DAFTAR TAGIHAN KLAIM RAWAT JALAN PASIEN JAMKESDA PUSKESMAS DARUL AZHAR KABUPATEN TANAH BUMBU

Provinsi : Kalimantan Selatan

Kabupaten : Tanah Bumbu
Bulan : Januari 2017

Umur Jenis Tgl Pelayanan Kesehaan dan Besaran Tarif sesuai PERDA (Rp) TTD
No Nama No KTP Diagnosa
(Th)Kelamin
Kunjungan Poli KIATT Caten/Tindik Rujukan IUD/ PP Konsultasi Bidan Tagihan Psn/ Klg
Bumil Telinga Bidan Implant Test Gizi
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
1 Didik Lestari 631009570484000 4 33 P 3/1 G2P1A0 10,000 Bidan Rp10,000
2 Ika Zunia P 352408441199000 1 22 P 3/1 G2P0A1 10,000 Bidan Rp10,000
3 Nur Hasanah 631009541193000 3 24 P 3/1 G2P1A0 10,000 Bidan Rp10,000
4 Sri Nilawati 631009680688000 4 29 P 3/1 G3P1A1 10,000 Bidan Rp10,000
5 Dewi 631002501189000 2 28 P 3/1 G3P2A0 10,000 Bidan Rp10,000
6 Nurul Cahyaning631006710189000 1 28 P 3/1 G2P1A0 10,000 Bidan Rp10,000
7 Nisa Safitri 630102680897000 2 19 P 4/1 G1P0A0 10,000 Bidan Rp10,000
8 Marliani 631006570589000 1 28 P 4/1 G4P3A0 10,000 Bidan Rp10,000
9 Nor Bayah 631009460588000 4 29 P 4/1 G3P2A0 10,000 Bidan Rp10,000
10 Nadya Afriliyant631002680494000 1 23 P 4/1 G1P0A0 10,000 Bidan Rp10,000
11 Sariatul 631009460886000 5 31 P 4/1 G3P1A1 10,000 Bidan Rp10,000
12 Kardianah 631009480877001 1 40 P 4/1 G4P3A0 10,000 Bidan Rp10,000
13 Srini 631009430385000 5 32 P 5/1 G3P2A0 10,000 Bidan Rp10,000
14 Noor Huda F 631009420272001 4 23 P 5/1 G1P0A0 10,000 Bidan Rp10,000
15 Erfina Damayant631009520294000 7 23 P 6/1 G3P2A0 10,000 Bidan Rp10,000
16 Rusmawati 631009510593000 1 24 P 6/1 G2P1A0 10,000 Bidan Rp10,000
17 Siti Maryana 631007500982000 1 35 P 6/1 G3P2A0 10,000 Bidan Rp10,000
18 Siti Mariatul 631009540486000 4 31 P 6/1 G3P2A0 10,000 Bidan Rp10,000
19 Mutmainah 631006410797001 7 20 P 6/1 Konsultasi 10,000 Bidan Rp10,000
20 Halima 631009470488000 8 29 P 7/1 G2P1A0 10,000 Bidan Rp10,000
21 Ratna 630412440595000 2 22 P 7/1 G1P0A0 10,000 Bidan Rp10,000
Umur Jenis Tgl Pelayanan Kesehaan dan Besaran Tarif sesuai PERDA (Rp) TTD
No Nama No KTP Diagnosa
(Th)Kelamin Kunj Poli KIATT Caten/Tindik Rujukan IUD/ PP Konsultasi Bidan Tagihan Psn/ Klg
Bumil Telinga Bidan Implant Test Gizi
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
22 Susilawati 631009580286000 0 31 P 7/1 G3P1A1 10,000 Bidan Rp10,000
23 Saniah 631009471189000 4 28 P 9/1 G2P1A0 10,000 Bidan Rp10,000
24 Risna Wati 631009590487000 2 30 P 9/1 G3P2A0 10,000 Bidan Rp10,000
25 Nurul Isnaeni 330503570889000 4 28 P 9/1 G2P1A0 10,000 Bidan Rp10,000
26 Mursyidah 631009450393000 5 24 P 9/1 G1P0A0 10,000 Bidan Rp10,000
27 Hanirah 631009610580000 6 37 P 9/1 G6P5A0 10,000 Bidan Rp10,000
28 Yanti Susanti 631009501293000 3 24 P 10/1 G3P2A0 10,000 Bidan Rp10,000
29 Nisa Safitri 630102680897000 2 19 P 10/1 G1P0A0 10,000 Bidan Rp10,000
30 Mujalifah 631009651187000 2 30 P 10/1 G3P2A0 10,000 Bidan Rp10,000
31 Risnawati 631009601289000 9 28 P 11/1 G2P1A0 10,000 Bidan Rp10,000
32 St.Mina Maulida630706530297000 6 20 P 11/1 G3P2A0 10,000 Bidan Rp10,000
33 Minah 631009490882001 3 35 P 11/1 G4P3A0 10,000 Bidan Rp10,000
34 Mulyani 631006550791000 1 20 P 11/1 G2P1A0 10,000 Bidan Rp10,000
35 Hj.Zainah 631009451072000 7 45 P 11/1 Konsultasi 10,000 Bidan Rp10,000
36 Marwah 631009470789001 2 28 P 11/1 Konsultasi 10,000 Bidan Rp10,000
37 Nur Shela S 630905431195000 2 22 P 12/1 G1P0A0 10,000 Bidan Rp10,000
38 Srini 631009430385000 5 32 P 12/1 G3P2A0 10,000 Bidan Rp10,000
39 Risna Wati 631009590487000 2 30 P 12/1 G3P2A0 10,000 Bidan Rp10,000
40 Mey Narti 631009480679000 3 38 P 12/1 G3P2A0 10,000 Bidan Rp10,000
41 Irma Yanti 631009570696000 1 21 P 12/1 G2P1A0 10,000 Bidan Rp10,000
42 Endang Murniat631009490879000 1 40 P 12/1 G4P3A0 10,000 Bidan Rp10,000
43 Siti Zulaika 631009450292000 9 25 P 12/1 G2P1A0 10,000 Bidan Rp10,000
44 Fitri Anita 631009620996000 1 21 P 13/1 G2P1A0 10,000 Bidan Rp10,000
45 Kasria 631009540490000 8 27 P 13/1 G2P1A0 10,000 Bidan Rp10,000
46 Normatika 631009570374000 5 43 P 13/1 G4P3A0 10,000 Bidan Rp10,000
47 Murniati 352607510194000 2 23 P 13/1 G1P0A0 10,000 Bidan Rp10,000
48 Misnawati 631009411285000 4 32 P 13/1 G4P3A0 10,000 Bidan Rp10,000
49 Siti Kartika Sari631009520791000 5 26 P 13/1 G3P2A0 10,000 Bidan Rp10,000
50 Daryani 63100944118000 3 30 P 14/1 Konsultasi 10,000 Bidan Rp10,000
51 Noor Hayati 631009570887001 1 30 P 14/1 G4P2A1 10,000 Bidan Rp10,000
Umur Jenis Tgl Pelayanan Kesehaan dan Besaran Tarif sesuai PERDA (Rp) TTD
No Nama No KTP Diagnosa
(Th)Kelamin Kunj Poli KIATT Caten/Tindik Rujukan IUD/ PP Konsultasi Bidan Tagihan Psn/ Klg
Bumil Telinga Bidan Implant Test Gizi
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
52 Murdia 631009431276000 3 41 P 14/1 Konsultasi 10,000 Bidan Rp10,000
53 Isnun Purnawaty631009450284000 7 33 P 16/1 G3P2A0 10,000 Bidan Rp10,000
54 Dwi Anggraini 631009691095000 1 22 P 16/1 G2P1A0 10,000 Bidan Rp10,000
55 Yama 631009491178000 3 39 P 16/1 G5P4A0 10,000 Bidan Rp10,000
56 Jumiati 631009450783000 9 34 P 16/1 Konsultasi 10,000 Bidan Rp10,000
57 Sulistiyaningsih631009580276000 4 41 P 16/1 G10P9A0 10,000 Bidan Rp10,000
58 Hidayati 631009460687001 0 30 P 16/1 G2P1A0 10,000 Bidan Rp10,000
59 Dessy Erliani 631009591292000 4 25 P 16/1 G2P1A0 10,000 Bidan Rp10,000
60 Mahdalina 630805650881000 2 36 P 16/1 Konsultasi 10,000 Bidan Rp10,000
61 Sukarni 631009691271000 1 46 P 16/1 G4P3A0 10,000 Bidan Rp10,000
62 Eka Rahmi Julia631009530793000 7 24 P 17/1 G1P0A0 10,000 Bidan Rp10,000
63 Rusniati 631009711283001 0 34 P 17/1 G5P3A1 10,000 Bidan Rp10,000
64 Armawati 631009510876000 7 41 P 18/1 G5P4A0 10,000 Bidan Rp10,000
65 Rahma 631009490882000 9 35 P 18/1 G3P2A0 10,000 Bidan Rp10,000
66 Marni 631009620886000 5 31 P 19/1 G2P1A0 10,000 Bidan Rp10,000
67 Maymunah 631009650395000 3 22 P 20/1 G1P0A0 10,000 Bidan Rp10,000
68 Yuyut Windawat631009530189000 2 28 P 20/1 G5P2A2 10,000 Bidan Rp10,000
69 Nisa Safitri 630102680897000 2 28 P 20/1 G1P0A0 10,000 Bidan Rp10,000
70 Aliyah 631009410778018 2 39 P 20/1 Konsultasi 10,000 Bidan Rp10,000
71 Yama 631009491178000 3 39 P 20/1 G5P4A0 10,000 Bidan Rp10,000
72 Devita Rohmadi352420630190000 1 27 P 21/1 G3P2A0 10,000 Bidan Rp10,000
73 Santi 631006430991000 1 26 P 21/1 G3P2A0 10,000 Bidan Rp10,000
74 Warni 631009570372000 1 45 P 21/1 G3P2A0 10,000 Bidan Rp10,000
75 Ruspatmawati 631009430596000 3 21 P 21/1 G1P0A0 10,000 Bidan Rp10,000
76 Sarmah 631009681179000 5 38 P 21/1 Konsultasi 10,000 Bidan Rp10,000
77 Halima 631009470488000 8 29 P 21/1 G2P1A0 10,000 Bidan Rp10,000
78 Sarfiah 631002470784001 1 33 P 23/1 G2P1A0 10,000 Bidan Rp10,000
79 Merlita 631009511277000 4 40 P 23/1 G2P1A0 10,000 Bidan Rp10,000
80 Amini Fujianti 631002430497000 3 20 P 23/1 Konsultasi 10,000 Bidan Rp10,000
81 Risna Amalina 631009681283000 1 34 P 23/1 G2P1A0 10,000 Bidan Rp10,000
Umur Jenis Tgl Pelayanan Kesehaan dan Besaran Tarif sesuai PERDA (Rp) TTD
No Nama No KTP Diagnosa
(Th)Kelamin Kunj Poli KIATT Caten/Tindik Rujukan IUD/ PP Konsultasi Bidan Tagihan Psn/ Klg
Bumil Telinga Bidan Implant Test Gizi
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
82 Nurdiati 631009540476000 3 41 P 23/1 G6P4A1 10,000 Bidan Rp10,000
83 Rika Novitasari 631009650292000 4 25 P 23/1 G1P0A0 10,000 Bidan Rp10,000
84 Linda Wati 631009451281000 5 36 P 23/1 G3P2A0 10,000 Bidan Rp10,000
85 Endang Susanti 631009681091000 8 26 P 24/1 G3P1A1 10,000 Bidan Rp10,000
86 Nur Aeni Rosali631009450588001 0 29 P 24/1 G3P1A1 10,000 Bidan Rp10,000
87 Mursyidah 631009450393000 5 24 P 24/1 G1P0A0 10,000 Bidan Rp10,000
88 Ita Dewi Lestari631009501085001 2 32 P 24/1 G3P1A1 10,000 Bidan Rp10,000
89 Musrini 631009450778001 1 39 P 25/1 G3P2A0 10,000 Bidan Rp10,000
90 Nurul Hikmah 631009450296000 4 27 P 25/1 G2P1A0 10,000 Bidan Rp10,000
91 Ika Zunia P 352408441199000 1 22 P 25/1 G2P0A1 10,000 Bidan Rp10,000
92 Noor Hayati 631009570887001 1 30 P 26/1 G4P2A1 10,000 Bidan Rp10,000
93 Nurul Hikmah 631009610997000 2 20 P 26/1 G1P0A0 10,000 Bidan Rp10,000
94 Salma Raihani 631009461084000 4 33 P 26/1 G4P2A1 10,000 Bidan Rp10,000
95 Nurul Aeni 631010431294000 3 23 P 23/1 G1P0A0 10,000 Bidan Rp10,000
96 Jumrawati 731310410789001 3 23 P 26/1 G1P0A0 10,000 Bidan Rp10,000
97 Herlina 631010680190000 1 27 P 26/1 G2P1A0 10,000 Bidan Rp10,000
98 Hasnaba 631009500881000 5 36 P 26/1 G6P5A0 10,000 Bidan Rp10,000
99 Mariana 631009600587000 5 30 P 26/1 G10P9A0 10,000 Bidan Rp10,000
100 Yuyun Elviana 631009690994000 5 26 P 27/1 Konsultasi 10,000 Bidan Rp10,000
101 Yama 631009491178000 3 39 P 30/1 G5P4A0 10,000 Bidan Rp10,000
102 Herlina 631009630793000 2 24 P 30/1 G2P1A0 10,000 Bidan Rp10,000
103 Nur Cahaya 631010600292000 1 25 P 30/1 G2P1A0 10,000 Bidan Rp10,000
104 Nor Bayah 631009460588000 4 29 P 30/1 G3P2A0 10,000 Bidan Rp10,000
105 Mallianti 631009660597000 4 20 P 30/1 G2P1A0 10,000 Bidan Rp10,000
106 Mursyidah 631009450393000 5 24 P 30/1 G1P0A0 10,000 Bidan Rp10,000
107 Kardianah 631009480877001 1 40 P 30/1 Konsultasi 10,000 Bidan Rp10,000
108 Mariana 631009600587000 5 30 P 30/1 G1P0A0 10,000 Bidan Rp10,000
109 Hayuradiana 631009430588000 6 29 P 31/1 G2P1A0 10,000 Bidan Rp10,000
110 Siti Mariatul 631009540486000 4 31 P 31/1 G4P2A1 10,000 Bidan Rp10,000
111 Nursidah 631009570781000 8 36 P 31/1 G3P2A0 10,000 Bidan Rp10,000
Umur Jenis Tgl Pelayanan Kesehaan dan Besaran Tarif sesuai PERDA (Rp) TTD
No Nama No KTP Diagnosa
(Th)Kelamin Kunj Poli KIATT Caten/Tindik Rujukan IUD/ PP Konsultasi Bidan Tagihan Psn/ Klg
Bumil Telinga Bidan Implant Test Gizi
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
112 Erfina Damayant631009520294000 7 23 P 31/1 G3P2A0 10,000 Bidan Rp10,000
113 Fatmawati 631009530388000 2 29 P 31/1 G1P0A0 10,000 Bidan Rp10,000

TOTAL 1.130.000
Simpang Empat, 02 Februari 2017
Mengetahui, Bendahara Jamkesda
Kepala Puskesmas Darul Azhar Puskesmas Darul Azhar

dr.Muhammad Erhamsyah Nur Wahyu P, S.Kep, Ners.

Nip.19700111 200312 1 004 NIP.19820527 200804 2 002
 DAFTAR TAGIHAN KLAIM RAWAT JALAN PASIEN JAMKESDA PUSKESMAS DARUL AZHAR KABUPATEN TANAH BUMBU

