ispa Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
41 Mariyat 0000306216191 42 P /4/2013 GE Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
42 Aminah 0000306213399 35 P /4/2013 Keputhan Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
43 Kartni 0000306213456 29 P /4/2013 Vc Rp. 3,000 Rp. 24,500 - - - Rp. 3,000 Rp. 30,500
44 Nurhayat 0000305816589 26 P /4/2013 Ispa Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
45 Tuminah 0000306219069 37 L /4/2013 Rematoid Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
46 Riyanto 0000306216156 18 L /4/2013 Gastrits Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
47 Rohmat 0000306219104 17 L /4/2013 Vc Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
48 Triazi 0000306219699 40 P /4/2013 Rematoid Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
49 Ali 0000306219194 23 L /4/2013 Gastrits Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
50 Heni 0000305819291 37 P /4/2013 Hypertensi Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
51 Rohman.F 0000306102194 20 L /4/2013 Caries dents Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
52 Siswo 0000306101823 27 L /4/2013 GE Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
53 Ninik.H 0000306211601 9 P /4/2013 Skabies Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
54 Ahlun 0000305819201 21 P /4/2013 Asma Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
55 Serli 0000305819324 4 P /4/2013 Alergi Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
56 Yuyun 0000306211533 15 P /4/2013 Konjuntfits Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
57 Halima 0000305217505 28 P /4/2013 KB Rp. 3,000 - - - Rp. 15,000 - Rp. 18,000

24 M.Komarudin 0000305537332 50 L /4/2013 Ispa Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
25 Amat Diono 0000305558898 55 L /4/2013 RA Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
26 Ahmad Kamim 0000305572983 35 L /4/2013 Diare Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
27 Wahyu 0000706409291 29 L /4/2013 Ispa Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
28 Sumardi 0000706407153 31 L /4/2013 Caries dents Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
29 Rosit 0000706409245 32 L /4/2013 Ispa Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
30 Tuham 0000707000073 35 L /4/2013 Faringits Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
31 Syukur 0000706405634 50 L /4/2013 Hypertensi Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
32 Kateni 0000306105603 47 P /4/2013 Obs Hypertensi Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
33 Kurna Arini 0000305820112 30 P /4/2013 Gastrits Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
34 Rita 0000305818209 28 P /4/2013 KB Rp. 3,000 - - - Rp. 15,000 - Rp. 18,000
35 Endang 0000306221106 39 P /4/2013 Imlant Rp. 3,000 - - - Rp. 45,000 - Rp. 48,000
36 Ahmad Taslim 0000306101553 65 L /4/2013 Febris Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
37 Saprak 0000306220882 52 L /4/2013 Luka Rp. 3,000 Rp. 27,500 - - - Rp. 3,000 Rp. 33,500
38 Suwardi 0000306219317 50 L /4/2013 Rematoid Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
39 Ngatni 0000306224144 42 P /4/2013 Ispa Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
40 Sit Anggun 0000305816433 15 P /4/2013 Ispa Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
41 Mariyat 0000306216191 42 P /4/2013 GE Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
42 Aminah 0000306213399 35 P /4/2013 Keputhan Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
43 Kartni 0000306213456 29 P /4/2013 Vc Rp. 3,000 Rp. 24,500 - - - Rp. 3,000 Rp. 30,500
44 Nurhayat 0000305816589 26 P /4/2013 Ispa Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
45 Tuminah 0000306219069 37 L /4/2013 Rematoid Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
46 Riyanto 0000306216156 18 L /4/2013 Gastrits Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
47 Rohmat 0000306219104 17 L /4/2013 Vc Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
48 Triazi 0000306219699 40 P /4/2013 Rematoid Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
49 Ali 0000306219194 23 L /4/2013 Gastrits Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
50 Heni 0000305819291 37 P /4/2013 Hypertensi Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
51 Rohman.F 0000306102194 20 L /4/2013 Caries dents Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
52 Siswo 0000306101823 27 L /4/2013 GE Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
53 Ninik.H 0000306211601 9 P /4/2013 Skabies Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
54 Ahlun 0000305819201 21 P /4/2013 Asma Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
55 Serli 0000305819324 4 P /4/2013 Alergi Rp. 3,000 Rp. 4,500 - - - Rp. 3,000 Rp. 10,500
56 Yuyun 0000306211533 15 P /4/2013 Konjuntfits Rp. 3,000 - - - - Rp. 3,000 Rp. 6,000
57 Halima 0000305217505 28 P /4/2013 KB Rp. 3,000 - - - Rp. 15,000 - Rp. 18,000
t hanis
072005012011

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