Jaspel 2017

Umur Jenis Tanggal Pelayanan Kes dan Besaran Tarif sesuai dengan PERDA (Rp*)) Total
NO NAMA PASIEN Alamat (Thn) Kelamin Kunjungan Diagnosa Poli KIA Biaya
(L/P) Konsultasi Pemeriksaan Rutin Tindakan Imunisasi ( Rp )
Jumlah Pindahan 0
By ny rohmania Bolo 1 bln L 11-1-2018 BCG, P1 2,500 2,500 3,000 8,000
azalia Bolo 11 bln P 11-1-2018 IPV, MR 2,500 2,500 3,000 8,000
zilul Bolo 5 bln L 11-1-2018 D3, P4 2,500 2,500 3,000 8,000
firza Bolo 5 bln P 11-1-2018 D3, P4 2,500 2,500 3,000 8,000
putri Bolo 5 bln P 11-1-2018 D3, P4 2,500 2,500 3,000 8,000
hizbi Bolo 5 bln L 11-1-2018 IPV 2,500 2,500 3,000 8,000
hariz Bolo 5 bln L 11-1-2018 IPV 2,500 2,500 3,000 8,000
andra Bolo 9 bln P 11-1-2018 MR 2,500 2,500 3,000 8,000
syafiah Bolo 19 bln P 11-1-2018 MR 2,500 2,500 3,000 8,000
musa Bolo 2 bln L 11-1-2018 D1, P2 2,500 2,500 3,000 8,000
firzan Bolo 4 bln L 11-1-2018 D2, P3 2,500 2,500 3,000 8,000
ahi Bolo 5 bln L 11-1-2018 IPV 2,500 2,500 3,000 8,000
zaki Bolo 26 bln P 11-1-2018 D4 2,500 2,500 3,000 8,000
azira Bolo 19 bln P 11-1-2018 MR 2,500 2,500 3,000 8,000
By by Iliyatin Bolo 1 bln L 11-1-2018 BCG, P1 2,500 2,500 3,000 8,000
M. Hafiz Bolo 2 bln L 11-1-2018 D1, P2 2,500 2,500 3,000 8,000
ah. Sakha Bolo 2 bln L 11-1-2018 D1, P2 2,500 2,500 3,000 8,000
Evano Bolo 4 bln L 11-1-2018 D2, P3 2,500 2,500 3,000 8,000
musyaf Bolo 4 bln L 11-1-2018 D3, P4 2,500 2,500 3,000 8,000
tiara Bolo 9 bln P 11-1-2018 MR 2,500 2,500 3,000 8,000
Gibran Bolo 18 bln L 11-1-2018 MR 2,500 2,500 3,000 8,000
Al haqi Bolo 18 bln L 11-1-2018 MR 2,500 2,500 3,000 8,000
Handayani K.A 2 bln P 1/12/2018 HBO 2,500 2,500 3,000 8,000
qurotun nada K.A 1 bln P 1/12/2018 BCG, P1 2,500 2,500 3,000 8,000
nur azka K.A 1 bln P 1/12/2018 BCG, P1 2,500 2,500 3,000 8,000
by yati K.A 3 bln P 1/12/2018 Combo 1, Polio 2 2,500 2,500 3,000 8,000
by ana K.A 3 bln P 1/12/2018 Combo 1, Polio 2 2,500 2,500 3,000 8,000
nazilatur K.A 4 bln P 1/12/2018 combo 2, polio 3 2,500 2,500 3,000 8,000
fauzul K.A 0 bln L 1/12/2018 HBO 2,500 2,500 3,000 8,000
denina K.A 0 bln P 1/12/2018 HBO 2,500 2,500 3,000 8,000
auliya K.A 1 bln P 1/12/2018 BCG, P1 2,500 2,500 3,000 8,000
yunita K.A 1 bln P 1/12/2018 BCG, P1 2,500 2,500 3,000 8,000
arif K.A 1 bln L 1/12/2018 BCG, P1 2,500 2,500 3,000 8,000
Jumlah
Jumlah Pindahan #REF! #REF! #REF! #REF! #REF!