Provinsi : Kalimantan Selatan

Kabupaten : Tanah Bumbu
Bulan : Februari 2017

UmurJenis Tgl Pelayanan Kesehaan dan Besaran Tarif sesuai PERDA (Rp) TTD
No Nama No KTP Diagnosa
(Th)Kelamin
Kunjungan Poli KIATT Caten/TindikRujukan IUD/ PP Konsultasi Bidan Tagihan Psn/ Klg
Bumil TelingaBidan Implant Test Gizi
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
1 Mahrita 631009611186000 4 31 P 2/2 G2P1A0 10,000 Bidan Rp10,000
2 Rahmadaniah 631009420880001 2 37 P 2/2 G5P4A0 10,000 Bidan Rp10,000
3 Marni 631009620886000 5 31 P 2/2 G2P1A0 10,000 Bidan Rp10,000
4 Sariatul 631009460886000 5 31 P 2/2 G3P1A1 10,000 Bidan Rp10,000
5 Murdia 631009431276000 3 41 P 4/2 Konsultasi 10,000 Bidan Rp10,000
6 Mariati 631009500495001 0 22 P 4/2 G2P1A0 10,000 Bidan Rp10,000
7 Sulistiyaningsih 631009580276000 4 41 P 6/2 G10P9A0 10,000 Bidan Rp10,000
8 Kasmiati 631009500684000 8 33 P 6/2 Perawatan Luka Tanpa Jahitan 15,000 Bidan Rp15,000
9 Sri Nilawati 631009680688000 4 29 P 6/2 G3P1A1 10,000 Bidan Rp10,000
10 Irhamna 631009651283000 6 34 P 6/2 G4P2A1 10,000 Bidan Rp10,000
11 Hj.Bondeng 631009521274001 5 43 P 7/2 Konsultasi 10,000 Bidan Rp10,000
12 Muliawati 631009700993000 2 24 P 7/2 G2P1A0 10,000 Bidan Rp10,000
13 Sukmah 631009701094000 2 23 P 7/2 G2P0A1 10,000 Bidan Rp10,000
14 Jamilah 631009500181000 6 36 P 8/2 G3P2A0 10,000 Bidan Rp10,000
15 Nurul Cahyaningsih 631006710189000 1 28 P 8/2 G2P1A0 10,000 Bidan Rp10,000
16 Armawati 631009510876000 7 41 P 8/2 G5P4A0 10,000 Bidan Rp10,000
17 Kartini 631006630483000 1 34 P 8/2 Konsultasi 10,000 Bidan Rp10,000
18 Misnah 631001650580000 2 37 P 9/2 G4P3A0 10,000 Bidan Rp10,000
19 Marselina Srimuryani 531001661184000 2 33 P 9/2 Konsultasi 10,000 Bidan Rp10,000
20 Marni 631009620886000 5 31 P 9/2 G2P1A0 10,000 Bidan Rp10,000
 UmurJenis Tgl Pelayanan Kesehaan dan Besaran Tarif sesuai PERDA (Rp) TTD
No Nama No KTP Diagnosa
(Th)KelaminKunj Poli KIATT Caten/TindikRujukan IUD/ PP Konsultasi Bidan Tagihan Psn/ Klg
Bumil TelingaBidan Implant Test Gizi
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
21 Yuniarty 630209560680000 1 37 P 10/2 G5P3A1 10,000 Bidan Rp10,000
22 Ngaenur Rokhmah 631009660291000 1 26 P 10/2 G2P1A0 10,000 Bidan Rp10,000
23 Ita Dewi Lestari 631009501085001 2 32 P 10/2 G3P1A1 10,000 Bidan Rp10,000
24 Asmaniah 631009650477000 1 40 P 10/2 G4P3A0 10,000 Bidan Rp10,000
25 Ika Zunia Pratiwi 352408441199000 1 22 P 10/2 G2P0A1 10,000 Bidan Rp10,000
26 Nurul Hikmah 631009450296000 4 21 P 10/2 G2P1A0 10,000 Bidan Rp10,000
27 Mariaty Helda 631009480886000 7 31 P 11/2 Konsultasi 10,000 Bidan Rp10,000
28 Syarmiah 631009490788000 4 29 P 13/2 Konsultasi 10,000 Bidan Rp10,000
29 Ela Hartini 631009460190000 2 27 P 13/2 G3P2A0 10,000 Bidan Rp10,000
30 Marwah 631009470789001 2 28 P 13/2 Konsultasi 10,000 Bidan Rp10,000
31 Hasneni 631009540889000 6 28 P 13/2 Konsultasi 10,000 Bidan Rp10,000
32 Ngaenur Rokhmah 631009660291000 1 26 P 13/2 G2P1A0 10,000 Bidan Rp10,000
33 Aulia Putrianoor 631002610197000 7 20 P 13/2 G1P0A0 10,000 Bidan Rp10,000
34 Salamah 631006500982000 2 35 P 13/2 G4P3A0 10,000 Bidan Rp10,000
35 Sariyani 631009701270000 4 47 P 13/2 G4P3A0 10,000 Bidan Rp10,000
36 Fatmawati 631009530388000 2 29 P 13/2 G1P0A0 10,000 Bidan Rp10,000
37 St.Mina Maulida Y 630706530297000 6 20 P 13/2 G1P0A0 10,000 Bidan Rp10,000
38 Sabariah 631009580790000 8 27 P 14/2 G2P1A0 10,000 Bidan Rp10,000
39 Rusniati 631009711283001 0 34 P 14/2 G5P3A1 10,000 Bidan Rp10,000
40 Mursyidah 631009450393000 5 24 P 14/2 G1P0A0 10,000 Bidan Rp10,000
41 Merlita 631009511277000 4 40 P 14/2 G2P1A0 10,000 Bidan Rp10,000
42 Raudah 631009501085001 6 32 P 14/2 G4P3A0 10,000 Bidan Rp10,000
43 Murniati 352607510194000 2 23 P 14/2 G1P0A0 10,000 Bidan Rp10,000
44 Fitri Anita 631009620996000 1 21 P 15/2 G2P1A0 10,000 Bidan Rp10,000
45 Linda Wati 631009451281000 5 36 P 15/2 G3P2A0 10,000 Bidan Rp10,000
46 Ngaenur Rokhmah 631009660291000 1 26 P 16/2 G2P1A0 10,000 Bidan Rp10,000
47 Sadariyah 631009581287000 2 30 P 16/2 G2P1A0 10,000 Bidan Rp10,000
48 Ruspatmawati 631009430596000 3 21 P 16/2 G1P0A0 10,000 Bidan Rp10,000
49 Isnun Purnawaty 631009450284000 7 33 P 16/2 G3P2A0 10,000 Bidan Rp10,000
50 Listy Ariany 631009471177000 4 40 P 16/2 G3P2A0 10,000 Bidan Rp10,000
 UmurJenis Tgl Pelayanan Kesehaan dan Besaran Tarif sesuai PERDA (Rp) TTD
No Nama No KTP Diagnosa
(Th)KelaminKunj Poli KIATT Caten/TindikRujukan IUD/ PP Konsultasi Bidan Tagihan Psn/ Klg
Bumil TelingaBidan Implant Test Gizi
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
51 Hidayati 631009460687001 0 30 P 16/2 G2P1A0 10,000 Bidan Rp10,000
52 Fatmawati 631009680892000 2 25 P 16/2 G2P1A0 10,000 Bidan Rp10,000
53 Leni Purnama 631009590589000 3 28 P 16/2 G2P1A0 10,000 Bidan Rp10,000
54 Nurul Isnaeni 330503570889000 4 28 P 16/2 G2P1A0 10,000 Bidan Rp10,000
55 Erfina Damayanti 631009520294000 7 23 P 17/2 G3P2A0 10,000 Bidan Rp10,000
56 Haty 631009500476000 5 41 P 17/2 G6P5A0 10,000 Bidan Rp10,000
57 Asmaniah 631009650477000 1 40 P 17/2 G4P3A0 10,000 Bidan Rp10,000
58 Mulyani 631006550791000 1 26 P 18/2 G2P1A0 10,000 Bidan Rp10,000
59 Mariani 631002411084000 3 33 P 20/2 Konsultasi 10,000 Bidan Rp10,000
60 Irma 631009690989000 2 28 P 20/2 G3P2A0 10,000 Bidan Rp10,000
61 Didik Lestari 631009570484000 4 33 P 20/2 G2P1A0 10,000 Bidan Rp10,000
62 Risna Amalina 631009681283000 1 34 P 20/2 G2P1A0 10,000 Bidan Rp10,000
63 Putri Lestari 631006590488000 2 29 P 20/2 G1P0A0 10,000 Bidan Rp10,000
64 Jumrawati 731310410789001 3 23 P 21/2 G1P0A0 10,000 Bidan Rp10,000
65 Norhayati 631009650593000 6 24 P 21/2 G4P3A0 10,000 Bidan Rp10,000
66 Susi Herlinawati 631001460279000 1 38 P 21/2 G4P3A0 10,000 Bidan Rp10,000
67 Iin Komariah 631009650677000 4 40 P 21/2 G3P2A0 10,000 Bidan Rp10,000
68 Fitriah Laumma 631009460979000 2 38 P 21/2 Konsultasi 10,000 Bidan Rp10,000
69 Defi Nofitasari 631009610193000 5 24 P 23/2 G1P0A0 10,000 Bidan Rp10,000
70 Salamaih 631006500982000 2 35 P 23/2 G4P3A0 10,000 Bidan Rp10,000
71 Riah 631001441092000 2 25 P 23/2 G1P0A0 10,000 Bidan Rp10,000
72 Hasnaba 631009500881000 5 36 P 23/2 G6P5A0 10,000 Bidan Rp10,000
73 Mahdalina 630805650881000 2 36 P 23/2 G3P2A0 10,000 Bidan Rp10,000
74 Haruna 631009600483000 6 34 P 24/2 Konsultasi 10,000 Bidan Rp10,000
75 Lily Maisarah 631009600580000 9 37 P 24/2 Konsultasi 10,000 Bidan Rp10,000
76 Romiyati 332306490975000 2 42 P 24/2 G3P2A0 10,000 Bidan Rp10,000
77 Raudah 631009501085001 6 32 P 24/2 G4P3A0 10,000 Bidan Rp10,000
78 Mariana 631009600587000 5 30 P 24/2 G3P2A0 10,000 Bidan Rp10,000
79 Siti Maimunah 631009500984000 6 33 P 24/2 G6P5A0 10,000 Bidan Rp10,000
80 Eni Rusiah 631009620686000 2 31 P 24/2 Konsultasi 10,000 Bidan Rp10,000
81 Erna Wati 631009470986000 7 31 P 25/2 Perawatan Luka Tanpa Jahitan 15,000 Bidan Rp15,000
82 Sri Hatmi 631009691183000 4 34 P 25/2 G2P1A0 10,000 Bidan Rp10,000
 UmurJenis Tgl Pelayanan Kesehaan dan Besaran Tarif sesuai PERDA (Rp) TTD
No Nama No KTP Diagnosa
(Th)KelaminKunj Poli KIATT Caten/TindikRujukan IUD/ PP Konsultasi Bidan Tagihan Psn/ Klg
Bumil TelingaBidan Implant Test Gizi
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
83 Nurul Lutfiah 631009490681000 2 26 P 25/2 G4P2A1 10,000 Bidan Rp10,000
84 Rita 631009510784001 4 33 P 25/2 G1P0A0 10,000 Bidan Rp10,000
85 Isnianti 631009660794000 4 23 P 25/2 G2P1A0 10,000 Bidan Rp10,000
86 Salasiah 631009470483000 6 34 P 25/2 G2P1A0 10,000 Bidan Rp10,000
87 Linda Agustina 631009530888000 5 29 P 25/2 G2P1A0 10,000 Bidan Rp10,000
88 Musrianti Purnama S 631009590386000 1 31 P 27/2 G3P1A1 10,000 Bidan Rp10,000
89 Noor Haida 637205481090000 5 27 P 27/2 G2P1A0 10,000 Bidan Rp10,000
90 Rita Hery P 631009581075000 1 42 P 28/2 G5P4A0 10,000 Bidan Rp10,000

TOTAL Rp910,000
Mengetahui, Bendahara Jamkesda
Kepala Puskesmas Darul Azhar Puskesmas Darul Azhar

dr.Muhammad Erhamsyah Nur Wahyu P, S.Kep, Ners.

Nip.19700111 200312 1 004 NIP.19820527 200804 2 002
 DAFTAR TAGIHAN KLAIM RAWAT JALAN PASIEN JAMKESDA PUSKESMAS DARUL

Provinsi : Kalimantan Selatan

Kabupaten : Tanah Bumbu
Bulan : Januari 2017

Umur Jenis Tgl Pelayanan Kesehaan dan Besara

No Nama No KTP Diagnosa
(Th) Kelamin
Kunjungan Poli KIA TT Caten/ Tindik
Bumil Telinga
1 2 3 4 5 6 7 8 9 10
1 P 10,000
2 P 10,000
3 P 10,000
4 P 10,000
5 P 10,000
6 P 10,000
7 P 10,000
8 P 10,000
9 P 10,000
10 P 10,000
11 P 10,000
12 P 10,000
13 P 10,000
14 P 10,000
15 P 10,000
16 P 10,000
17 P 10,000
18 P 10,000
19 P 10,000
20 P 10,000
21 P 10,000
Umur Jenis Tgl Pelayanan Kesehaan dan Besara
No Nama No KTP Diagnosa
(Th) Kelamin Kunj Poli KIA TT Caten/ Tindik
Bumil Telinga
1 2 3 4 5 6 7 8 9 10
22 P 10,000
23 P 10,000
24 P 10,000
25 P 10,000
26 P 10,000
27 P 10,000
28 P 10,000
29 P 10,000
30 P 10,000
31 P 10,000
32 P 10,000
33 P 10,000
34 P 10,000
35 P 10,000
36 P 10,000
37 P 10,000
38 P 10,000
39 P 10,000
40 P 10,000
41 P 10,000
42 P 10,000
43 P 10,000
44 P 10,000
45 P 10,000
46 P 10,000
47 P 10,000
48 P 10,000
49 P 10,000
50 P 10,000
51 P 10,000
Umur Jenis Tgl Pelayanan Kesehaan dan Besara
No Nama No KTP Diagnosa
(Th) Kelamin Kunj Poli KIA TT Caten/ Tindik
Bumil Telinga
1 2 3 4 5 6 7 8 9 10
52 P 10,000
53 P 10,000
54 P 10,000
55 P 10,000
56 P 10,000
57 P 10,000
58 P 10,000
59 P 10,000
60 P 10,000
61 P 10,000
62 P 10,000
63 P 10,000
64 P 10,000
65 P 10,000
66 P 10,000
67 P 10,000
68 P 10,000
69 P 10,000
70 P 10,000
71 P 10,000
72 P 10,000
73 P 10,000
74 P 10,000
75 P 10,000
76 P 10,000
77 P 10,000
78 P 10,000
79 P 10,000
80 P 10,000
81 P 10,000
Umur Jenis Tgl Pelayanan Kesehaan dan Besara
No Nama No KTP Diagnosa
(Th) Kelamin Kunj Poli KIA TT Caten/ Tindik
Bumil Telinga
1 2 3 4 5 6 7 8 9 10
82 P 10,000
83 P 10,000
84 P 10,000
85 P 10,000
86 P 10,000
87 P 10,000
88 P 10,000
89 P 10,000
90 P 10,000
91 P 10,000
92 P 10,000
93 P 10,000
94 P 10,000
95 P 10,000
96 P 10,000
97 P 10,000
98 P 10,000
99 P 10,000
100 P 10,000
101 P 10,000
102 P 10,000
103 P 10,000
104 P 10,000
105 P 10,000
106 P 10,000
107 P 10,000
108 P 10,000
109 P 10,000
110 P 10,000
111 P 10,000
Umur Jenis Tgl Pelayanan Kesehaan dan Besara
No Nama No KTP Diagnosa
(Th) Kelamin Kunj Poli KIA TT Caten/ Tindik
Bumil Telinga
1 2 3 4 5 6 7 8 9 10
112 P 10,000
113 P 10,000
114 P 10,000
115 P 10,000
116 P 10,000
117 P 10,000
118 P 10,000
119 P 10,000
120 P 10,000
121 P 10,000
122 P 10,000
123 P 10,000
124 P 10,000
125 P 10,000
126 P 10,000
127 P 10,000
128 P 10,000
129 P 10,000
PUSKESMAS DARUL AZHAR KABUPATEN TANAH BUMBU

nan Kesehaan dan Besaran Tarif sesuai PERDA (Rp) TTD

Rujukan IUD/ PP Konsultasi Bidan Tagihan Psn/ Klg
Bidan Implant Test Gizi
11 12 13 14 15 16 17
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
nan Kesehaan dan Besaran Tarif sesuai PERDA (Rp) TTD
Rujukan IUD/ PP Konsultasi Bidan Tagihan Psn/ Klg
Bidan Implant Test Gizi
11 12 13 14 15 16 17
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
 Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
nan Kesehaan dan Besaran Tarif sesuai PERDA (Rp) TTD
Rujukan IUD/ PP Konsultasi Bidan Tagihan Psn/ Klg
Bidan Implant Test Gizi
11 12 13 14 15 16 17
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
 Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
nan Kesehaan dan Besaran Tarif sesuai PERDA (Rp) TTD
Rujukan IUD/ PP Konsultasi Bidan Tagihan Psn/ Klg
Bidan Implant Test Gizi
11 12 13 14 15 16 17
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
 Bidan Rp10,000
nan Kesehaan dan Besaran Tarif sesuai PERDA (Rp) TTD
Rujukan IUD/ PP Konsultasi Bidan Tagihan Psn/ Klg
Bidan Implant Test Gizi
11 12 13 14 15 16 17
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
 DAFTAR TAGIHAN KLAIM RAWAT JALAN PASIEN JAMKESDA PUSKESMAS DARUL AZHAR KABUPATEN TANAH BUMBU

Provinsi : Kalimantan Selatan

Kabupaten : Tanah Bumbu
Bulan : Maret 2017

Umur Jenis Tgl Pelayanan Kesehaan dan Besaran Tarif sesuai PERDA (Rp) TTD
No Nama No KTP Diagnosa
(Th)Kelamin
Kunjungan Poli KIATT Caten/ Tindik Rujukan IUD/ PP Konsultasi Bidan Tagihan Psn/ Klg
Bumil Telinga Bidan Implant Test Gizi
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
1 Norsinah 631009410172001 6 45 P 01/03 Konsultasi 10,000 Bidan Rp10,000
2 Eka Septia N 63100966987000 3 30 P 01/03 G4P3A0 10,000 Bidan Rp10,000
3 Sadariyah 631009581287000 2 30 P 01/03 G2P1A0 10,000 Bidan Rp10,000
4 Maulidah 631009530690000 2 27 P 01/03 G2P1A0 10,000 Bidan Rp10,000
5 Nor Hadiah 631009460479000 5 38 P 01/03 G3P2A0 10,000 Bidan Rp10,000
6 Norlina 631002451096000 2 22 P 01/03 G1P0A0 10,000 Bidan Rp10,000
7 Nor Hasanah 631008661292000 1 25 P 01/03 G1P0A0 10,000 Bidan Rp10,000
8 Norfiah 631009511281000 5 36 P 01/03 G4P3A0 10,000 Bidan Rp10,000
9 Nurdiati 631009540476000 3 41 P 01/03 G6P4A1 10,000 Bidan Rp10,000
10 Nurul Hikmah 631009450296000 4 21 P 01/03 G2P1A0 10,000 Bidan Rp10,000
11 Nelly Yanti A 631009451093000 6 24 P 01/03 Konsultasi 10,000 Bidan Rp10,000
12 Sarfiah 631002470784001 1 33 P 01/03 G2P1A0 10,000 Bidan Rp10,000
13 Herlina 631010680190000 1 27 P 01/03 G2P1A0 10,000 Bidan Rp10,000
14 Kardianah 631009480877001 1 40 P 02/03 G3P2A0 10,000 Bidan Rp10,000
15 Endang Wahyunin631009490966000 3 51 P 02/03 Konsultasi 10,000 Bidan Rp10,000
16 Fatmawati 631009660593000 1 24 P 02/03 G1P0A0 10,000 Bidan Rp10,000
17 Nur Walidainy 631009450594000 2 24 P 02/03 G1P0A0 10,000 Bidan Rp10,000
18 Erfina Damayanti 631009520294000 7 23 P 02/03 G3P2A0 10,000 Bidan Rp10,000
19 Fatimah Ratu A 631009530773000 4 44 P 02/03 Konsultasi 10,000 Bidan Rp10,000
20 Noor Halimah 631009480291000 2 26 P 02/03 G3P2A0 10,000 Bidan Rp10,000
21 Fatmawati 631009530388000 2 29 P 02/03 G1P0A0 10,000 Bidan Rp10,000
22 Siti Maimunah 631009500984000 6 33 P 02/03 G6P5A0 10,000 Bidan Rp10,000
23 Juhar Latifah 631009410489000 4 28 P 02/03 G2P1A0 10,000 Bidan Rp10,000
24 Mei Koswati 831009410583000 6 34 P 02/03 G4P2A1 10,000 Bidan Rp10,000
Umur Jenis Tgl Pelayanan Kesehaan dan Besaran Tarif sesuai PERDA (Rp) TTD
No Nama No KTP Diagnosa
(Th)Kelamin
Kunj Poli KIATT Caten/ Tindik Rujukan IUD/ PP Konsultasi Bidan Tagihan Psn/ Klg
Bumil Telinga Bidan Implant Test Gizi
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
25 Siti Kamah 631009500882001 1 35 P 02/03 G6P3A2 10,000 Bidan Rp10,000
26 Rusniati 631009711283001 0 34 P 02/03 G5P3A1 10,000 Bidan Rp10,000
27 Mahriati 631009288089000 2 28 P 02/03 G3P2A0 10,000 Bidan Rp10,000
28 Yulia Astuti 631009470689000 3 28 P 02/03 G3P2A0 10,000 Bidan Rp10,000
29 Amelia 631009660893000 1 24 P 02/03 G1P0A0 10,000 Bidan Rp10,000
30 Ruspatmawati 631009430596000 3 21 P 02/03 G1P0A0 10,000 Bidan Rp10,000
31 Dewi Sartika 631010610498000 4 19 P 02/03 G1P0A0 10,000 Bidan Rp10,000
32 Lisnawati 651009660395000 22 P 02/03 G1P0A0 10,000 Bidan Rp10,000
33 Selly Ainuniyyah 630209500396000 1 26 P 03/03 G1P0A0 10,000 Bidan Rp10,000
34 Sri Astuti 631009620692000 4 25 P 03/03 G2P1A0 10,000 Bidan Rp10,000
35 Kasmiati 631009500684000 8 33 P 03/03 Konsultasi 10,000 Bidan Rp10,000
36 Khusnul Khatima 631009510493000 2 24 P 04/03 Konsultasi 10,000 Bidan Rp10,000
37 Nur Aeni Rosalina631009450588001 0 29 P 04/03 G3P1A1 10,000 Bidan Rp10,000
38 Syarmiah 631009490788000 4 29 P 06/03 G3P2A0 10,000 Bidan Rp10,000
39 Ita Dewi Lestari 631009501085001 2 32 P 06/03 G3P1A1 10,000 Bidan Rp10,000
40 Asmaniah 631009650477000 1 40 P 06/03 G4P3A0 10,000 Bidan Rp10,000
41 Linda Wati 631009451281000 5 36 P 06/03 G3P1A1 10,000 Bidan Rp10,000
42 Rahmiyati 631009470480000 8 37 P 07/03 G3P2A0 10,000 Bidan Rp10,000
43 Dewi 631002501189000 2 28 P 07/03 G3P2A0 10,000 Bidan Rp10,000
44 Santi 631006430991000 1 26 P 07/03 G3P2A0 10,000 Bidan Rp10,000
45 Rika Hartini 631009500887001 0 30 P 07/03 G2P1A0 10,000 Bidan Rp10,000
46 Nor Ainah 631006580983000 1 34 P 07/03 G3P2A0 10,000 Bidan Rp10,000
47 Endang Susanti 631009681091000 8 26 P 07/03 G3P1A1 10,000 Bidan Rp10,000
48 Sari Amalia 631009501079001 9 38 P 07/03 G5P4A0 10,000 Bidan Rp10,000
49 Kardianah 631009480877001 1 40 P 07/03 G3P2A0 10,000 Bidan Rp10,000
50 Sukmah 631009701094000 2 23 P 08/03 G2P0A1 10,000 Bidan Rp10,000
51 Susilawati 631009580286000 3 31 P 08/03 G3P2A0 10,000 Bidan Rp10,000
52 Irmayanti 631009670696000 1 21 P 08/03 G2P1A0 10,000 Bidan Rp10,000
53 Asty Azis 631009451281000 6 36 P 09/03 G3P2A0 10,000 Bidan Rp10,000
54 Rizka Dewi 631009520391000 4 26 P 09/03 G3P1A1 10,000 Bidan Rp10,000
Umur Jenis Tgl Pelayanan Kesehaan dan Besaran Tarif sesuai PERDA (Rp) TTD
No Nama No KTP Diagnosa
(Th)Kelamin
Kunj Poli KIATT Caten/ Tindik Rujukan IUD/ PP Konsultasi Bidan Tagihan Psn/ Klg
Bumil Telinga Bidan Implant Test Gizi
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
55 Nurul Cahyanings631006710189000 1 28 P 09/03 G2P1A0 10,000 Bidan Rp10,000
56 Sri Nilawati 631009680688000 4 29 P 09/03 G3P1A0 10,000 Bidan Rp10,000
57 Asmaniah 631009650477000 1 40 P 09/03 G4P3A0 10,000 Bidan Rp10,000
58 Nani 631009430380000 7 37 P 09/03 G5P4A0 10,000 Bidan Rp10,000
59 Iis Robiatun 631006641095000 1 22 P 10/03 G2P1A0 10,000 Bidan Rp10,000
60 Miftakhul Yulyah 352422540792000 1 25 P 10/03 G1P0A0 10,000 Bidan Rp10,000
61 Mallianti 631009660597000 4 20 P 10/03 G2P1A0 10,000 Bidan Rp10,000
62 Melisa Dona 631002660591000 1 26 P 10/03 G2P1A0 10,000 Bidan Rp10,000
63 Sriatin 631006410881000 2 36 P 11/03 G4P2A1 10,000 Bidan Rp10,000
64 Ika Zunia Pratiwi 352408441199000 1 22 P 11/03 G2P0A1 10,000 Bidan Rp10,000
65 Nurul Maimunah 631001440117000 1 2 Bulan P 11/03Tindik Telinga 20,000 Bidan Rp20,000
66 Serly Putri Khayla631006630117000 1 2 Bulan P 11/03Tindik Telinga 20,000 Bidan Rp20,000
67 Nurul Aeni 631010431294000 3 23 P 11/03 G1P0A0 10,000 Bidan Rp10,000
68 Yulia Asih 630216551192000 1 25 P 11/03 G2P1A0 10,000 Bidan Rp10,000
69 Lia Martina 631009450188000 5 29 P 11/03 G3P2A0 10,000 Bidan Rp10,000
70 Yurni 631009610565000 2 52 P 13/03 Konsultasi 10,000 Bidan Rp10,000
71 Nurdiati 631009540476000 3 41 P 13/03 G6P4A1 10,000 Bidan Rp10,000
72 Fitri Anita 631009620996000 1 21 P 13/03 G2P1A0 10,000 Bidan Rp10,000
73 Murniati 352607510194000 2 23 P 13/03 G1P0A0 10,000 Bidan Rp10,000
74 ST. Mina Maulida630706530297000 6 20 P 13/03 G3P2A0 10,000 Bidan Rp10,000
75 Rusniati 631009711283001 0 34 P 14/03 G5P3A1 10,000 Bidan Rp10,000
76 Marsinah 631009600590000 5 27 P 14/03 G3P2A0 10,000 Bidan Rp10,000
77 Fatmawati 631009530388000 2 29 P 14/03 G1P0A0 10,000 Bidan Rp10,000
78 Hidayati 631009460687001 0 30 P 15/03 G2P1A0 10,000 Bidan Rp10,000
79 Murdia 631009431276000 3 41 P 15/03 Konsultasi 10,000 Bidan Rp10,000
80 Nurul Isnaeni 330503570889000 4 28 P 15/03 G2P1A0 10,000 Bidan Rp10,000
81 Sarmah 631009681179000 5 38 P 15/03 Konsultasi 10,000 Bidan Rp10,000
82 Astuti 631009510185000 4 32 P 16/03 G4P3A0 10,000 Bidan Rp10,000
83 Sri Astuti 631009620692000 4 25 P 17/03 G2P1A0 10,000 Bidan Rp10,000
84 Herlina 631010680190000 1 27 P 17/03 G2P1A0 10,000 Bidan Rp10,000
Umur Jenis Tgl Pelayanan Kesehaan dan Besaran Tarif sesuai PERDA (Rp) TTD
No Nama No KTP Diagnosa
(Th)Kelamin
Kunj Poli KIATT Caten/ Tindik Rujukan IUD/ PP Konsultasi Bidan Tagihan Psn/ Klg
Bumil Telinga Bidan Implant Test Gizi
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
85 Ruspatmawati 631009430596000 3 21 P 17/03 G1P0A0 10,000 Bidan Rp10,000
86 Nurul Isnaeni 330503570889000 4 28 P 17/03 G2P1A0 10,000 Bidan Rp10,000
87 Mahdalina 630805650881000 2 36 P 17/03 Konsultasi 10,000 Bidan Rp10,000
88 Rina Wati 630711481296000 2 21 P 20/03 G1P0A0 10,000 Bidan Rp10,000
89 Megawati 631009521192000 6 25 P 20/03 G1P0A0 10,000 Bidan Rp10,000
90 Erfina Damayanti 631009520294000 7 23 P 20/03 G3P2A0 10,000 Bidan Rp10,000
91 Noor Jennah 631009500382000 4 35 P 20/03 Konsultasi 10,000 Bidan Rp10,000
92 Noor Haida 637205481090000 5 27 P 20/03 G6P5A0 10,000 Bidan Rp10,000
93 Nurdiati 631009540476000 3 41 P 20/03 G6P4A1 10,000 Bidan Rp10,000
94 Marwah 631009470789001 2 28 P 20/03 G2P1A0 10,000 Bidan Rp10,000
95 Linda Wati 631009451281000 5 36 P 20/03 G3P2A0 10,000 Bidan Rp10,000
96 Mutmainah 631006410797001 7 20 P 21/03 Konsultasi 10,000 Bidan Rp10,000
97 Hijriya Nur Hidaya631009700593000 7 24 P 21/03 G1P0A0 10,000 Bidan Rp10,000
98 Risnawati 631009811080000 5 37 P 21/03 G3P2A0 10,000 Bidan Rp10,000
99 Rosnaeni 631009701291000 2 26 P 21/03 G2P1A0 10,000 Bidan Rp10,000
100 Raudah 631009501085001 6 32 P 21/03 G3P2A0 10,000 Bidan Rp10,000
101 Leny Malia 631009700593000 8 22 P 21/03 Konsultasi 10,000 Bidan Rp10,000
102 Asmaniah 631009650477000 1 40 P 22/03 G4P3A0 10,000 Bidan Rp10,000
103 Didik Lestari 631009570484000 4 33 P 22/03 G2P1A0 10,000 Bidan Rp10,000
104 Defi Nofitasari 631009610193000 5 24 P 22/03 G1P0A0 10,000 Bidan Rp10,000
105 Maulidah 631009530690000 2 27 P 22/03 G2P1A0 10,000 Bidan Rp10,000
106 Tri Istanti 631009580884000 3 33 P 22/03 G2P1A0 10,000 Bidan Rp10,000
107 Asty Azis 631009451281000 6 36 P 22/03 G3P2A0 10,000 Bidan Rp10,000
108 Musrini 631009450778001 1 39 P 22/03 G3P2A0 10,000 Bidan Rp10,000
109 Yunita Sari 631009630389000 4 28 P 22/03 G3P2A0 10,000 Bidan Rp10,000
110 Sri Astuti 631009620692000 4 25 P 22/03 G2P1A0 10,000 Bidan Rp10,000
111 Fatmawati 631002470779000 3 38 P 22/03 G3P2A0 10,000 Bidan Rp10,000
112 Iin Komariah 631009650677000 4 40 P 22/03 G3P2A0 10,000 Bidan Rp10,000
113 Risna Amalina 631009681283000 1 34 P 22/03 G2P1A0 10,000 Bidan Rp10,000
114 Sri Nilawati 631009680688000 4 29 P 22/03 G3P1A1 10,000 Bidan Rp10,000
Umur Jenis Tgl Pelayanan Kesehaan dan Besaran Tarif sesuai PERDA (Rp) TTD
No Nama No KTP Diagnosa
(Th)Kelamin
Kunj Poli KIATT Caten/ Tindik Rujukan IUD/ PP Konsultasi Bidan Tagihan Psn/ Klg
Bumil Telinga Bidan Implant Test Gizi
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
115 Marlina 631009640778000 5 39 P 22/03 G3P1A1 10,000 Bidan Rp10,000
116 Sukmah 631009701094000 2 23 P 23/03 G2P0A1 10,000 Bidan Rp10,000
117 Indah 631009540296000 3 21 P 23/03 Konsultasi 10,000 Bidan Rp10,000
118 Syariyani 631009601282001 0 35 P 23/03 G3P2A0 10,000 Bidan Rp10,000
119 Mahriati 631009280889000 2 28 P 23/03 G3P2A0 10,000 Bidan Rp10,000
120 Hasnaba 631009500881700 5 36 P 24/03 G6P5A0 10,000 Bidan Rp10,000
121 Ernawati 631009460493000 3 24 P 25/03 Konsultasi 10,000 Bidan Rp10,000
122 Devita Rohmadini352420630190000 1 27 P 27/03 G3P1A1 10,000 Bidan Rp10,000
123 Santi 631006430991000 1 26 P 27/03 G3P2A0 10,000 Bidan Rp10,000
124 Imelda Ervina 631006440498000 5 19 P 27/03 G2P1A0 10,000 Bidan Rp10,000
125 Noor Lena 631009701287000 2 30 P 27/03 Konsultasi 10,000 Bidan Rp10,000
126 Sulistiyangsih 631009580276000 4 41 P 27/03 G10P9A0 10,000 Bidan Rp10,000
127 Megawati 631009570376000 1 41 P 27/03 Konsultasi 10,000 Bidan Rp10,000
128 Tri Susanti 631008590992000 3 25 P 27/03 Konsultasi 10,000 Bidan Rp10,000
129 Endang Susanti 631009681091000 8 26 P 27/03 G3P1A1 10,000 Bidan Rp10,000
130 Norjenah 631009460674000 7 43 P 30/03 G4P3A0 10,000 Bidan Rp10,000
131 Asmaniah 631009650477000 1 40 P 30/03 G4P3A0 10,000 Bidan Rp10,000
132 Syarmiah 631009490788000 4 29 P 30/03 Konsultasi 10,000 Bidan Rp10,000

TOTAL Rp1,340,000
Simpang Empat, 03 Maret 2017
Mengetahui, Bendahara Jamkesda
Kepala Puskesmas Darul Azhar Puskesmas Darul Azhar
dr.Muhammad Erhamsyah Nur Wahyu P, S.Kep, Ners.
Nip.19700111 200312 1 004 NIP.19820527 200804 2 002
 DAFTAR TAGIHAN KLAIM RAWAT JALAN PASIEN JAMKESDA PUSKESMAS DARUL AZHAR KABUPATEN TANAH BUMBU