Luluk Bolo 27 P 1/2/2018 Kb suntik 3 bln 2,500 2,500 10,000 15,000
Musriati Bolo 45 P 1/2/2018 Kb suntik 3 bln 2,500 2,500 10,000 15,000
Nurul Bolo 36 P 3-1-2018 Kb suntik 3 bln 2,500 2,500 10,000 15,000
Sikiyah Bolo 46 P 3-1-2018 Kb suntik 3 bln 2,500 2,500 10,000 15,000
Zahrotul Bolo 25 P 3-1-2018 Kb suntik 3 bln 2,500 2,500 10,000 15,000
Sumaibah Bolo 40 P 1/4/2018 Kb suntik 3 bln 2,500 2,500 10,000 15,000
Mimbaul Bolo 32 P 08-1-2018 Kb suntik 3 bln 2,500 2,500 10,000 15,000
Ramiyati Bolo 21 P 08-1-2018 Kb suntik 3 bln 2,500 2,500 10,000 15,000
Fitri Bolo 27 P 08-1-2018 Kb suntik 3 bln 2,500 2,500 10,000 15,000
Isnanik Bolo 31 P 08-1-2018 Kb suntik 3 bln 2,500 2,500 10,000 15,000
Ruqoiyah Bolo 38 P 08-1-2018 Kb suntik 3 bln 2,500 2,500 10,000 15,000
Nazikha Bolo 40 P 08-1-2018 Kb suntik 3 bln 2,500 2,500 10,000 15,000
Isnanik Bolo 40 P 09-1-2018 Kb suntik 3 bln 2,500 2,500 10,000 15,000
Machsunah Bolo 31 P 09-1-2018 Kb suntik 3 bln 2,500 2,500 10,000 15,000
Alfi Bolo 32 P 12-1-2018 Kb suntik 3 bln 2,500 2,500 10,000 15,000
siti Khodijah Bolo 36 P 12-1-2018 Kb suntik 3 bln 2,500 2,500 10,000 15,000
titin Bolo 27 P 12-1-2018 Kb suntik 3 bln 2,500 2,500 10,000 15,000
khoiroh Bolo 45 P 12-1-2018 Kb suntik 3 bln 2,500 2,500 10,000 15,000
eli Bolo 31 P 1/13/2018 Kb suntik 3 bln 2,500 2,500 10,000 15,000
dawanah Bolo 43 P 1/14/2018 Kb suntik 3 bln 2,500 2,500 10,000 15,000
watul Bolo 27 P 1/14/2018 Kb suntik 3 bln 2,500 2,500 10,000 15,000
ronayatul Bolo 24 P 16-1-2018 Kb suntik 3 bln 2,500 2,500 10,000 15,000
ma'rifah Bolo 39 P 16-1-2018 Kb suntik 3 bln 2,500 2,500 10,000 15,000
rohmaniningsih Bolo 32 P 16-1-2018 Kb suntik 3 bln 2,500 2,500 10,000 15,000
mustalifah Bolo 39 P 16-1-2018 Kb suntik 3 bln 2,500 2,500 10,000 15,000
mufarikha Bolo 45 P 16-1-2018 Kb suntik 3 bln 2,500 2,500 10,000 15,000
ninik Bolo 30 P 8/17/2018 Kb suntik 3 bln 2,500 2,500 10,000 15,000
mahmudah Bolo 46 P 18-1-2018 Kb suntik 3 bln 2,500 2,500 10,000 15,000
siti muarifah Bolo 39 P 18-1-2018 Kb suntik 3 bln 2,500 2,500 10,000 15,000
husnul Bolo 46 P 18-1-2018 Kb suntik 3 bln 2,500 2,500 10,000 15,000
suamah Bolo 37 P 19-1-2018 Kb suntik 3 bln 2,500 2,500 10,000 15,000
cicik Bolo 47 P 19-1-2018 Kb suntik 3 bln 2,500 2,500 10,000 15,000
nurul Bolo 46 P 1/22/2018 Kb suntik 3 bln 2,500 2,500 10,000 15,000
jumlah
Jumlah Pindahan