Provinsi : Kalimantan Selatan

Kabupaten : Tanah Bumbu
Bulan : April 2017

No Nama No KTP Umur JenisPelayanan

Tgl Kesehaan
Diagnosadan Besaran Tarif sesuai PERDA (Rp) TTD
(Th)Kelamin
Kunjungan Poli KIATT Caten/ Tindik Rujukan IUD/ PP Konsultasi Bidan Tagihan Psn/ Klg
Bumil Telinga Bidan Implant Test Gizi
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
1 Faridah 631009590785000 2 32 P 1/4 G3P1A1 10,000 Bidan Rp10,000
2 Sri Nilawati 631009680688000 4 29 P 1/4 G3P1A1 10,000 Bidan Rp10,000
3 Ngaenur Rokhmah 631009660291000 1 26 P 1/4 G2P1A0 10,000 Bidan Rp10,000
4 Siti Zakiah 631009830168000 2 49 P 1/4 Konsultasi 10,000 Bidan Rp10,000
5 Ika Zunia Pratiwi 352408441199000 1 22 P 1/4 G1P0A0 10,000 Bidan Rp10,000
6 Noviana Ekawati 631009451178000 3 39 P 1/4 G6P5A0 10,000 Bidan Rp10,000
7 Mallianti 631009660597000 4 20 P 1/4 G2P1A0 10,000 Bidan Rp10,000
8 Marini 631009551087000 2 30 P 1/4 G3P1A1 10,000 Bidan Rp10,000
9 Yanti Susanti 631009501293000 3 24 P 1/4 G3P2A0 10,000 Bidan Rp10,000
10 Siti Zubaidah 630602570992000 1 25 P 1/4 G1P0A0 10,000 Bidan Rp10,000
11 Maulidah 631009530690000 2 27 P 1/4 Konsultasi 10,000 Bidan Rp10,000
12 Ani Rosalina 631006560798000 1 19 P 1/4 G2P0A1 10,000 Bidan Rp10,000
13 Khairiyati 630810451091000 2 26 P 1/4 G2P1A0 10,000 Bidan Rp10,000
14 Listy Ariany 631009471177000 4 40 P 3/4 G3P2A0 10,000 Bidan Rp10,000
15 Fatmawati 631009530388000 2 29 P 3/4 G1P0A0 10,000 Bidan Rp10,000
16 Sukmah 631009701094000 2 23 P 4/4 G2P0A1 10,000 Bidan Rp10,000
17 Noviana Ekawati 631009451178000 3 39 P 4/4 G6P5A0 10,000 Bidan Rp10,000
18 Sri Astuti 631009620692000 4 25 P 5/4 G2P1A0 10,000 Bidan Rp10,000
19 Sarmah 631009681179000 5 38 P 5/4 Konsultasi 10,000 Bidan Rp10,000
20 Hijriya Nur Hidayati 631009700593000 7 24 P 6/4 G1P0A0 10,000 Bidan Rp10,000
21 Asmaniah 631009650477000 1 40 P 6/4 G4P3A0 10,000 Bidan Rp10,000
22 Sabariah 631009580790000 8 27 P 6/4 G2P1A0 10,000 Bidan Rp10,000
23 Rusniati 631009711283001 0 34 P 6/4 G5P3A1 10,000 Bidan Rp10,000
24 Megawati 631009521192000 6 25 P 6/4 G1P0A0 10,000 Bidan Rp10,000
No Nama No KTP Umur JenisPelayanan
Tgl Kesehaan
Diagnosadan Besaran Tarif sesuai PERDA (Rp) TTD
(Th)Kelamin Kunj Poli KIATT Caten/ Tindik Rujukan IUD/ PP Konsultasi Bidan Tagihan Psn/ Klg
Bumil Telinga Bidan Implant Test Gizi
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
25 Siti Maisyarah 630510550490000 1 27 P 7/4 Konsultasi 10,000 Bidan Rp10,000
26 Mahriati 631009280889000 2 28 P 7/4 G3P2A0 10,000 Bidan Rp10,000
27 Noorjanah 631009410780019 4 37 P 7/4 G4P3A0 10,000 Bidan Rp10,000
28 Rayuradiana 631009430588000 6 29 P 8/4 G2P1A0 10,000 Bidan Rp10,000
29 Nor Ainah 631006580983000 1 34 P 8/4 G3P2A0 10,000 Bidan Rp10,000
30 Sri Nilawati 631009680688000 4 29 P 8/4 G3P1A1 10,000 Bidan Rp10,000
31 Novia Sari 631004671084000 2 33 P 8/4 G4P2A1 10,000 Bidan Rp10,000
32 Ruspi Susaanti 631005670890000 1 27 P 8/4 Konsultasi 10,000 Bidan Rp10,000
33 Mariani 631009700186000 5 31 P 8/4 G3P1A1 10,000 Bidan Rp10,000
34 Juleha 631009470888001 2 29 P 8/4 G3P2A0 10,000 Bidan Rp10,000
35 Dewi Sartika 631010610498000 4 19 P 8/4 G1P0A0 10,000 Bidan Rp10,000
36 Kamsiani 631009431091000 6 26 P 10/4 G2P1A0 10,000 Bidan Rp10,000
37 Sarfiah 631002470784001 1 33 P 10/4 G2P1A0 10,000 Bidan Rp10,000
38 Eka Wahyuni 640502450390000 1 27 P 10/4 G2P1A0 10,000 Bidan Rp10,000
39 Marsinah 631009600590000 5 27 P 10/4 G3P2A0 10,000 Bidan Rp10,000
40 Nurul Cahyaningsih 631006710189000 1 28 P 11/4 G2P1A0 10,000 Bidan Rp10,000
41 Fatmawati 631009530388000 2 29 P 11/4 G1P0A0 10,000 Bidan Rp10,000
42 Hajrah 631009490984000 4 33 P 11/4 G5P3A1 10,000 Bidan Rp10,000
43 Isnun Purnawaty 631009450284000 7 33 P 12/4 G3P2A0 10,000 Bidan Rp10,000
44 Sukmah 631009701094000 2 23 P 12/4 G2P0A1 10,000 Bidan Rp10,000
45 Fitri Anita 631009620996000 1 21 P 13/4 G2P1A0 10,000 Bidan Rp10,000
46 Mahriati 631009280889000 2 28 P 13/4 G3P2A0 10,000 Bidan Rp10,000
47 Rita 630605450197000 1 20 P 13/4 G2P1A0 10,000 Bidan Rp10,000
48 Amelia 631009660893000 1 24 P 13/4 G1P0A0 10,000 Bidan Rp10,000
49 Murniati 352607510194000 2 23 P 13/4 G1P0A0 10,000 Bidan Rp10,000
50 Mahdalina 630805650881000 2 36 P 15/4 G3P2A0 10,000 Bidan Rp10,000
51 Raulina Ningsih 631009610792000 1 25 P 15/4 G4P3A0 10,000 Bidan Rp10,000
52 Dwi Anggraini 631009691095000 1 21 P 17/4 G2P1A0 10,000 Bidan Rp10,000
53 Rita 630605450197000 1 20 P 17/4 G2P1A0 10,000 Bidan Rp10,000
54 Erfina Damayanti 631009520294000 7 23 P 17/4 G3P2A0 10,000 Bidan Rp10,000
55 Arbayah 631006530286000 3 31 P 17/4 Konsultasi 10,000 Bidan Rp10,000
No Nama No KTP Umur JenisPelayanan
Tgl Kesehaan
Diagnosadan Besaran Tarif sesuai PERDA (Rp) TTD
(Th)Kelamin Kunj Poli KIATT Caten/ Tindik Rujukan IUD/ PP Konsultasi Bidan Tagihan Psn/ Klg
Bumil Telinga Bidan Implant Test Gizi
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
56 Mirna 620303501288000 8 29 P 18/4 G2P1A0 10,000 Bidan Rp10,000
57 Siti Maimunah 631009500984000 6 33 P 18/4 G6P5A0 10,000 Bidan Rp10,000
58 Muliawati 631009700993000 2 24 P 18/4 G2P1A0 10,000 Bidan Rp10,000
59 Didik Lestari 631009570484000 4 33 P 18/4 G2P1A0 10,000 Bidan Rp10,000
60 Hidayati 631009460687001 0 30 P 18/4 G2P1A0 10,000 Bidan Rp10,000
61 Herwinda 631009650586000 1 31 P 18/4 G3P1A1 10,000 Bidan Rp10,000
62 Haty 631009500476000 5 41 P 19/4 G6P5A0 10,000 Bidan Rp10,000
63 Syamsiah 631009540784001 7 33 P 19/4 Konsultasi 10,000 Bidan Rp10,000
64 Mahriati 631009280889000 2 28 P 20/4 G3P2A0 10,000 Bidan Rp10,000
65 Yunita Sari 63100963089000 4 28 P 20/4 G3P2A0 10,000 Bidan Rp10,000
66 Lasiyem Dila P 631009660687000 1 30 P 20/4 G2P1A0 10,000 Bidan Rp10,000
67 Halimatus Sa'diah 631009570294000 3 23 P 20/4 G1P0A0 10,000 Bidan Rp10,000
68 Raulina Ningsih 631009610792000 1 25 P 20/4 G4P3A0 10,000 Bidan Rp10,000
69 Marlina 631009640778000 5 39 P 21/4 G3P1A1 10,000 Bidan Rp10,000
70 Asty Azis 631009451281000 6 36 P 21/4 G3P2A0 10,000 Bidan Rp10,000
71 Hj.Zainah 631009451072000 7 45 P 21/4 Konsultasi 10,000 Bidan Rp10,000
72 Herlina 6310106810190000 1 27 P 22/4 G2P1A0 10,000 Bidan Rp10,000
73 Defi Novitasari 631009610193000 5 24 P 22/4 G1P0A0 10,000 Bidan Rp10,000
74 Asmah 631009550873000 6 44 P 22/4 Konsultasi 10,000 Bidan Rp10,000
75 Siti Sawiyah 631009541080000 4 37 P 22/4 Konsultasi 10,000 Bidan Rp10,000
76 Fitri Anita 631009620998000 1 21 P 25/4 G2P1A0 10,000 Bidan Rp10,000
77 Isnianti 631009660794000 4 23 P 25/4 Konsultasi 10,000 Bidan Rp10,000
78 Riska Dewi 631009520391000 4 25 P 25/4 G3P1A1 10,000 Bidan Rp10,000
79 Novi Arsita 631009491193000 4 24 P 25/4 G2P1A0 10,000 Bidan Rp10,000
80 Musrini 631009450778001 1 39 P 25/4 G3P2A0 10,000 Bidan Rp10,000
81 Aminah 631009430695000 4 22 P 25/4 G3P2A0 10,000 Bidan Rp10,000
82 Marwah 631009470789001 2 28 P 26/4 Konsultasi 10,000 Bidan Rp10,000
83 Hasnaba 631009500881000 5 36 P 26/4 G6P5A0 10,000 Bidan Rp10,000
84 Rusma 631009471182000 4 35 P 26/4 G2P1A0 10,000 Bidan Rp10,000
85 Syamsiah 631009540784001 7 33 P 26/4 G3P2A0 10,000 Bidan Rp10,000
86 Nurul Hikmah 631009450778000 6 39 P 26/4 G6P5A0 10,000 Bidan Rp10,000
No Nama No KTP Umur JenisPelayanan
Tgl Kesehaan
Diagnosadan Besaran Tarif sesuai PERDA (Rp) TTD
(Th)Kelamin Kunj Poli KIATT Caten/ Tindik Rujukan IUD/ PP Konsultasi Bidan Tagihan Psn/ Klg
Bumil Telinga Bidan Implant Test Gizi
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
87 Tri Wahyuni 631009410683000 6 34 P 26/4 G3P2A0 10,000 Bidan Rp10,000
88 Hariyani 631009410878000 6 39 P 26/4 G2P1A0 10,000 Bidan Rp10,000
89 ST.Lisdayani 630202490799000 1 18 P 26/4 G1P0A0 10,000 Bidan Rp10,000
90 Norhayati 631009650593000 6 24 P 26/4 G1P0A0 10,000 Bidan Rp10,000
91 Rusmini 631009450390000 5 27 P 27/4 Konsultasi 10,000 Bidan Rp10,000
92 Salmah 631009410295000 7 22 P 28/4 Konsultasi 10,000 Bidan Rp10,000
93 Mahriati 631009280889000 2 28 P 29/4 G3P2A0 10,000 Bidan Rp10,000
94 Murdia 631009431276000 3 41 P 29/4 Konsultasi 10,000 Bidan Rp10,000
95 Amelia 631009660893000 1 24 P 29/4 G1P0A0 10,000 Bidan Rp10,000
P
TOTAL P Rp950,000

Simpang Empat, 02 Mei 2017

Mengetahui, Bendahara Jamkesda
Kepala Puskesmas Darul Azhar Puskesmas Darul Azhar

dr.Muhammad Erhamsyah Nur Wahyu P, S.Kep, Ners.

Nip.19700111 200312 1 004 NIP.19820527 200804 2 002
 DAFTAR TAGIHAN KLAIM RAWAT JALAN PASIEN JAMKESDA PUSKESMAS DARUL AZHAR KABUPATEN TANAH BUMBU

Provinsi : Kalimantan Selatan

Kabupaten : Tanah Bumbu
Bulan : Juni 2017
UmurJenisTgl Pelayanan Kesehaan dan Besaran Tarif sesuai PERDA (Rp) TTD
No Nama No KTP Diagnosa
(Th)
Kelamin
Kunjungan Poli KIATT Caten/ Tindik Rujukan IUD/ PP Konsultasi Bidan Tagihan Psn/ Klg
Bumil Telinga Bidan Implant Test Gizi
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
1 Heny Yarti 631009550883000 7 34 P 2/6 G4P2A1 10,000 Bidan Rp10,000
2 Nikhayati 631009460775000 4 42 P 2/6 Konsultasi 10,000 Bidan Rp10,000
3 Maulidah 631009530690000 2 27 P 2/6 G2P1A0 10,000 Bidan Rp10,000
4 Irmayanti 631009670696000 1 21 P 2/6 G2P1A0 10,000 Bidan Rp10,000
5 Asty Azis 631009451281000 6 36 P 2/6 G3P2A0 10,000 Bidan Rp10,000
6 Murdia 631009431276000 3 41 P 2/6 Konsultasi 10,000 Bidan Rp10,000
7 Masridah 631009580383000 4 34 P 3/6 G2P0A1 10,000 Bidan Rp10,000
8 Siti Kartika sari 631009520791000 5 26 P 3/6 Konsultasi 10,000 Bidan Rp10,000
9 Marniah 630201550686000 2 36 P 3/6 G3P2A0 10,000 Bidan Rp10,000
10 Nur Rahmah 631009540892000 4 25 P 3/6 Konsultasi 10,000 Bidan Rp10,000
11 Nia Amelia 631009611194000 4 23 P 3/6 G1P0A0 10,000 Bidan Rp10,000
12 Indah Masliani 631009640584000 1 33 P 5/6 G1P0A0 10,000 Bidan Rp10,000
13 Tri Susanti 631008590992000 3 25 P 5/6 Konsultasi 10,000 Bidan Rp10,000
14 Heny Yarti 631009550883000 7 34 P 5/6 G4P2A1 10,000 Bidan Rp10,000
15 Herlina 631010680190000 1 27 P 5/6 G2P1A0 10,000 Bidan Rp10,000
16 Hj. Marhadi 631009600378000 6 39 P 5/6 Konsultasi 10,000 Bidan Rp10,000
17 Fatmawati 631009530388000 2 29 P 5/6 G1P0A0 10,000 Bidan Rp10,000
18 Iin Komariah 631009650677000 4 40 P 6/6 G3P2A0 10,000 Bidan Rp10,000
19 Marsinah 631009600590000 5 27 P 6/6 G2P1A0 10,000 Bidan Rp10,000
20 Hasnaba 631009500881000 5 36 P 7/6 G6P5A0 10,000 Bidan Rp10,000
21 Humairah 631006630495000 2 36 P 7/6 G3P2A0 10,000 Bidan Rp10,000
22 Sarmah 631009681179000 5 38 P 7/6 Konsultasi 10,000 Bidan Rp10,000
23 Martini 631009610183000 4 34 P 7/6 G4P3A0 10,000 Bidan Rp10,000
24 Mahdalina 630805650881000 2 36 P 9/6 Konsultasi 10,000 Bidan Rp10,000
25 Irmayanti 631009670696000 1 21 P 10/6 G2P1A0 10,000 Bidan Rp10,000
 UmurJenisTgl Pelayanan Kesehaan dan Besaran Tarif sesuai PERDA (Rp) TTD
No Nama No KTP Diagnosa
(Th)
Kelamin
Kunj Poli KIATT Caten/ Tindik Rujukan IUD/ PP Konsultasi Bidan Tagihan Psn/ Klg
Bumil Telinga Bidan Implant Test Gizi
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
26 Tina Wati 631009450489000 5 28 P 10/6 G3P2A0 10,000 Bidan Rp10,000
27 Arbayah 631009500381000 7 36 P 12/6 G4P3A0 10,000 Bidan Rp10,000
28 Yuliana 631009420777000 7 40 P 12/6 Konsultasi 10,000 Bidan Rp10,000
29 Nurul Hikmah 631009450778000 6 39 P 12/6 G6P5A0 10,000 Bidan Rp10,000
30 Murniati 352607510194000 2 23 P 12/6 G1P0A0 10,000 Bidan Rp10,000
31 Aisyah Ar Rodhiyah 631003580217000 2 4 Bln P 12/6Tindik Telinga 20,000 Bidan Rp20,000
32 Hajrah 631009481184000 4 33 P 12/6 Konsultasi 10,000 Bidan Rp10,000
33 Masridah 631009580383000 4 34 P 12/6 G2P0A1 10,000 Bidan Rp10,000
34 Norjenah 631009460674000 7 43 P 12/6 Konsultasi 10,000 Bidan Rp10,000
35 Rini Sumarni 631009410789020 9 28 P 12/6 G3P2A0 10,000 Bidan Rp10,000
36 Meilia Fidimastutik. L. 631009570598000 7 19 P 12/6 G1P0A0 10,000 Bidan Rp10,000
37 Mallianti 631009660597000 4 20 P 12/6 G3P2A0 10,000 Bidan Rp10,000
38 Nia Amelia 631009611194000 4 23 P 12/6 G1P0A0 10,000 Bidan Rp10,000
39 Ruhana 631009621278000 3 38 P 13/6 G6P5A0 10,000 Bidan Rp10,000
40 Hidayah 631009570290000 2 27 P 13/6 G2P1A0 10,000 Bidan Rp10,000
41 Yuliana 631009420777000 7 40 P 13/6 G3P2A0 10,000 Bidan Rp10,000
42 Raudhatul Jannah 631006650417000 1 2 Bln P 13/6Tindik Telinga 20,000 Bidan Rp20,000
43 Mariana 631006420487000 1 30 P 13/6 G4P2A1 10,000 Bidan Rp10,000
44 Evi Novianti 327204661294000 1 23 P 13/6 G2P1A0 10,000 Bidan Rp10,000
45 Herawati 631009470494000 3 23 P 14/6 G1P0A0 10,000 Bidan Rp10,000
46 Nurliana 732408440795000 1 22 P 14/6 G1P0A0 10,000 Bidan Rp10,000
47 St. Mina Maulida Yanti 630706530297000 6 20 P 14/6 G1P0A0 10,000 Bidan Rp10,000
48 Rahmawati 631009590183000 4 34 P 14/6 G4P3A0 10,000 Bidan Rp10,000
49 Iin Komariah 631009650677000 4 40 P 14/6 G3P2A0 10,000 Bidan Rp10,000
50 Ruspi Susanti 631005670890000 1 27 P 15/6 G2P1A0 10,000 Bidan Rp10,000
51 Didik lestari 63100957084000 4 33 P 15/6 Konsultasi 10,000 Bidan Rp10,000
52 Nur Ajizah 631009550497000 5 20 P 16/6 G1P0A0 10,000 Bidan Rp10,000
53 Siti Zubaidah 630602570992000 1 25 P 16/6 Konsultasi 10,000 Bidan Rp10,000
54 Herlina 631010680190000 1 27 P 16/6 G2P1A0 10,000 Bidan Rp10,000
 UmurJenisTgl Pelayanan Kesehaan dan Besaran Tarif sesuai PERDA (Rp) TTD
No Nama No KTP Diagnosa
(Th)
Kelamin
Kunj Poli KIATT Caten/ Tindik Rujukan IUD/ PP Konsultasi Bidan Tagihan Psn/ Klg
Bumil Telinga Bidan Implant Test Gizi
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
55 Bastaniah 631009570881000 5 36 P 16/6 G2P1A0 10,000 Bidan Rp10,000
56 Rusidah 631009600891000 3 26 P 16/6 G4P3A0 10,000 Bidan Rp10,000
57 Sria Tin 631006410881000 2 36 P 17/6 G4P2A1 10,000 Bidan Rp10,000
58 Salmiah 631009540787000 7 30 P 19/6 Konsultasi 10,000 Bidan Rp10,000
59 Syamsiah 631009540784001 7 33 P 19/6 G3P2A0 10,000 Bidan Rp10,000
60 Nurul Hikmah 631009450778000 6 39 P 19/6 G6P5A0 10,000 Bidan Rp10,000
61 Masridah 631009580383000 4 34 P 19/6 G2P0A1 10,000 Bidan Rp10,000
62 Manis 631009700578000 3 39 P 19/6 Konsultasi 10,000 Bidan Rp10,000
63 Fatimah Ratu Laila 631009530773000 4 44 P 19/6 Konsultasi 10,000 Bidan Rp10,000
64 Masriah 631002410798021 2 19 P 19/6 G1P0A0 10,000 Bidan Rp10,000
65 Haty 631009500476000 5 41 P 19/6 PNC 10,000 Bidan Rp10,000
66 Herlina 631010680190000 1 27 P 20/6 G2P1A0 10,000 Bidan Rp10,000
67 Fitri Wahyuni 631009590296000 5 21 P 20/6 G1P0A0 10,000 Bidan Rp10,000
68 Janipah 630301480496000 1 21 P 20/6 G1P0A0 10,000 Bidan Rp10,000
69 Kamariah 631001590384000 1 34 P 21/6 G5P3A1 10,000 Bidan Rp10,000
70 Mirna 620303501288000 8 29 P 21/6 G2P1A0 10,000 Bidan Rp10,000
71 Siti Aminah 631009510478000 4 27 P 21/6 G1P0A0 10,000 Bidan Rp10,000
72 St. Mina Maulida Yanti 630706530297000 6 20 P 21/6 G1P0A0 10,000 Bidan Rp10,000
73 Asnayati 631009510478000 4 39 P 22/6 G9P5A3 10,000 Bidan Rp10,000
74 Murniati 325607510194000 2 23 P 22/ G1P0A0 10,000 Bidan Rp10,000
75 Ernawati 631009540483001 1 34 P 22/4 G4P3A0 10,000 Bidan Rp10,000
TOTAL Rp770,000
Simpang Empat, 8 Agustus 2017
Mengetahui, Bendahara Jamkesda
Kepala Puskesmas Darul Azhar Puskesmas Darul Azhar
dr.Muhammad Erhamsyah Sumarning Samariana, A.Md.Kep
Nip.19700111 200312 1 004 NIP.19790702 200903 2 002
 DAFTAR TAGIHAN KLAIM RAWAT JALAN PASIEN JAMKESDA PUSKESMAS DARUL AZHAR KABUPATEN TANAH BUMBU