Nur halimah Bolo 32 P 22-1-2018 Kb suntik 1 bln 2,500 2,500 10,000 15,000
Fajriyah Bolo 47 P 1/22/2018 Kb suntik 3 bln 2,500 2,500 10,000 15,000
Mansuriyah Bolo 44 P 1/23/2018 Kb suntik 3 bln 2,500 2,500 10,000 15,000
Ma'rifah Bolo 40 P 1/24/2018 Kb suntik 3 bln 2,500 2,500 10,000 15,000
Nafiatin Bolo 40 P 1/25/2018 Kb suntik 3 bln 2,500 2,500 10,000 15,000
Muliyati Bolo 41 P 1/25/2018 Kb suntik 3 bln 2,500 2,500 10,000 15,000
Zumrotul K.A 38 P 1/2/2018 Kb suntik 1 bln 2,500 2,500 10,000 15,000
muarofah K.A 41 P 1/3/2018 Kb suntik 3 bln 2,500 2,500 10,000 15,000
azidah K.A 39 P 1/4/2018 Kb suntik 3 bln 2,500 2,500 10,000 15,000
nuzula K.A 33 P 1/4/2018 Kb suntik 3 bln 2,500 2,500 10,000 15,000
Kunaidah K.A 40 P 1/5/2018 Kb suntik 3 bln 2,500 2,500 10,000 15,000
syafaatun K.A 38 P 1/6/2018 Kb suntik 3 bln 2,500 2,500 10,000 15,000
khilma K.A 43 P 1/6/2018 Kb suntik 3 bln 2,500 2,500 10,000 15,000
supening K.A 44 P 1/7/2018 Kb suntik 3 bln 2,500 2,500 10,000 15,000
aminah K.A 39 P 1/11/2018 Kb suntik 1 bln 2,500 2,500 10,000 15,000
shaliha K.A 45 P 1/15/2018 Kb suntik 3 bln 2,500 2,500 10,000 15,000
soman K.A 43 P 1/20/2018 Kb suntik 3 bln 2,500 2,500 10,000 15,000
armona K.A 40 P 1/20/2018 Kb suntik 3 bln 2,500 2,500 10,000 15,000
ririn K.A 37 P 1/21/2018 Kb suntik 3 bln 2,500 2,500 10,000 15,000
siti yatima K.A 40 P 1/21/2018 Kb suntik 3 bln 2,500 2,500 10,000 15,000
ayus K.A 29 P 1/22/2018 Kb suntik 3 bln 2,500 2,500 10,000 15,000
sualik K.A 37 P 1/22/2018 Kb suntik 3 bln 2,500 2,500 10,000 15,000
nailis K.A 33 P 1/23/2018 Kb suntik 3 bln 2,500 2,500 10,000 15,000
khilma K.A 22 P 1/23/2018 Kb suntik 3 bln 2,500 2,500 10,000 15,000
khotimah K.A 40 P 1/23/2018 Kb suntik 3 bln 2,500 2,500 10,000 15,000
fauziah K.A 29 P 1/24/2018 Kb suntik 3 bln 2,500 2,500 10,000 15,000
mardiyah K.A 37 P 1/25/2018 Kb suntik 3 bln 2,500 2,500 10,000 15,000
dyah K.A 33 P 1/25/2018 Kb suntik 3 bln 2,500 2,500 10,000 15,000
sania K.A 22 P 1/25/2018 Kb suntik 3 bln 2,500 2,500 10,000 15,000
warti K.A 40 P 1/25/2018 Kb suntik 3 bln 2,500 2,500 10,000 15,000
saudah K.A 27 P 1/25/2018 Kb suntik 3 bln 2,500 2,500 10,000 15,000
narti K.A 26 P 1/25/2018 Kb suntik 3 bln 2,500 2,500 10,000 15,000
ida K.A 27 P 1/25/2018 Kb suntik 3 bln 2,500 2,500 10,000 15,000
Jumlah
DAFTAR TAGIHAN KLAIM RAWAT JALAN PASIEN UMUM DALAM
TAHUN 2017
PROPINSI : Jawa Timur

KAB / KOTA : Gresik
Kepada Yth
Kepala Dinas Kesehatan Kab/Kota Gresik
Di. Tempat
Bersama ini Kami ajukan tagihan klaim Pelayanan Kesehatan Rawat Jalan Pasien Umum
Umur Jenis Tanggal

NO NAMA PASIEN Alamat (Thn) Kelamin Kunjungan
(L/P)
1 Juna Bolo 2 bln L 10-02-2018
2 zilul Bolo 6 bln L 10-02-2018
3 fiza Bolo 6 bln P 10-02-2018
4 putri Bolo 6 bln P 10-02-2018
5 syaka Bolo 10 bln L 10-02-2018
6 adit Bolo 12 bln L 10-02-2018
7 najwa Bolo 2 bln P 10-02-2018
8 musa Bolo 3 bln L 10-02-2018
9 firzan Bolo 5 bln L 10-02-2018
10 alfat Bolo 10 bln L 10-02-2018
11 azira Bolo 21 bln P 10-02-2018
12 dafa Bolo 17 bln L 10-02-2018
13 arista Bolo 2 bln P 10-02-2018
14 hafiz Bolo 3 bln L 10-02-2018
15 sakha Bolo 3 bln L 10-02-2018
16 evano Bolo 5 bln L 10-02-2018
17 musyaf Bolo 5 bln L 10-02-2018
18 zildan Bolo 4 bln L 10-02-2018
19 haidar Bolo 11 bln L 10-02-2018
20 haqi Bolo 19 bln L 10-02-2018
21 gibran Bolo 19 bln L 10-02-2018
22 niken Bolo 19 bln P 10-02-2018
jumlah
Umur Jenis Tanggal

(L/P)
Jumlah Pindahan
23 Balqis K.A 0 bln P 2/13/2018
24 by qoridatul K.A 0 bln P 2/13/2018
25 handayani K.A 2 bln P 2/13/2018
26 qurotun nada K.A 2 bln P 2/13/2018
27 nur azka K.A 2 bln P 2/13/2018
28 by yati K.A 3 bln P 2/13/2018
29 by ana K.A 1 bln P 2/13/2018
30 nazilatur K.A 0 bln P 2/13/2018
31 fauzil K.A 10 bln L 2/13/2018
32 Erisa K.A 8 bln P 2/13/2018
33 denina K.A 8 bln P 2/13/2018
34 zayyan K.A 7 bln L 2/13/2018
35 syarifudin K.A 8 bln L 2/13/2018
36 berliana K.A 7 bln P 2/13/2018
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
Jumlah
Umur Jenis Tanggal

(L/P)
Jumlah Pindahan
122 Mahfudimah Bolo 45 P 2/1/2018
123 marfuatun Bolo 39 P 2/1/2018
124 muzayanah Bolo 47 P 2/1/2018
125 mubariroh Bolo 47 P 2/1/2018
126 atiatul Bolo 35 P 2/1/2018
127 eka nur Bolo 25 P 2/3/2018
128 munafiah Bolo 40 P 2/3/2018
129 yuyun Bolo 35 P 2/4/2018
130 ridha Bolo 42 P 2/6/2018
131 asmamik Bolo 37 P 2/7/2018
132 nur afiyah Bolo 43 P 2/7/2018
133 nur hanik Bolo 36 P 2/8/2018
134 ervina Bolo 40 P 2/8/2018
135 fina Bolo 27 P 2/9/2018
136 suciati Bolo 40 P 2/9/2018
137 asmaul Bolo 25 P 2/10/2018
138 diah afnani Bolo 24 P 2/11/2018
139 zuni syafitri Bolo 22 P 2/12/2018
140 masuliyatul Bolo 26 P 2/12/2018
141 siti fatimah Bolo 34 P 2/17/2018
142 rohmatul Bolo 34 P 2/17/2018
143 lina Bolo 45 P 2/18/2018