Provinsi : Kalimantan Selatan

Kabupaten : Tanah Bumbu
Bulan : Juli 2017

Umur Jenis Tgl Pelayanan Kesehaan dan Besaran Tarif sesuai PERDA (Rp) TTD
No Nama No KTP Diagnosa
(Th)Kelamin
Kunjungan Poli KIATT Caten/ Tindik Rujukan IUD/ PP Konsultasi Bidan Tagihan Psn/ Klg
Bumil Telinga Bidan Implant Test Gizi
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
1 Fatmawati 631009530388000 2 29 P 3/7 G1P0A0 10,000 Bidan Rp10,000
2 Khusnul Khatimah 631009510493000 2 24 P 3/7 G2P1A0 10,000 Bidan Rp10,000
3 Lia Martina 631009450188000 5 29 P 3/7 Konsultasi 10,000 Bidan Rp10,000
4 Mahdalina 630805650881000 2 36 P 3/7 Konsultasi 10,000 Bidan Rp10,000
5 Hadariyah 631009590273000 3 42 P 3/7 G3P2A0 10,000 Bidan Rp10,000
6 Yunita Sari 631009630389000 4 28 P 3/7 G3P2A0 10,000 Bidan Rp10,000
7 Nurul Hikmah 631009450778000 6 39 P 3/7 G6P5A0 10,000 Bidan Rp10,000
8 Andi Netty Windart 631009430795000 3 22 P 3/7 G2P1A0 10,000 Bidan Rp10,000
9 Masridah 631009580383000 4 34 P 3/7 G2P0A1 10,000 Bidan Rp10,000
10 Siti Zubaidah 630602570992000 1 25 P 3/7 Konsultasi 10,000 Bidan Rp10,000
11 Riska Dewi 631009520391000 4 25 P 3/7 G3P2A0 10,000 Bidan Rp10,000
12 Megawati 631009521192000 6 25 P 3/7 G1P0A0 10,000 Bidan Rp10,000
13 Khairiyati 630810451091000 2 26 P 3/7 G2P1A0 10,000 Bidan Rp10,000
14 Muflihah 631009530593000 7 24 P 3/7 G1P0A0 10,000 Bidan Rp10,000
15 Mallianti 631009660597000 4 20 P 3/7 G2P1A0 10,000 Bidan Rp10,000
16 Sariyani 631009701270000 4 47 P 3/7 Konsultasi 10,000 Bidan Rp10,000
17 Sadariyah 631009581287000 2 28 P 3/7 G2P1A0 10,000 Bidan Rp10,000
18 Asty Azis 631009451281000 6 36 P 3/7 G3P2A0 10,000 Bidan Rp10,000
19 Norma 631009551175000 7 42 P 5/7 Konsultasi 10,000 Bidan Rp10,000
20 Mili Martini 631009420289000 4 30 P 5/7 G2P1A0 10,000 Bidan Rp10,000
21 Manisah 631009450575001 9 42 P 5/7 G3P2A0 10,000 Bidan Rp10,000
Umur Jenis Tgl Pelayanan Kesehaan dan Besaran Tarif sesuai PERDA (Rp) TTD
No Nama No KTP Diagnosa
(Th)KelaminKunj Poli KIATT Caten/ Tindik Rujukan IUD/ PP Konsultasi Bidan Tagihan Psn/ Klg
Bumil Telinga Bidan Implant Test Gizi
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
22 Nur Hamidah 631009680288000 5 29 5/7 G3P1A1
23 Tina Wati 631009450489000 5 28 6/7 G3P2A0
24 Yulia 631009660889000 1 28 P 6/7 G4P3A0 10,000 Bidan Rp10,000
25 Rahmawati 631009650373000 1 44 P 6/7 G6P5A0 10,000 Bidan Rp10,000
26 Lia Martina 631009450188000 5 34 P 6/7 G3P2A0 10,000 Bidan Rp10,000
27 Rini 631009610195000 3 22 P 6/7 G1P0A0 10,000 Bidan Rp10,000
28 Rita Noviliana 631002571190000 1 27 P 6/7 G3P2A0 10,000 Bidan Rp10,000
29 Iin Komariah 631009650677000 4 40 P 6/7 G3P2A0 10,000 Bidan Rp10,000
30 Kardianah 631009480877001 1 40 P 6/7 Konsultasi 10,000 Bidan Rp10,000
31 Hidayah 631009550776000 8 41 P 6/7 G5P4A0 10,000 Bidan Rp10,000
32 Siti Fatimah 631009671180000 2 37 P 6/7 15,000
Perawatan Luka tanpa Jahitan Bidan Rp15,000
33 Noorma Juwita 631009691189000 2 28 P 6/7 G3P1A1 10,000 Bidan Rp10,000
34 Nur Syafah Aprilia 631006470417000 1 3 bulan P 6/7 20,000 Tindik Telinga Bidan Rp20,000
35 Siti Hasanah 63100945075001 6 22 P 6/7 Konsultasi 10,000 Bidan Rp10,000
36 Rina Permatasari 631009440497000 8 20 P 7/7 G1P0A0 10,000 Bidan Rp10,000
37 Rusidah 631009600891000 3 26 P 8/7 G4P3A0 10,000 Bidan Rp10,000
38 Khusnul Khatimah 631009510493000 2 24 P 10/7 G3P1A1 10,000 Bidan Rp10,000
39 Farida Hayati 631009431280000 7 37 P 10/7 G5P4A0 10,000 Bidan Rp10,000
40 Maulidah 631009530690000 2 27 P 10/7 G2P1A0 10,000 Bidan Rp10,000
41 Rahmawati 631009650373000 1 44 P 10/7 G6P4A1 10,000 Bidan Rp10,000
42 Fatmawati 631009530388000 2 29 P 10/7 G1P0A0 10,000 Bidan Rp10,000
43 Rini Sumarni 631009410789020 8 28 P 10/7 G2P1A0 10,000 Bidan Rp10,000
44 Hidayah 631009570290000 2 27 P 11/7 G2P1A0 10,000 Bidan Rp10,000
45 Nor Hasanah 631009440483000 5 34 P 11/7 G3P2A0 10,000 Bidan Rp10,000
46 Nur Ajizah 631009550497000 5 20 P 11/7 G1P0A0 10,000 Bidan Rp10,000
47 Kardianah 631009480877001 1 40 P 12/7 Konsultasi 10,000 Bidan Rp10,000
48 Nor Sari 631009450573001 1 44 P 12/7 G4P3A0 10,000 Bidan Rp10,000
49 Juriah 63720490791000 1 26 P 12/7 G3P2A0 10,000 Bidan Rp10,000
50 Erna Wati 631009540483001 1 34 P 13/7 G3P2A0 10,000 Bidan Rp10,000
51 Pika Nor Jennah 631009540591000 8 26 P 13/7 G2P1A0 10,000 Bidan Rp10,000
Umur Jenis Tgl Pelayanan Kesehaan dan Besaran Tarif sesuai PERDA (Rp) TTD
No Nama No KTP Diagnosa
(Th)KelaminKunj Poli KIATT Caten/ Tindik Rujukan IUD/ PP Konsultasi Bidan Tagihan Psn/ Klg
Bumil Telinga Bidan Implant Test Gizi
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
52 Ayu Novitasari 631009621191000 1 26 P 13/7 G2P1A0 10,000 Bidan Rp10,000
53 Yeni Afriani 631009590494000 4 23 P 14/7 G3P2A0 10,000 Bidan Rp10,000
54 Rinawati 631009570892001 4 25 P 14/7 Konsultasi 10,000 Bidan Rp10,000
55 Dwi Anggraini 631009691095000 1 22 P 15/7 G2P1A0 10,000 Bidan Rp10,000
56 Nur Aeni Rosalina 631009450588001 0 29 P 15/7 G3P1A1 10,000 Bidan Rp10,000
57 Arbayah 631009530194000 2 25 P 17/7 G1P0A0 10,000 Bidan Rp10,000
58 Dewi Oktavia Bagus631001431094000 1 23 P 17/7 G1P0A0 10,000 Bidan Rp10,000
59 Hefni Heriani 631009601285000 1 32 P 18/7 Konsultasi 10,000 Bidan Rp10,000
60 Nuril Chatimah 631009530985000 2 32 P 18/7 Konsultasi 10,000 Bidan Rp10,000
61 Nur Walidainy 631009450594000 2 21 P 18/7 G3P2A0 10,000 Bidan Rp10,000
62 Yurni 631009610565000 2 52 P 19/7 Konsultasi 10,000 Bidan Rp10,000
63 Rahmi Lidiani 631009501189000 6 28 P 19/7 G2P1A0 10,000 Bidan Rp10,000
64 Mallianti 631009660597000 4 20 P 19/7 G2P1A0 10,000 Bidan Rp10,000
65 Fatimah Azzahra 631009520292000 4 25 P 19/7 G2P1A0 10,000 Bidan Rp10,000
66 Siti Aminah 631009430687000 7 27 P 19/7 G1P0A0 10,000 Bidan Rp10,000
67 Jubaidah 631009481178000 4 39 P 19/7 G3P2A0 10,000 Bidan Rp10,000
68 Yunita Sari 631009630389000 4 29 P 19/7 G3P2A0 10,000 Bidan Rp10,000
69 Kalbiah 631009420690000 3 27 P 19/7 G2P1A0 10,000 Bidan Rp10,000
70 Amelia Juhra 631009440788000 3 29 P 20/7 G3P2A0 10,000 Bidan Rp10,000
71 Norjenah 631009460674000 7 43 P 20/7 Konsultasi 10,000 Bidan Rp10,000
72 Mahdalina 630805650881000 2 36 P 20/7 G3P2A0 10,000 Bidan Rp10,000
73 Harni Irianti Candra637102651284000 9 33 P 20/7 G3P2A0 10,000 Bidan Rp10,000
74 Megawati 631001580889000 1 28 P 20/7 G3P2A0 10,000 Bidan Rp10,000
75 Nikma Sasnita Sari 631009681196000 1 21 P 20/7 G1P0A0 10,000 Bidan Rp10,000
76 Evi Novianti 327204661294000 1 23 P 20/7 G2P1A0 10,000 Bidan Rp10,000
77 Sarpiani 630202550696000 1 21 P 20/7 G1P0A0 10,000 Bidan Rp10,000
78 Rahmawati 631009590183000 4 34 P 21/7 G4P3A0 10,000 Bidan Rp10,000
79 Sumiati 631009581289000 6 28 P 21/7 G2P1A0 10,000 Bidan Rp10,000
Umur Jenis Tgl Pelayanan Kesehaan dan Besaran Tarif sesuai PERDA (Rp) TTD
No Nama No KTP Diagnosa
(Th)KelaminKunj Poli KIATT Caten/ Tindik Rujukan IUD/ PP Konsultasi Bidan Tagihan Psn/ Klg
Bumil Telinga Bidan Implant Test Gizi
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
80 Marlina 631009640778000 5 48 P 21/7 G3P1A1 10,000 Bidan Rp10,000
81 Saniah 631009410886000 4 31 P 22/7 G4P3A0 10,000 Bidan Rp10,000
82 Nia Amelia 631009611194000 4 23 P 22/7 Konsultasi 10,000 Bidan Rp10,000
83 Lena 631009641268000 1 49 P 24/7Polimenorhoe 10,000 Bidan Rp10,000
84 Rahmawati 631009650373000 1 44 P 25/7 G6P4A1 10,000 Bidan Rp10,000
85 Sriatin 631006410881000 2 36 P 25/7 G4P2A1 10,000 Bidan Rp10,000
86 Fitria 631009471281000 2 36 P 25/7 G3P2A0 10,000 Bidan Rp10,000
87 Nor Hayati 631009640388000 4 29 P 25/7 G3P2A0 10,000 Bidan Rp10,000
88 Nia 630803560192000 1 25 P 25/7 G3P1A1 10,000 Bidan Rp10,000
89 Yulia Asih 630216551192000 1 25 P 25/7 G1P0A0 10,000 Bidan Rp10,000
90 Aniyah 631002470191000 1 26 P 26/7 G2P1A0 10,000 Bidan Rp10,000
91 ST Ramlah 631009450292000 7 25 P 27/7 G4P3A0 10,000 Bidan Rp10,000
92 Marlina 631009640778000 5 39 P 28/7 G3P1A1 10,000 Bidan Rp10,000
93 Suwaibatul Aslamiy631009471083000 7 34 P 28/7 G2P1A0 10,000 Bidan Rp10,000
94 Syamsiah 631009540784001 7 33 P 28/7 G3P2A0 10,000 Bidan Rp10,000
95 Murdia 631009431276000 3 41 P 29/7 Konsultasi 10,000 Bidan Rp10,000
96 Rusidah 631009600891000 3 26 P 29/7 G4P3A0 10,000 Bidan Rp10,000
97 Siti Hapsah 631009560292000 2 25 P 31/7 G1P0A0 10,000 Bidan Rp10,000
98 Lisna Wati 631005541091000 1 26 P 31/7 G1P0A0 10,000 Bidan Rp10,000

TOTAL Rp995,000
Simpang Empat, 31 Juli 2017
Mengetahui, Bendahara Jamkesda
Kepala Puskesmas Darul Azhar Puskesmas Darul Azhar
dr.Muhammad Erhamsyah Sumarning Samariana, A.Md.Kep
Nip.19700111 200312 1 004 NIP.19790702 200903 2 002
 DAFTAR TAG+A1:R37IHAN KLAIM RAWAT JALAN PASIEN JAMKESDA PUSKESMAS DARUL AZHAR KABUPATEN TANAH BUMBU