144 qoidah Bolo 41 P 2/18/2018
145 atiyatul Bolo 37 P 2/20/2018
146 munafiah Bolo 45 P 2/20/2018
147 nikmatul Bolo 48 P 2/20/2018
148 riatun Bolo 45 P 2/21/2018
149 nur faizah Bolo 38 P 2/22/2018
150 sulasning Bolo 31 P 2/22/2018
151 hamdanah Bolo 30 P 2/24/2018
152 isasun Bolo 36 P 2/25/2018
153 lilis Bolo 40 P 2/25/2018
154 lilik Bolo 41 P 2/25/2018
Jumlah
Umur Jenis Tanggal

(L/P)
Jumlah Pindahan
155 Ainiyah K.A 28 P 2/1/2018
156 kaniah K.A 25 P 2/2/2018
157 wiwik K.A 27 P 2/3/2018
158 titik K.A 39 P 2/4/2018
159 fitria K.A 21 P 2/5/2018
160 khamidah K.A 22 P 2/6/2018
161 khoridah K.A 40 P 2/7/2018
162 Nuriyatin K.A 30 P 2/8/2018
163 ismi K.A 37 P 2/9/2018
164 muamalah K.A 39 P 2/9/2018
165 kusmiati K.A 30 P 2/10/2018
166 muntamah K.A 40 P 2/11/2018
167 marmi K.A 43 P 2/11/2018
168 siti rofiah K.A 37 P 2/12/2018
169 ismikarti K.A 40 P 2/12/2018
170 andri K.A 23 P 2/20/2018
171 zulaika K.A 30 P 2/20/2018
172 alivia K.A 23 P 2/21/2018
173 purwati K.A 30 P 2/21/2018
174 erni K.A 31 P 2/21/2018
175 yani K.A 29 P 2/22/2018
176 ismi K.A 32 P 2/22/2018
177 aminah K.A 34 P 2/23/2018
178 saadah K.A 32 P 2/23/2018
179 sari K.A 43 P 2/24/2018
180 ari K.A 31 P 2/24/2018
181 qonita K.A 27 P 2/24/2018
182 salsa K.A 28 P 2/24/2018
183 anik K.A 32 P 2/25/2018
184 anisa K.A 38 P 2/25/2018
185 nanik K.A 33 P 2/25/2018
186 anisa K.A 37 P 2/25/2018
187 amel K.A 80 P 2/25/2018
Jumlah
RAWAT JALAN PASIEN UMUM DALAM DAN LUAR GEDUNG
TAHUN 2017
PUSKESMAS : Sekapuk
BULAN :Feb
Pelayanan Kes dan Besaran Tarif sesuai dengan PERDA (Rp*)) Total
Diagnosa Poli KIA Biaya
Konsultasi Pemeriksaan Rutin Tindakan Imunisasi ( Rp )
combo 1, polio 2 2,500 2,500 3,000 8,000
IPV 2,500 2,500 3,000 8,000
IPV 2,500 2,500 3,000 8,000
IPV 2,500 2,500 3,000 8,000
MR 1 2,500 2,500 3,000 8,000
MR 2 2,500 2,500 3,000 8,000
combo 1, polio 2 2,500 2,500 3,000 8,000
combo 2, polio 3 2,500 2,500 3,000 8,000
combo 3, polio 4 2,500 2,500 3,000 8,000
MR 1 2,500 2,500 3,000 8,000
MR 2 2,500 2,500 3,000 8,000
combo 1, polio 2 2,500 2,500 3,000 8,000
combo 2, polio 3 2,500 2,500 3,000 8,000
combo 3, polio 4 2,500 2,500 3,000 8,000
IPV 2,500 2,500 3,000 8,000
MR 2,500 2,500 3,000 8,000
MR 2,500 2,500 3,000 8,000
MR 2 2,500 2,500 3,000 8,000
MR 2,500 2,500 3,000 8,000
MR 2 2,500 2,500 3,000 8,000
MR 2 2,500 2,500 3,000 8,000
MR 2 2,500 2,500 3,000 8,000