Provinsi : Kalimantan Selatan

Kabupaten : Tanah Bumbu
Bulan : Agustus 2017

UmurJenis Tgl Pelayanan Kesehaan dan Besaran Tarif sesuai PERDA (Rp) TTD
No Nama No KTP Diagnosa
(Th)Kelamin
Kunjungan Poli KIATT Caten/Tindik Rujukan IUD/ PP Konsultasi Bidan Tagihan Psn/ Klg
Bumil Telinga Bidan Implant Test Gizi
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
1 Rahmawati 631009650373000 1 44 P 1/8 G6P4A1 10,000 Bidan Rp10,000
2 Karmila 630801670596000 1 21 P 1/8 G1P0A0 10,000 Bidan Rp10,000
3 Melda Wati 631009630493000 5 24 P 1/8 G2P1A0 10,000 Bidan Rp10,000
4 Nor Latifah 631009410686000 8 31 P 2/8 G3P2A0 10,000 Bidan Rp10,000
5 Mallianti 631009660597000 4 20 P 2/8 G2P1A0 10,000 Bidan Rp10,000
6 Yeni Afriani 631009590494000 4 23 P 2/8 G2P1A0 10,000 Bidan Rp10,000
7 Yunita Sari 631009630389000 4 28 P 2/8 G3P2A0 10,000 Bidan Rp10,000
8 Rosminah 631002410290001 0 27 P 2/8 G2P1A0 10,000 Bidan Rp10,000
9 Misna 630204411087000 1 30 P 3/8 Konsultasi 10,000 Bidan Rp10,000
10 Eka Wahyuni 640502450390000 1 27 P 3/8 G2P1A0 10,000 Bidan Rp10,000
11 Amalia Fitria D 631001420889000 1 28 P 3/8 G3P2A0 10,000 Bidan Rp10,000
12 Siti Aisyah 630217630996000 1 21 P 3/8 G1P0A0 10,000 Bidan Rp10,000
13 Megawati 631009521192000 6 22 P 3/8 G1P0A0 10,000 Bidan Rp10,000
14 Sadariyah 631009581287000 2 30 P 3/8 G2P1A0 10,000 Bidan Rp10,000
15 Norsiah 631009480682000 6 35 P 3/8 G3P2A0 10,000 Bidan Rp10,000
16 Ruhana 631009621278000 3 39 P 4/8 G6P5A0 10,000 Bidan Rp10,000
17 Yeny 631006660887000 1 30 P 4/8 Konsultasi 10,000 Bidan Rp10,000
18 Muflihah 631009530593000 7 24 P 4/8 G1P0A0 10,000 Bidan Rp10,000
19 Mili Martini 631009420289000 4 28 P 4/8 G2P1A0 10,000 Bidan Rp10,000
20 Herlina 631010680190000 1 27 P 4/8 Mastitis 10,000 Bidan Rp10,000
21 Siti Aminah 631009501287001 0 30 P 4/8 G3P2A0 10,000 Bidan Rp10,000
22 Siti Zubaidah 630602570992000 1 25 P 4/8 PNC 10,000 Bidan Rp10,000
23 Jubaidah 631009481178000 4 39 P 4/8 G4P3A0 10,000 Bidan Rp10,000
24 Rahmadaniah 631009420880001 2 37 P 4/8 G3P2A0 10,000 Bidan Rp10,000
UmurJenis Tgl Pelayanan Kesehaan dan Besaran Tarif sesuai PERDA (Rp) TTD
No Nama No KTP Diagnosa
(Th)Kelamin
Kunjungan Poli KIATT Caten/Tindik Rujukan IUD/ PP Konsultasi Bidan Tagihan Psn/ Klg
Bumil Telinga Bidan Implant Test Gizi
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
25 Misna 630204411087000 1 30 P 4/8 G3P2A0 10,000 Bidan Rp10,000
26 Nurul Isnaeni 330503570889000 4 28 P 5/8 Konsultasi 10,000 Bidan Rp10,000
27 Manisah 631009450575001 9 42 P 5/8 G3P2A0 10,000 Bidan Rp10,000
28 Nana Mariana 631009670881000 2 36 P 7/8 G4P3A0 10,000 Bidan Rp10,000
29 Siti Nursilawati 631009510675000 4 42 P 8/8 G7P3A3 10,000 Bidan Rp10,000
30 Eka Septia Ningsih 631009660987000 3 30 P 9/8 G4P3A0 10,000 Bidan Rp10,000
31 ST Ramlah 631009450292000 7 25 P 9/8 G3P2A0 10,000 Bidan Rp10,000
32 Asty Azis 631009451281000 6 36 P 10/8 G3P2A0 10,000 Bidan Rp10,000
33 Sarmini 631009491081000 4 36 P 10/8 Konsultasi 10,000 Bidan Rp10,000
34 Siti Aisyah 630217630996000 1 21 P 10/8 G1P0A0 10,000 Bidan Rp10,000
35 Eki Dahlia 630107480198000 2 20 P 10/8 G1P0A0 10,000 Bidan Rp10,000
36 Nidaul Hasanah 630605550495000 1 22 P 10/8 G1P0A0 10,000 Bidan Rp10,000
37 Nia 630803560192000 1 25 P 10/8 G3P1A1 10,000 Bidan Rp10,000
38 Yenni Pattya S 631009550693000 3 24 P 10/8 G2P0A1 10,000 Bidan Rp10,000
39 Nor Sari 631009450573001 1 44 P 10/8 G4P3A0 10,000 Bidan Rp10,000
40 Hidayah 631009570290000 2 27 P 11/8 G2P1A0 10,000 Bidan Rp10,000
41 Misdinawati 631009650592000 3 25 P 13/8 G4P2A1 10,000 Bidan Rp10,000
42 Herlina 631010680190000 1 27 P 14/8 Konsultasi 10,000 Bidan Rp10,000
43 Maulidah 631009530690000 2 27 P 14/8 G2P1A0 10,000 Bidan Rp10,000
44 Dewi Oktavia Bagus 631001431094000 1 23 P 14/8 G1P0A0 10,000 Bidan Rp10,000
45 Marlina 631009640778000 5 39 P 15/8 G3P2A0 10,000 Bidan Rp10,000
46 Rahmawati 631009550188000 4 29 P 15/8 Konsultasi 10,000 Bidan Rp10,000
47 Yurni 631009610565000 2 52 P 15/8 Konsultasi 10,000 Bidan Rp10,000
48 Nikma Sasnita S 631009681196000 1 21 P 15/8 G1P0A0 10,000 Bidan Rp10,000
49 Harni Irianti C 637204651284000 4 33 P 15/8 G3P1A1 10,000 Bidan Rp10,000
50 Fitri Wahyuni 631009590296000 5 21 P 15/8 G1P0A0 10,000 Bidan Rp10,000
51 Rusmiati 631009670783000 5 34 P 16/8 G2P1A0 10,000 Bidan Rp10,000
52 Siti Hadijah 631009450895000 6 22 P 16/8 G1P0A0 10,000 Bidan Rp10,000
53 Farida Hayati 631009431280000 7 37 P 16/8 G5P4A0 10,000 Bidan Rp10,000
54 Kardianah 631009480877001 1 40 P 16/8 Konsultasi 10,000 Bidan Rp10,000
UmurJenis Tgl Pelayanan Kesehaan dan Besaran Tarif sesuai PERDA (Rp) TTD
No Nama No KTP Diagnosa
(Th)Kelamin
Kunjungan Poli KIATT Caten/Tindik Rujukan IUD/ PP Konsultasi Bidan Tagihan Psn/ Klg
Bumil Telinga Bidan Implant Test Gizi
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
55 Irusma 631009431081000 3 36 P 16/8 Konsultasi 10,000 Bidan Rp10,000
56 Ruhana 631009621278000 3 39 P 18/8 G6P5A0 10,000 Bidan Rp10,000
57 Noorma Juwita 631009691189000 2 28 P 18/8 G2P1A0 10,000 Bidan Rp10,000
58 ST Ramlah 631009450292000 7 25 P 19/8 G4P3A0 10,000 Bidan Rp10,000
59 Saniah 631009410886000 4 31 P 19/8 G3P2A0 10,000 Bidan Rp10,000
60 Syarifah 631009621084000 3 36 P 19/8 G4P3A0 10,000 Bidan Rp10,000
61 Nur Hamidah 631009680288000 5 29 P 19/8 G3P1A1 10,000 Bidan Rp10,000
62 Sarpiani 630202550696000 1 21 P 19/8 G1P0A0 10,000 Bidan Rp10,000
63 Fakhriah 631006500382000 3 35 P 19/8 G3P2A0 10,000 Bidan Rp10,000
64 Eka Wahyuni 640502450390000 1 27 P 19/8 G2P1A0 10,000 Bidan Rp10,000
65 Masliani 631009511272000 2 45 P 19/8 G4P3A0 10,000 Bidan Rp10,000
66 Sumiati 631009581289000 6 28 P 21/8 G2P1A0 10,000 Bidan Rp10,000
67 Rahmawati 631009650373000 1 44 P 21/8 G6P4A1 10,000 Bidan Rp10,000
68 Nur Hikmah 631009621292000 8 25 P 21/8 Konsultasi 10,000 Bidan Rp10,000
69 Arlina 631009600569000 2 48 P 21/8 Konsultasi 10,000 Bidan Rp10,000
70 Misdinawati 631009650592000 3 25 P 22/8 G4P2A1 10,000 Bidan Rp10,000
71 Nor Hayati 631009640388000 4 29 P 22/8 G3P2A0 10,000 Bidan Rp10,000
72 Murdia 631009431276000 3 41 P 23/8 Konsultasi 10,000 Bidan Rp10,000
73 Masriyah 631009550570001 3 47 P 23/8 Konsultasi 10,000 Bidan Rp10,000
74 Diana Andika Sari 631009410986000 5 31 P 23/8 Konsultasi 10,000 Bidan Rp10,000
75 Arpah 631009560580001 1 37 P 24/8 G2P1A0 10,000 Bidan Rp10,000
76 Syamsiah 631009540784001 7 33 P 24/8 G3P2A0 10,000 Bidan Rp10,000
77 Nor Hayani 630206690490000 5 27 P 24/8 G2P1A0 10,000 Bidan Rp10,000
78 Siti Aminah 631009430687000 7 27 P 25/8 G1P0A0 10,000 Bidan Rp10,000
79 Jubaidah 631009481178000 4 37 P 25/8 G4P3A0 10,000 Bidan Rp10,000
80 Kalbiah 631009420690000 3 27 P 26/8 G2P1A0 10,000 Bidan Rp10,000
81 Noor Aisyah 631009580892000 4 25 P 26/8 G2P1A0 10,000 Bidan Rp10,000
82 Fitriani 630413580394000 3 23 P 28/8 G2P0A1 10,000 Bidan Rp10,000
83 Sajeriah 631009600587000 4 30 P 28/8 G3P2A0 10,000 Bidan Rp10,000
84 Juriah 637204690791000 1 26 P 28/8 G3P2A0 10,000 Bidan Rp10,000
UmurJenis Tgl Pelayanan Kesehaan dan Besaran Tarif sesuai PERDA (Rp) TTD
No Nama No KTP Diagnosa
(Th)Kelamin
Kunjungan Poli KIATT Caten/Tindik Rujukan IUD/ PP Konsultasi Bidan Tagihan Psn/ Klg
Bumil Telinga Bidan Implant Test Gizi
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
85 Nor Hasanah 631008661292000 1 25 P 28/8 G4P3A0 10,000 Bidan Rp10,000
86 Asmaniah 631009650477000 1 40 P 28/8 G4P3A0 10,000 Bidan Rp10,000
87 Sadariyah 631009581287000 2 30 P 28/8 G2P1A0 10,000 Bidan Rp10,000
88 Darminah 631002500584000 3 33 P 28/8 G5P3A1 10,000 Bidan Rp10,000
89 Ati sholihatin D 631009571095000 1 23 P 28/8 G1P0A0 10,000 Bidan Rp10,000
90 Fitri Wahyuni 631009590296000 5 21 P 29/8 G1P0A0 10,000 Bidan Rp10,000

TOTAL Rp900,000

Simpang Empat, 2 September 2017

Mengetahui, Bendahara Jamkesda
Kepala Puskesmas Darul Azhar Puskesmas Darul Azhar

dr.Mardalena Sumarning Samariana, A.Md.Kep

NIP.19791127 200904 2 005 NIP.19790702 200903 2 002
 DAFTAR TAGIHAN KLAIM RAWAT JALAN PASIEN JAMKESDA PUSKESMAS DARUL A

Provinsi : Kalimantan Selatan

Kabupaten : Tanah Bumbu
Bulan : September 2017

Umur Jenis Tgl Pelayanan Kesehaan dan Besaran Tarif

No Nama No KTP Diagnosa
(Th) Kelamin Kunjungan Poli KIA TT Caten/ Tindik
Bumil Telinga
1 2 3 4 5 6 7 8 9 10
1 Dewi Okta631001431 23 P 04/9 G1P0A0 10,000
2 Rihnida Di631009651 32 P 04/9 G4P2A1 10,000
3 Diana 631009580 35 P 04/9 G3P2A0 10,000
4 Susilawati 631009470 43 P 04/9 G3P2A0 10,000
5 Netty Hera631009570 36 P 04/9 G3P2A0 10,000
6 Nikhayati 631009460 42 P 04/9 Konsultasi 10,000
7 Marlinda 631009471 29 P 04/9 G2P1A0 10,000
8 Asty Azis 631009451 36 P 04/9 G3P2A0 10,000
9 Syarifah 631009621 33 P 04/9 G4P3A0 10,000
10 Haty 631009500 41 P 04/9 G3P2A0 10,000
11 Eka Wahyu640502450 27 P 04/9 G2P1A0 10,000
12 Siti Aisyah631009550 35 P 04/9 G2P1A0 10,000
13 Ariani 631009570 30 P 05/9 G2P1A0 10,000
14 Manisah 631009450 42 P 05/9 G3P2A0 10,000
15 Norsiah 631009480 35 P 05/9 Konsultasi 10,000
16 Nely Ayu U631009680 27 P 05/9 G2P1A0 10,000
17 Sri Wahyun631009441 32 P 06/9 G2P1A0 10,000
18 Dwi Yulai 631009670 23 P 07/9 G2P1A0 10,000
19 Muflihah 631009530 24 P 08/9 G1P0A0 10,000
20 Jubaidah 631009481 39 P 08/9 G4P3A0 10,000
21 Fitri wahy 631009590 21 P 08/9 G1P0A0 10,000
Umur Jenis Tgl Pelayanan Kesehaan dan Besaran Tarif
No Nama No KTP Diagnosa
(Th) Kelamin Kunj Poli KIA TT Caten/ Tindik
Bumil Telinga
1 2 3 4 5 6 7 8 9 10
22 Bastaniah 631009570 36 P 08/9 G2P1A0 10,000
23 Rina Perma631009440 20 P 08/9 G1P0A0 10,000
24 Siti Nursil 631009510 42 P 09/9 G7P3A3 10,000
25 Rahmawati631009650 44 P 11/9 G6P4A1 10,000
26 Hidayah 631009570 27 P 11/9 G2P1A0 10,000
27 Mili Marti631009420 28 P 11/9 G2P1A0 10,000
28 Kardianah 631009480 40 P 11/9 Konsultasi 10,000
 29 Rosminah 631002410 27 P 12/9 G2P1A0 10,000
30 Misdinawat631009650 25 P 13/9 G4P2A1 10,000
31 Maulidah 631009530 27 P 13/9 G2P1A0 10,000
32 Raudatul J620304670 21 P 13/9 Konsultasi 10,000
33 Megawati 631009521 25 P 13/9 G1P0A0 10,000
34 Friska Vaul631009590 25 P 15/9 G1P0A0 10,000
35 Marlianti 631009481 34 P 15/9 G7P3A3 10,000
36 Siti Nursil 631009510 42 P 15/9 G7P3A3 10,000
37 Rhisya Afri631009690 28 P 15/9 G1P0A0 10,000
38 Hasnah 631009481 28 P 15/9 G2P1A0 10,000
39 Nur Hamid631009680 28 P 16/9 G3P1A1 10,000
40 Indah Pahr631009561 27 P 18/9 Konsultasi 10,000
41 Ani Rosali631006560 19 P 18/9 G2P0A1 10,000
42 Nursidah 631009570 36 P 18/9 Konsultasi 10,000
43 Nia Ameli 631009611 23 P 18/9 Konsultasi 10,000
44 Risnawati 630206470 32 P 18/9 G3P2A0 10,000
45 Siti Aisyah631009580 43 P 18/9 G3P2A0 10,000
46 Eka Wahyu940502450 27 P 18/9 G2P1A0 10,000
47 Desi Anggr631009550 35 P 18/9 G4P3A0 10,000
48 Isnaniyah 631009590 42 P 18/9 G4P3A0 10,000
49 Mukarama631009411 25 P 19/9 G2P1A0 10,000
50 Farida Hay631009431 37 P 19/9 G5P4A0 10,000
51 Susi Herli 631001460 38 P 19/9 G6P4A1 10,000
Umur Jenis Tgl Pelayanan Kesehaan dan Besaran Tarif
No Nama No KTP Diagnosa
(Th) Kelamin Kunj Poli KIA TT Caten/ Tindik
Bumil Telinga
1 2 3 4 5 6 7 8 9 10
52 Norhidaya631009450 32 P 19/9 G3P2A0 10,000
53 Ella Darmi631006600 25 P 19/9 Konsultasi 10,000
54 Eva Artant631009460 35 P 20/9 G4P2A1 10,000
55 Salmiah 631009540 30 P 20/9 Konsultasi 10,000
56 Dewi Okta631001431 23 P 20/9 G1P0A0 10,000
57 Norhayati 631009690 30 P 20/9 Konsultasi 10,000
58 Puji Tuani 631009521 43 P 20/9 Konsultasi 10,000
59 Amelia Juh631009440 29 P 20/9 G3P2A0 10,000
60 Megawati 631001580 28 P 20/9 G3P2A0 10,000
61 Marlinda 631009471 29 P 22/9 Konsultasi 10,000
62 Rahmiyati 631009470 37 P 22/9 G3P2A0 10,000
63 Sarmini 631009491 36 P 22/9 Konsultasi 10,000
64 Nikma Sasn 631009681 21 P 22/9 G1P0A0 10,000
65 Apin Mardi631010570 24 P 22/9 G1P0A0 10,000
66 Salwatul'ai631006500 2 Bln P 22/9 Tindik Telinga 20,000
67 Mahdalina630805650 36 P 22/9 G3P2A0 10,000
68 Siti Zubai 630602570 25 P 23/9 Konsultasi 10,000
69 Noor Aisy 631009580 25 P 23/9 G2P1A0 10,000
70 Saniah 631009410 31 P 23/9 15,000
Perawatan Luka Tanpa Jahitan
71 Juriah 637204690 26 P 25/9 G3P2A0 10,000
72 Sajeriah 631009600 30 P 25/9 G3P2A0 10,000
73 Jumiati 631009620 28 P 25/9
Perawatan Luka Tanpa 15,000
Jahitan
74 Syamsiah 631009540 33 P 26/9 G3P2A0 10,000
75 Kalbiah 631009420 27 P 26/9 G2P1A0 10,000
76 Arbainah 631009500 29 P 26/9 G3P2A0 10,000
77 Megawati 631009521 25 P 26/9 G1P0A0 10,000
78 Nidaul Ha 630605550 22 P 26/9 G3P2A0 10,000
79 Sarpiani 630202550 21 P 26/9 G1P0A0 10,000
80 Mirna 620303501 29 P 27/9 G2P1A0 10,000
81 Diana 631009580 35 P 27/9 G5P4A0 10,000
Umur Jenis Tgl Pelayanan Kesehaan dan Besaran Tarif
No Nama No KTP Diagnosa
(Th) Kelamin Kunj Poli KIA TT Caten/ Tindik
Bumil Telinga
1 2 3 4 5 6 7 8 9 10
82 Siti Aisyah631009580 43 P 27/9 G3P2A0 10,000
83 Hj.Ummi K631009590 33 P 27/9 G5P4A0 10,000
84 Fitriani 630413580 23 P 28/9 G2P0A1 10,000
85 Friska Vaul631009590 25 P 28/9 G1P0A0 10,000
86 Arlina 631009600 48 P 29/9 Konsultasi 10,000
87 Nia Ameli 631009611 23 P 29/9 Konsultasi 10,000
88 Ati Sholih 631009571 23 P 29/9 G1P0A0 10,000
89 Defi Nofita631009610 24 P 29/9 G1P0A0 10,000
90 ST.Lisdaya630202490 18 P 30/9 G1P0A0 10,000
91 Raudatul J620304670 21 P 30/9 Konsultasi 10,000
TOTAL

Mengetahui,
Kepala Puskesmas Darul Azhar

dr.Mardalena
NIP.19791127 200904 2 005
ESDA PUSKESMAS DARUL AZHAR KABUPATEN TANAH BUMBU

nan Kesehaan dan Besaran Tarif sesuai PERDA (Rp) TTD

Rujukan IUD/ PP Konsultasi Bidan Tagihan Psn/ Klg
Bidan Implant Test Gizi
11 12 13 14 15 16 17
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
nan Kesehaan dan Besaran Tarif sesuai PERDA (Rp) TTD
Rujukan IUD/ PP Konsultasi Bidan Tagihan Psn/ Klg
Bidan Implant Test Gizi
11 12 13 14 15 16 17
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
 Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
nan Kesehaan dan Besaran Tarif sesuai PERDA (Rp) TTD
Rujukan IUD/ PP Konsultasi Bidan Tagihan Psn/ Klg
Bidan Implant Test Gizi
11 12 13 14 15 16 17
Bidan 10,000
Bidan 10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp20,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
 Bidan Rp15,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp15,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
nan Kesehaan dan Besaran Tarif sesuai PERDA (Rp) TTD
Rujukan IUD/ PP Konsultasi Bidan Tagihan Psn/ Klg
Bidan Implant Test Gizi
11 12 13 14 15 16 17
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Bidan Rp10,000
Rp960,000

Simpang Empat, 2 Oktober 2017

Bendahara Jamkesda
Puskesmas Darul Azhar

Sumarning Samariana, A.Md.Kep

NIP.19790702 200903 2 002
 DAFTAR TAGIHAN KLAIM RAWAT JALAN PASIEN JAMKESDA PUSKESMAS DARUL AZHAR KABUPATEN TANAH BUMBU

Provinsi : Kalimantan Selatan

Kabupaten : Tanah Bumbu
Bulan : Oktober 2017

Umur Jenis Tgl Pelayanan Kesehaan dan Besaran Tarif sesuai PERDA (Rp) TTD
No Nama No KTP Diagnosa
(Th)Kelamin
Kunjungan Poli KIATT Caten/Tindik Rujukan IUD/ PP Konsultasi Bidan Tagihan Psn/ Klg
Bumil Telinga Bidan Implant Test Gizi
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
1 Sumiati 631009581289000 6 28 P 2/10 G2P1A0 10,000 Bidan Rp10,000
2 Anik Yuliastuti N 631009410776012 3 41 P Perawatan
2/10 Luka Tanpa15,000
Jahitan Bidan Rp15,000
3 Siti Aisyah 631009550482000 2 35 P 2/10 G2P1A0 10,000 Bidan Rp10,000
4 Marhana 631009660790000 2 27 P 2/10 Konsultasi 10,000 Bidan Rp10,000
5 Sri Wahyuni 631009440185000 4 32 P 2/10 G2P1A0 10,000 Bidan Rp10,000
6 Mariana 630217500791000 1 26 P 2/10 Konsultasi 10,000 Bidan Rp10,000
7 Mulianti 631009410284000 7 33 P 2/10 Konsultasi 10,000 Bidan Rp10,000
8 Salamah 631009420383000 5 34 P Perawatan
2/10 Luka Tanpa15,000
Jahitan Bidan Rp15,000
9 Rahmawati 631009650373000 1 44 P 2/10 G6P4A1 10,000 Bidan Rp10,000
10 Titi Partikem 631009590871000 5 46 P Perawatan
3/10 Luka Tanpa15,000
Jahitan Bidan Rp15,000
11 Anita Rahayu 631009501096001 1 21 P 3/10 G1P0A0 10,000 Bidan Rp10,000
12 Mariana Jenatul A 631009670896000 2 21 P 3/10 G1P0A0 10,000 Bidan Rp10,000
13 Ahyani Khoirunnisa 631009630699000 7 18 P 3/10 G1P0A0 10,000 Bidan Rp10,000
14 Sri Hernani 631009660285001 7 32 P 4/10 G3P2A0 10,000 Bidan Rp10,000
15 Noorma Juwita 631009691189000 2 28 P 4/10 G3P1A1 10,000 Bidan Rp10,000
16 Martini 631009610183000 4 34 P 4/10 G4P3A0 10,000 Bidan Rp10,000
17 Juriah 637204690791000 1 26 P 5/10 G3P2A0 10,000 Bidan Rp10,000
18 Manisah 631009450575001 9 42 P 5/10 G3P2A0 10,000 Bidan Rp10,000
19 Norhidayah 631009450285000 1 32 P 5/10 G3P2A0 10,000 Bidan Rp10,000
20 Mili Martini 631009420289000 4 28 P 6/10 G2P1A0 10,000 Bidan Rp10,000
21 Titi Partikem 631009590871000 5 46 P 6/10 Konsultasi 10,000 Bidan Rp10,000
Umur Jenis Tgl Pelayanan Kesehaan dan Besaran Tarif sesuai PERDA (Rp) TTD
No Nama No KTP Diagnosa
No Nama No KTP Diagnosa
(Th)Kelamin Kunj Poli KIATT Caten/Tindik Rujukan IUD/ PP Konsultasi Bidan Tagihan Psn/ Klg
Bumil Telinga Bidan Implant Test Gizi
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
22 Endang Mastika 631002460593000 2 24 P 6/10 Konsultasi 10,000 Bidan Rp10,000
23 Dayah 630309421096000 1 21 P 7/10 Konsultasi 10,000 Bidan Rp10,000
24 Nikma Sasnita S 631009681196000 1 21 P 7/10 G1P0A0 10,000 Bidan Rp10,000
25 Nabella Firdiena F 637202551295000 4 22 P 7/10 G1P0A0 10,000 Bidan Rp10,000
26 Darminah 631002500584000 3 33 P 7/10 G5P3A1 10,000 Bidan Rp10,000
27 Harmina 631009530685000 6 32 P 7/10 G2P1A0 10,000 Bidan Rp10,000
28 Muflihah 631009530593000 7 24 P 7/10 G1P0A0 10,000 Bidan Rp10,000
29 Fithriyah 631006460783000 2 34 P 9/10 G3P2A0 10,000 Bidan Rp10,000
30 Haty 631009500476000 5 41 P 9/10 Konsultasi 10,000 Bidan Rp10,000
31 Leni Mardiyanti 631009701176000 4 41 P 9/10 G4P3A0 10,000 Bidan Rp10,000
32 Titi Partikem 631009590871000 5 46 P 9/10 Konsultasi 10,000 Bidan Rp10,000
33 Siti Rusminah 631009651192000 5 25 P 9/10 Konsultasi 10,000 Bidan Rp10,000
34 Saidah Murni 631009691086000 1 31 P 9/10 G3P2A0 10,000 Bidan Rp10,000
35 Rahmawati 631009650373000 1 44 P 9/10 G6P4A1 10,000 Bidan Rp10,000
36 Sriatin 631006410881000 2 36 P 9/10 G4P2A1 10,000 Bidan Rp10,000
37 Eka Wahyuni 640502450390000 1 27 P 10/10 G2P1A0 10,000 Bidan Rp10,000
38 Rosminah 631002410290001 0 27 P 10/10 G2P1A0 10,000 Bidan Rp10,000
39 Syamsiah 631009540784001 7 33 P 10/10 G3P2A0 10,000 Bidan Rp10,000
40 Rina Permatasari 631009440497000 8 20 P 10/10 G1P0A0 10,000 Bidan Rp10,000
41 Ahlianoor 630802621189000 1 29 P 10/10 Konsultasi 10,000 Bidan Rp10,000
42 Nia Amelia 631009611194000 4 23 P 10/10 Konsultasi 10,000 Bidan Rp10,000
43 Manisah 631009450575001 9 42 P 10/10 G3P2A0 10,000 Bidan Rp10,000
44 Fitri Maimunah 317202470686000 8 31 P 10/10 G5P3A1 10,000 Bidan Rp10,000
45 Dahliana 631009700485000 3 32 P 11/10 Konsultasi 10,000 Bidan Rp10,000
46 Hidayah 631009570290000 2 27 P 11/10 G2P1A0 10,000 Bidan Rp10,000
47 Novita Sari 631009411191000 5 26 P Perawatan
11/10 Luka Tanpa20,000
Jahitan Bidan Rp20,000
48 Ernawati 631009460493000 3 24 P 13/10 G2P1A0 10,000 Bidan Rp10,000
49 Rabiatul Hidah 631009440790000 3 25 P 13/10 G1P0A0 10,000 Bidan Rp10,000
50 Noor Aida 631009440794000 4 23 P 13/10 G1P0A0 10,000 Bidan Rp10,000
51 Rusidah 631009600891000 3 26 P 14/10 G3P2A0 10,000 Bidan Rp10,000
52 Kalbiah 63100942069000 3 27 P 14/10 G2P1A0 10,000 Bidan Rp10,000
53 Maylina Sri R 631009520598000 6 19 P 14/10 G3P2A0 10,000 Bidan Rp10,000
Umur Jenis Tgl Pelayanan Kesehaan dan Besaran Tarif sesuai PERDA (Rp) TTD
No Nama No KTP Diagnosa
(Th)Kelamin Kunj Poli KIATT Caten/Tindik Rujukan IUD/ PP Konsultasi Bidan Tagihan Psn/ Klg
Bumil Telinga Bidan Implant Test Gizi
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
52 Tatik Sunarmi 631009500678000 8 39 P 16/10 G3P2A0 10,000 Bidan Rp10,000
53 Mulianti 631009410284000 7 33 P 16/10 Konsultasi 10,000 Bidan Rp10,000
54 Pariyatun 317103531177000 2 40 P 17/10 G2P1A0 10,000 Bidan Rp10,000
55 Sriatin 631006410881000 2 36 P 17/10 G4P2A1 10,000 Bidan Rp10,000
56 Hj.Fitriani 631009711287000 1 30 P 17/10 G3P2A0 10,000 Bidan Rp10,000
57 Rahmawati 631009650373000 1 44 P 17/10 G6P4A1 10,000 Bidan Rp10,000
58 Eva Artatnti 631009460882000 7 35 P 17/10 G4P2A1 10,000 Bidan Rp10,000
59 Rini Sumarni 631009410789020 8 28 P 17/10 G2P1A0 10,000 Bidan Rp10,000
60 Marlinda 631009471188000 2 29 P 17/10 Konsultasi 10,000 Bidan Rp10,000
61 Rosminah 631002410290001 0 27 P 18/10 G2P1A0 10,000 Bidan Rp10,000
62 Hidayah 631009550776000 8 41 P 18/10 G5P4A0 10,000 Bidan Rp10,000
63 Dewi Oktavia Bagus 6310001431094000 1 23 P 18/10 G1P0A0 10,000 Bidan Rp10,000
64 Jubaidah 6310094811788000 4 39 P 19/10 `G4P3A0 10,000 Bidan Rp10,000
65 Sri Rahayu De;ima 630206650293000 7 24 P 19/10 G1P0A0 10,000 Bidan Rp10,000
66 Norhayati 631009698388000 4 24 P 19/10 Konsultasi 10,000 Bidan Rp10,000
67 Rusmiati 631009670783000 5 34 P 19/10 G2P1A0 10,000 Bidan Rp10,000
68 Mahdalina 630805650881000 2 36 P 19/10 Konsultasi 10,000 Bidan Rp10,000
69 Bastaniah 631009570881000 5 36 P 19/10 G2P1A0 10,000 Bidan Rp10,000
70 Ayu Maulana S 631006590197000 2 20 P 19/10 G1P0A0 10,000 Bidan Rp10,000
71 Sarmini 631009491081000 4 36 P 20/10 Konsultasi 10,000 Bidan Rp10,000
72 Amalia Fitria D 631001420889000 1 28 P 20/10 G3P2A0 10,000 Bidan Rp10,000
73 Kardianah 631009480877001 1 40 P 20/10 Konsultasi 10,000 Bidan Rp10,000
74 Rizky Amelia 631009440988000 4 29 P 20/10 G2P1A0 10,000 Bidan Rp10,000
75 Yenni Pattya S 631009550693000 3 24 P 20/10 G2P1A0 10,000 Bidan Rp10,000
76 Norlina 631009641094000 3 23 P 20/10 G3P2A0 10,000 Bidan Rp10,000
77 Hairun Nisa 631009470497000 5 21 P 21/10 G1P0A0 10,000 Bidan Rp10,000
78 Hasnah 631009440385001 3 32 P 23/10 Konsultasi 10,000 Bidan Rp10,000
79 Tatik Sunarmi 631009500678000 8 39 P 23/10 G3P2A0 10,000 Bidan Rp10,000
80 Fitriyah 631006460783000 2 34 P 23/10 G3P2A0 10,000 Bidan Rp10,000
81 Evi Novianti 631009590496000 1 27 P 23/10 G1P0A0 10,000 Bidan Rp10,000
Umur Jenis Tgl Pelayanan Kesehaan dan Besaran Tarif sesuai PERDA (Rp) TTD
No Nama No KTP Diagnosa
(Th)Kelamin Kunj Poli KIATT Caten/Tindik Rujukan IUD/ PP Konsultasi Bidan Tagihan Psn/ Klg
Bumil Telinga Bidan Implant Test Gizi
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
82 Arbainah 631009500488000 7 29 P 24/10 G5P4A0 10,000 Bidan Rp10,000
83 Lia Martina 631009450188000 5 29 P 25/10 Konsultasi 10,000 Bidan Rp10,000
84 Karniah 631009680380000 3 31 P 25/10 G4P3A0 10,000 Bidan Rp10,000
85 Sajeriah 631009600587000 4 30 P 26/10 G3P2A0 10,000 Bidan Rp10,000
86 Siti Zubaidah 630602570992000 1 25 P 26/10 Konsultasi 10,000 Bidan Rp10,000
87 Lulu Cahyati 637206410689000 1 28 P 26/10 Konsultasi 10,000 Bidan Rp10,000
88 Muflihah 631009530593000 7 24 P 26/10 G1P0A0 10,000 Bidan Rp10,000
89 Harni Irianti C 637204651284000 4 33 P 26/10 G3P1A1 10,000 Bidan Rp10,000
90 Raudatul Jannah 620304670596000 2 21 P 26/10 G1P0A0 10,000 Bidan Rp10,000
91 Sarpiani 630202550696000 1 21 P 26/10 G1P0A0 10,000 Bidan Rp10,000
92 Bastaniah 631009570881000 5 36 P 27/10 G2P1A0 10,000 Bidan Rp10,000
93 Yosefina Jelita E 631009710184000 2 23 P 27/10 Konsultasi 10,000 Bidan Rp10,000
94 Noor Aida 631009440794000 4 23 P 27/10 G1P0A0 10,000 Bidan Rp10,000
95 Eva Artatnti 631009460882000 7 35 P 27/10 G4P2A1 10,000 Bidan Rp10,000
96 Dayah 630309421096000 1 21 P 27/10 Konsultasi 10,000 Bidan Rp10,000
97 Rahmawati 631009590183000 4 34 P 27/10 G4P3A0 10,000 Bidan Rp10,000
98 Marlina 631009420779001 0 38 P 28/10 Konsultasi 10,000 Bidan Rp10,000
99 Nur Hamidah 631009680288000 5 29 P 28/10 G3P1A1 10,000 Bidan Rp10,000
100 Rina Nordiana 630219440290000 1 27 P 28/10 Konsultasi 10,000 Bidan Rp10,000
101 Dewi Oktavia Bagus 631001431094000 1 23 P 28/10 G1P0A0 10,000 Bidan Rp10,000
102 Ati Sholihatin D 631009571095000 1 23 P 28/10 G1P0A0 10,000 Bidan Rp10,000
103 Nidaul Hasanah 630605550495000 1 22 P 28/10 G1P0A0 10,000 Bidan Rp10,000
104 Tatik Sunarmi 631009500678000 8 39 P 30/10 G4P3A0 10,000 Bidan Rp10,000
105 Kardianah 631009480877001 1 40 P 30/10 G4P3A0 10,000 Bidan Rp10,000
106 Ella Darmiati 631006600492000 1 25 P 30/10 Konsultasi 10,000 Bidan Rp10,000
107 Yuliani 631009540792000 7 25 P 30/10 Konsultasi 10,000 Bidan Rp10,000
108 Munarti 631009580887000 4 30 P 30/10 G3P2A0 10,000 Bidan Rp10,000
109 Murdia 631009431276000 3 41 P 31/10 Konsultasi 10,000 Bidan Rp10,000
110 Misriati 631009701290000 6 27 P 31/10 G3P2A0 10,000 Bidan Rp10,000
111 Jihairiyah 631009460985000 1 32 P 31/10 G5P4A0 10,000 Bidan Rp10,000
Umur Jenis Tgl Pelayanan Kesehaan dan Besaran Tarif sesuai PERDA (Rp) TTD
No Nama No KTP Diagnosa
(Th)Kelamin Kunj Poli KIATT Caten/Tindik Rujukan IUD/ PP Konsultasi Bidan Tagihan Psn/ Klg
Bumil Telinga Bidan Implant Test Gizi
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
112 Aisyah 631009701279000 7 38 P 31/10 G4P3A0 10,000 Bidan Rp10,000
113 Elsa Iriani 631009600993000 3 24 P 31/10 G1P0A0 10,000 Bidan Rp10,000
114 Sarpiani 630202550696000 1 21 P 31/10 G1P0A0 10,000 Bidan Rp10,000
TOTAL
 DAFTAR TAGIHAN KLAIM RAWAT JALAN PASIEN JAMKESDA PUSKESMAS DARUL AZHAR KABUPATEN TANAH BUMBU

Provinsi : Kalimantan Selatan

Kabupaten : Tanah Bumbu
Bulan : Nopember 2017

Umur Jenis Tgl Pelayanan Kesehaan dan Besaran Tarif sesuai PERDA (Rp) TTD
No Nama No KTP Diagnosa
(Th) Kelamin Kunjungan Poli KIATT Caten/Tindik Rujukan IUD/ PP Konsultasi Bidan Tagihan Psn/ Klg
Bumil Telinga Bidan Implant Test Gizi
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
1 Fitri 631009640897000 3 20 P 01/11 G1P0A0 10,000 Bidan Rp10,000
2 Sarpiani 630202550696000 1 21 P 01/11 G1P0A0 10,000 Bidan Rp10,000
3 Elsa Iriani 631009600993000 3 24 P 01/11 G1P0A0 10,000 Bidan Rp10,000
4 Maryati 631009560474000 3 43 P 01/11 Konsultasi 10,000 Bidan Rp10,000
5 Fenny Ariyanti 631009430193001 2 24 P 01/11 G2P1A0 10,000 Bidan Rp10,000
6 Linda Andreani 631009501285000 5 42 P 02/11 G4P3A0 10,000 Bidan Rp10,000
7 Sumiati 631009581289000 6 28 P 02/11 G2P1A0 10,000 Bidan Rp10,000
8 Ariska Wahyuni 631009510295000 7 22 P 03/11 G1P0A0 10,000 Bidan Rp10,000
9 Juriah 637204690791000 1 26 P 03/11 G3P2A0 10,000 Bidan Rp10,000
10 Munarti 631009580887000 4 30 P 04/11 G3P2A0 10,000 Bidan Rp10,000
11 Risnawati 630206470285000 4 32 P 04/11 G3P2A0 10,000 Bidan Rp10,000
12 Rahmawati 631009590183000 4 34 P 04/11 G4P3A0 10,000 Bidan Rp10,000
13 Isnawati 631009550785000 8 32 P 04/11 G3P2A0 10,000 Bidan Rp10,000
14 Manisah 631009450575001 9 42 P 04/11 G3P2A0 10,000 Bidan Rp10,000
15 Mirna 620303510288000 8 29 P 07/11 G2P1A0 10,000 Bidan Rp10,000
16 Normina Salsabila 631009670398000 2 17 P 07/11 G1P0A0 10,000 Bidan Rp10,000
17 Rusmini 631009460582000 6 35 P 07/11 G6P5A0 10,000 Bidan Rp10,000
18 Darminah 631002500584000 3 33 P 07/11 G5P4A0 10,000 Bidan Rp10,000
19 Syamsiah 631009540784001 7 33 P 07/11 G3P2A0 10,000 Bidan Rp10,000
20 Mita Trisnawati 631009700593000 5 18 P 09/11 G1P0A0 10,000 Bidan Rp10,000
21 Rusmawati 631009510593000 1 24 P 09/11 Konsultasi 10,000 Bidan Rp10,000
22 Fatima Saliman 631009460693000 8 24 P 09/11 Konsultasi 10,000 Bidan Rp10,000
Umur Jenis Tgl Pelayanan Kesehaan dan Besaran Tarif sesuai PERDA (Rp) TTD
No Nama No KTP Diagnosa
(Th) Kelamin Kunj Poli KIATT Caten/Tindik Rujukan IUD/ PP Konsultasi Bidan Tagihan Psn/ Klg
Bumil Telinga Bidan Implant Test Gizi
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
23 Rusdiah 631009501092001 3 25 P 09/11 Konsultasi 10,000 Bidan Rp10,000
24 Yatimah 350905420583000 1 34 P 09/11 G3P2A0 10,000 Bidan Rp10,000
25 Nabella Firdiena F 637202551295000 4 22 P 09/11 G1P0A0 10,000 Bidan Rp10,000
26 Muflihah 631009530593000 7 24 P 09/11 G1P0A0 10,000 Bidan Rp10,000
27 Mega Hastuti J 631009410187001 4 30 P 09/11 G3P2A0 10,000 Bidan Rp10,000
28 Tatik Sunarmi 631009500678000 8 39 P 09/11 10,000 Bidan Rp10,000
29 Sri Utami 630219681185000 2 32 P 10/11 Konsultasi 10,000 Bidan Rp10,000
30 Mariyani 631009490879000 4 38 P 10/11 G4P2A1 10,000 Bidan Rp10,000
31 Misriati 631009701290000 6 27 P 11/11 G3P2A0 10,000 Bidan Rp10,000
32 Hidayah 631009570290000 2 27 P 11/11 G2P1A0 10,000 Bidan Rp10,000
33 Noorma Juwita 631009691189000 2 28 P 11/11 G3P1A1 10,000 Bidan Rp10,000
34 Syarifah 631009621084000 3 33 P 11/11 G5P3A1 10,000 Bidan Rp10,000
35 Eva Artanti 631009460882000 7 35 P 13/11 G4P2A1 10,000 Bidan Rp10,000
36 Rahmawati 631009590183000 4 34 P 13/11 G4P3A0 10,000 Bidan Rp10,000
37 Rina Permatasari 631009440497000 8 20 P 13/11 G1P0A0 10,000 Bidan Rp10,000
38 Sarpiani 630202550696000 1 21 P 13/11 G1P0A0 10,000 Bidan Rp10,000
39 Dian Okta Arfiani 631008711098000 3 19 P 13/11 G1P0A0 10,000 Bidan Rp10,000
40 Rabiatul Hidah 631009440790000 3 25 P 14/11 G2P1A0 10,000 Bidan Rp10,000
41 Nikma Sasnita S 731204681196000 1 21 P 14/11 G1P0A0 10,000 Bidan Rp10,000
42 Dahliana 631009700485000 3 32 P 15/11 15,000
Perawatan Luka Tanpa Jahitan Bidan Rp15,000
43 Nia Amelia 631009611194000 4 23 P 16/11 G2P1A0 10,000 Bidan Rp10,000
44 Dewi Oktavia B 631001431094000 1 23 P 16/11 G1P0A0 10,000 Bidan Rp10,000
45 Nurhalimah 631009510287000 4 30 P 18/11 G2P1A0 10,000 Bidan Rp10,000
46 Rahmawati 631009590183000 4 34 P 18/11 G4P3A0 10,000 Bidan Rp10,000
47 Rusmini 631009460582000 6 34 P 18/11 G6P5A0 10,000 Bidan Rp10,000
48 Sri Rahayu D 630206650293000 7 34 P 18/11 G1P0A0 10,000 Bidan Rp10,000
49 Maria Ulfah 631009650983000 2 34 P 18/11 G3P2A0 10,000 Bidan Rp10,000
50 Anita Rahayu 631009501096001 1 21 P 18/11 G1P0A0 10,000 Bidan Rp10,000
51 Leni Anjarwati 631009430899000 3 17 P 18/11 G1P0A0 10,000 Bidan Rp10,000
52 Harni Irianti C 637204651284000 4 33 P 18/11 G3P2A0 10,000 Bidan Rp10,000
Umur Jenis Tgl Pelayanan Kesehaan dan Besaran Tarif sesuai PERDA (Rp) TTD
No Nama No KTP Diagnosa
(Th) Kelamin Kunj Poli KIATT Caten/Tindik Rujukan IUD/ PP Konsultasi Bidan Tagihan Psn/ Klg
Bumil Telinga Bidan Implant Test Gizi
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
53 Sarpiani 630202550696000 1 21 P 18/11 G1P0A0 10,000 Bidan Rp10,000
54 Marlianti 631009481083000 6 34 P 18/11 G1P0A0 10,000 Bidan Rp10,000
55 Mukaramah 631009411292000 2 25 P 18/11 G2P1A0 10,000 Bidan Rp10,000
56 Yuliyanti Saputri 631009420699001 0 18 P 18/11 G1P0A0 10,000 Bidan Rp10,000
57 Marhamah 631009450898001 0 19 P 18/11 G1P0A0 10,000 Bidan Rp10,000
58 Muarrafatul Fikriyah 631002711297000 1 20 P 18/11 G1P0A0 10,000 Bidan Rp10,000
59 Noorma Juwita 631009691189000 2 28 P 20/11 G2P1A0 10,000 Bidan Rp10,000
60 Martini 631009610183000 4 34 P 20/11 G3P2A0 10,000 Bidan Rp10,000
61 Risma Oktavia 631004511093000 4 24 P 20/11 G2P1A0 10,000 Bidan Rp10,000
62 Nurul Mahmudah 631009480280000 6 37 P 20/11 G3P2A0 10,000 Bidan Rp10,000
63 Dewi Oktavia B 631001431094000 1 24 P 20/11 G1P0A0 10,000 Bidan Rp10,000
64 Noor Haida 637202481090000 2 27 P 20/11 Konsultasi 10,000 Bidan Rp10,000
65 Rusdiana 631009510890000 5 27 P 20/11 G2P1A0 10,000 Bidan Rp10,000
66 Nor Bayah 631009600694000 5 23 P 20/11 G2P1A0 10,000 Bidan Rp10,000
67 Jamiatul Rasidah 631006490495000 1 22 P 20/11 Konsultasi 10,000 Bidan Rp10,000
68 Rahmawati 631009650373000 1 44 P G6P4A1 10,000 Bidan Rp10,000
69 Amelia Juhra 631009440788000 3 29 P G3P2A0 10,000 Bidan Rp10,000
70 Susi Herlinawati 631001460279000 1 38 P G3P2A0 10,000 Bidan Rp10,000
71 Eva Artanti 631009460882000 7 35 P G4P2A1 10,000 Bidan Rp10,000
72 Musdalifah 631006500991000 2 26 P G2P1A0 10,000 Bidan Rp10,000
73 Yuliani 631009460778001 4 39 P Konsultasi 10,000 Bidan Rp10,000
74 Elsa Iriani 631009600993000 3 24 P G1P0A0 10,000 Bidan Rp10,000
75 Harmina 631009530685000 6 32 P G2P1A0 10,000 Bidan Rp10,000
76 Amalia Fitria Dewi 631001420889000 1 28 P G3P2A0 10,000 Bidan Rp10,000
77 Marlina 631009420779001 0 34 P Konsultasi 10,000 Bidan Rp10,000
78 Agustina 631009570890000 7 27 P G3P2A0 10,000 Bidan Rp10,000
79 Hadijah 631009511172000 6 45 P Konsultasi 10,000 Bidan Rp10,000
80 Ayu Maulana S 631006590197000 2 20 P G1P0A0 10,000 Bidan Rp10,000
81 Hj.Fitriani 631009711287000 1 30 P G3P2A0 10,000 Bidan Rp10,000
82 Nia Amelia 631009611194000 4 23 P G2P1A0 10,000 Bidan Rp10,000
Umur Jenis Tgl Pelayanan Kesehaan dan Besaran Tarif sesuai PERDA (Rp) TTD
No Nama No KTP Diagnosa
(Th) Kelamin Kunj Poli KIATT Caten/Tindik Rujukan IUD/ PP Konsultasi Bidan Tagihan Psn/ Klg
Bumil Telinga Bidan Implant Test Gizi
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
83 Syaripah Hayyun 631009440886000 5 31 P G3P2A0 10,000 Bidan Rp10,000
84 Diana 631009580882000 8 35 P G5P4A0 10,000 Bidan Rp10,000
85 Mariana Jenatul A 631009670896000 2 21 P G1P0A0 10,000 Bidan Rp10,000
86 Rahmawati 631009590183000 4 31 P G4P3A0 10,000 Bidan Rp10,000
87 Ulfi Wahyuni 631009440383000 6 34 P G3P2A0 10,000 Bidan Rp10,000
88 Sajeriah 631009600587000 4 30 P G3P2A0 10,000 Bidan Rp10,000
89 Dewi Oktavia B 631001431094000 1 23 P G1P0A0 10,000 Bidan Rp10,000
90 Helma Yani 631009410493000 1 24 P G2P1A0 10,000 Bidan Rp10,000
91 Auliana Sari 631009620692000 5 25 P G4P1A2 10,000 Bidan Rp10,000
92 Syamsiah 631009540784001 7 33 P G3P2A0 10,000 Bidan Rp10,000
93 Sinnang 631009511074000 3 43 P Konsultasi 10,000 Bidan Rp10,000
94 Mustika Sari 631009570591000 4 26 P 25/11 Konsultasi 10,000 Bidan Rp10,000
95 Diah Nur Natalia 631009410102000 9 15 P 25/11 Konsultasi 10,000 Bidan Rp10,000
96 Koriyani 631009500286000 7 31 P 27/11 G2P1A0 10,000 Bidan Rp10,000
97 Bastaniah 631009570881000 5 36 P 27/11 G2P1A0 10,000 Bidan Rp10,000
98 Jubaidah 631009481178000 4 39 P 28/11 G4P3A0 10,000 Bidan Rp10,000
99 Noor Aida 631009440794000 4 23 P 28/11 G1P0A0 10,000 Bidan Rp10,000
100 P 10,000 Bidan Rp10,000
101 P 10,000 Bidan Rp10,000
102 P 10,000 Bidan Rp10,000
103 P 10,000 Bidan Rp10,000
104 P 10,000 Bidan Rp10,000
105 P 10,000 Bidan Rp10,000
106 P 10,000 Bidan Rp10,000
107 P 10,000 Bidan Rp10,000
108 P 10,000 Bidan Rp10,000
109 P 10,000 Bidan Rp10,000
110 P 10,000 Bidan Rp10,000
111 P 10,000 Bidan Rp10,000
112 P 10,000 Bidan Rp10,000
 DAFTAR TAGIHAN KLAIM RAWAT JALAN PASIEN JAMKESDA PUSKESMAS DARUL AZHAR KABUPATEN TANAH BUMBU

Provinsi : Kalimantan Selatan

Kabupaten : Tanah Bumbu
Bulan : Desember 2017

Umur Jenis Tgl Pelayanan Kesehaan dan Besaran Tarif sesuai PERDA (Rp) TTD
No Nama No KTP Diagnosa
(Th) Kelamin
Kunjungan Poli KIA TT Caten/ Tindik Rujukan IUD/ PP Konsultasi Bidan Tagihan Psn/ Klg
Bumil Telinga Bidan Implant Test Gizi
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
1 Syamsiah 631009540784001 7 33 P 2/12 G3P2A0 10,000 Bidan Rp10,000
2 Juriah 637204690791000 1 26 P 2/12 G3P2A0 10,000 Bidan Rp10,000
3 Diana 631009670791000 3 26 P 2/12 Konsultasi 10,000 Bidan Rp10,000
4 Rina Permatasari 631009440497000 8 20 P 2/12 G1P0A0 10,000 Bidan Rp10,000
5 Nur Hidayanti 631009420191001 2 26 P 2/12 G1P0A0 10,000 Bidan Rp10,000
6 Marlina 631009420779001 0 38 P 4/12 Konsultasi 10,000 Bidan Rp10,000
7 Marhamah 613009450898001 0 19 P 5/12 G1P0A0 10,000 Bidan Rp10,000
8 Isna Apriliani 631009540491000 6 26 P 5/12 G3P2A0 10,000 Bidan Rp10,000
9 Khusnul Khatimah 631009510493000 2 24 P 5/12 G3P1A1 10,000 Bidan Rp10,000
10 Rahmawati 631009650373000 1 44 P 5/12 G6P4A1 10,000 Bidan Rp10,000
11 Furwanti 631005461191000 1 26 P 6/12 G1P0A0 10,000 Bidan Rp10,000
12 Anindya Nur Adibah 631006110717000 5 5 Bulan P 6/12 Tindik Telinga 20,000 Bidan Rp20,000
13 Ismawati 631009571287000 3 20 P 6/12 G2P1A0 10,000 Bidan Rp10,000
14 Lia Martina 631009450188000 5 29 P 7/12 Konsultasi 10,000 Bidan Rp10,000
15 Fitri Maimunah 317202470686000 8 31 P 7/12 G5P4A0 10,000 Bidan Rp10,000
16 Musdalifah 631006500991000 2 26 P 7/12 G1P0A0 10,000 Bidan Rp10,000
17 Normina Salsabila 631009670398000 2 19 P 7/12 G1P0A0 10,000 Bidan Rp10,000
18 Rini Sumarni 631009410789020 8 28 P 8/12 G2P1A0 10,000 Bidan Rp10,000
19 Leni Mardiyanti 631009701176000 4 41 P 8/12 G4P3A0 10,000 Bidan Rp10,000
20 Misdinawati 631009650592000 3 25 P 8/12 G4P2A1 10,000 Bidan Rp10,000
21 Nur Hidayanti 631009420191001 2 26 P 8/12 G1P0A0 10,000 Bidan Rp10,000
22 Munarti 631009580887000 4 30 P 9/12 G3P2A0 10,000 Bidan Rp10,000
23 Siti Khadijah 631006510599000 2 18 P 9/12 G1P0A0 10,000 Bidan Rp10,000
24 Rahmawati 631009590183000 4 34 P 9/12 G4P3A0 10,000 Bidan Rp10,000
 Umur Jenis Tgl Pelayanan Kesehaan dan Besaran Tarif sesuai PERDA (Rp) TTD
No Nama No KTP Diagnosa
(Th) Kelamin Kunj Poli KIA TT Caten/ Tindik Rujukan IUD/ PP Konsultasi Bidan Tagihan Psn/ Klg
Bumil Telinga Bidan Implant Test Gizi
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
25 Ulfi Wahyuni 631009440383000 6 34 P 9/12 G3P2A0 10,000 Bidan Rp10,000
26 Dewi Oktavia B 631001431094000 1 23 P 9/12 G1P0A0 10,000 Bidan Rp10,000
27 Hidayah 631009570290000 2 27 P 11/12 G2P1A0 10,000 Bidan Rp10,000
28 Nurul Rahmah 631009630875000 1 42 P 13/12 Konsultasi 10,000 Bidan Rp10,000
29 Dahliana 631009700485000 3 32 P 13/12 Konsultasi 10,000 Bidan Rp10,000
30 Musdalifah 631006500991000 2 26 P 14/12 G1P0A0 10,000 Bidan Rp10,000
31 Mahdalina 630805650881000 2 36 P 15/12 Konsultasi 10,000 Bidan Rp10,000
32 Noor Lela 631009691186000 3 31 P 15/12 G2P1A0 10,000 Bidan Rp10,000
33 Ruhana 631009601077000 2 40 P 16/12 Konsultasi 10,000 Bidan Rp10,000
34 Nabella Firdiena F 637202551295000 4 22 P 16/12 G1P0A0 10,000 Bidan Rp10,000
35 Nazma Alifah 631006560817000 1 4 Bulam P 16/12 Tindik Telinga 20,000 Bidan Rp20,000
36 Rabiatul Hidah 631009440790000 3 25 P 16/12 G2P1A0 10,000 Bidan Rp10,000
37 Rahmawati 631009650373000 1 44 P 16/12 G6P4A1 10,000 Bidan Rp10,000
38 Sadariyah 631009581287000 2 40 P 19/12 Konsultasi 10,000 Bidan Rp10,000
39 Siti Sarah 631009561091000 9 26 P 19/12 G2P1A0 10,000 Bidan Rp10,000
40 Nikma Sasnita S 731204681196000 1 21 P 19/12 G1P0A0 10,000 Bidan Rp10,000
41 Ulfi Wahyuni 631009440383000 6 34 P 19/12 G3P2A0 10,000 Bidan Rp10,000
42 Yurni 631009610565000 2 52 P 19/12 Konsultasi 10,000 Bidan Rp10,000
43 Nor Hayati 631009700885000 7 32 P 19/12 Konsultasi 10,000 Bidan Rp10,000
44 Muslimah 631009580490000 2 27 P 19/12 G3P2A0 10,000 Bidan Rp10,000
45 Rahmawati 631009650373000 1 44 P 19/12 G6P4A1 10,000 Bidan Rp10,000
46 Saniah 631009410886000 4 31 P 19/12 G3P2A0 10,000 Bidan Rp10,000
47 Syamsiah 631009540784001 7 33 P 19/12 G3P2A0 10,000 Bidan Rp10,000
48 Sari Muliana 631009681088000 2 29 P 19/12 G3P2A0 10,000 Bidan Rp10,000
49 Aulia Fitriani 631009610393000 5 24 P 20/12 Konsultasi 10,000 Bidan Rp10,000
50 Nor Bayah 631009600694000 5 23 P 20/12 G2P1A0 10,000 Bidan Rp10,000
51 Mita Trisnawati 631009700593000 5 24 P 20/12 G1P0A0 10,000 Bidan Rp10,000
52 Nia Amelia 631009611194000 4 23 P 20/12 G2P1A0 10,000 Bidan Rp10,000
53 Susilawati 631006580274000 1 43 P 20/12 Konsultasi 10,000 Bidan Rp10,000
54 Lia Martina 631009450188000 5 29 P 20/12 Konsultasi 10,000 Bidan Rp10,000
55 Devin Januariska 631006680195000 1 22 P 21/12 G1P0A0 10,000 Bidan Rp10,000
 Umur Jenis Tgl Pelayanan Kesehaan dan Besaran Tarif sesuai PERDA (Rp) TTD
No Nama No KTP Diagnosa
(Th) Kelamin Kunj Poli KIA TT Caten/ Tindik Rujukan IUD/ PP Konsultasi Bidan Tagihan Psn/ Klg
Bumil Telinga Bidan Implant Test Gizi
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
56 Janipah 630301480496000 1 21 P 21/12 G1P0A0 10,000 Bidan Rp10,000
57 Furwanti 631005461191000 1 26 P 21/12 G1P0A0 10,000 Bidan Rp10,000
58 Elsa Iriani 631009600993000 3 24 P 21/12 G1P0A0 10,000 Bidan Rp10,000
59 Nur Intan Permata 631009430108000 6 9 P 21/12 Tindik Telinga 20,000 Bidan Rp20,000
60 Noor Aida 631009440794000 4 23 P 21/12 G1P0A0 10,000 Bidan Rp10,000
61 Siti Aisyah 631009550482000 2 35 P 21/12 G2P1A0 10,000 Bidan Rp10,000
62 Nia Amelia 631009611194000 4 23 P 21/12 G2P1A0 10,000 Bidan Rp10,000
63 Nor Satria 631009500186000 2 31 P 21/12 Perawatan Luka Tanpa Jahitan 15,000 Bidan Rp15,000
64 Yenni Pattya S 631009550693000 3 24 P 22/12 G2P1A0 10,000 Bidan Rp10,000
65 Novi Sylvia N 631009500694000 4 23 P 22/12 G1P0A0 10,000 Bidan Rp10,000
66 Intan Liana 631009510880001 0 30 P 22/12 G3P2A0 10,000 Bidan Rp10,000
67 Noordiyanti 631009600776000 5 42 P 22/12 Konsultasi 10,000 Bidan Rp10,000
68 Hayatun Nisa 631009671292000 4 25 P 22/12 G3P2A0 10,000 Bidan Rp10,000
69 Isna Apriliani 631009540491000 6 26 P 22/12 G3P2A0 10,000 Bidan Rp10,000
70 Siti Khadijah 631006510599000 2 18 P 22/12 G1P0A0 10,000 Bidan Rp10,000
71 Siti Fatimah 161707640888001 4 29 P 22/12 Konsultasi 10,000 Bidan Rp10,000
72 Khairunnisa 631009571092000 2 25 P 22/12 G2P1A0 10,000 Bidan Rp10,000

TOTAL Rp755,000

Simpang Empat, 22 Desember 2017

Mengetahui, Bendahara Jamkesda
Kepala Puskesmas Darul Azhar Puskesmas Darul Azhar

dr.Mardalena Sumarning Samariana, A.Md.Kep

NIP.19791127 200904 2 005 NIP.19790702 200903 2 002