55,000 55,000 0 66,000 176,000
55,000 55,000 0 66,000 176,000
HBO 2,500 2,500 3,000 8,000
HBO 2,500 2,500 3,000 8,000
DPT lanjutan 2,500 2,500 3,000 8,000
BCG, polio 1 2,500 2,500 3,000 8,000
combo 1, polio 2 2,500 2,500 3,000 8,000
combo 2, polio 3 2,500 2,500 3,000 8,000
BCG, polio 1 2,500 2,500 3,000 8,000
HBO 2,500 2,500 3,000 8,000
IPV 2,500 2,500 3,000 8,000
IPV 2,500 2,500 3,000 8,000
IPV 2,500 2,500 3,000 8,000
IPV 2,500 2,500 3,000 8,000
IPV 2,500 2,500 3,000 8,000
IPV 2,500 2,500 3,000 8,000
BCG 2,500 2,500 3,000 8,000
IPV 2,500 2,500 3,000 8,000
IPV 2,500 2,500 3,000 8,000
combo 3, polio 4 2,500 2,500 3,000 8,000
polio 4 2,500 2,500 3,000 8,000
IPV 2,500 2,500 3,000 8,000
Bcg, polio 1 2,500 2,500 3,000 8,000
combo 1, polio 2 2,500 2,500 3,000 8,000
combo 1, polio 2 2,500 2,500 3,000 8,000
combo 3, polio 4 2,500 2,500 3,000 8,000
Campak 2,500 2,500 3,000 8,000
combo 3, polio 4 2,500 2,500 3,000 8,000
combo 1, polio 2 2,500 2,500 3,000 8,000
combo 3, polio 4 2,500 2,500 3,000 8,000
polio 3 2,500 2,500 3,000 8,000
Bcg, polio 1 2,500 2,500 3,000 8,000
Campak 2,500 2,500 3,000 8,000
Campak 2,500 2,500 3,000 8,000
combo 3, polio 4 2,500 2,500 3,000 8,000
137,500 137,500 0 165,000 440,000
302,500 302,500 #REF! 363,000 968,000
Kb suntik 1 bln 2,500 2,500 10,000 15,000
Kb suntik 3 bln 2,500 2,500 10,000 15,000
Kb suntik 3 bln 2,500 2,500 10,000 15,000
Kb suntik 3 bln 2,500 2,500 10,000 15,000
Kb suntik 3 bln 2,500 2,500 10,000 15,000
Kb suntik 3 bln 2,500 2,500 10,000 15,000
Kb suntik 1 bln 2,500 2,500 10,000 15,000
Kb suntik 3 bln 2,500 2,500 10,000 15,000
Kb suntik 3 bln 2,500 2,500 10,000 15,000
Kb suntik 3 bln 2,500 2,500 10,000 15,000
Kb suntik 3 bln 2,500 2,500 10,000 15,000
Kb suntik 3 bln 2,500 2,500 10,000 15,000
Kb suntik 3 bln 2,500 2,500 10,000 15,000
Kb suntik 3 bln 2,500 2,500 10,000 15,000
Kb suntik 1 bln 2,500 2,500 10,000 15,000
Kb suntik 3 bln 2,500 2,500 10,000 15,000
Kb suntik 3 bln 2,500 2,500 10,000 15,000
Kb suntik 3 bln 2,500 2,500 10,000 15,000
Kb suntik 3 bln 2,500 2,500 10,000 15,000
Kb suntik 3 bln 2,500 2,500 10,000 15,000
Kb suntik 3 bln 2,500 2,500 10,000 15,000
Kb suntik 3 bln 2,500 2,500 10,000 15,000
Kb suntik 3 bln 2,500 2,500 10,000 15,000
Kb suntik 3 bln 2,500 2,500 10,000 15,000
Kb suntik 3 bln 2,500 2,500 10,000 15,000
Kb suntik 3 bln 2,500 2,500 10,000 15,000
Kb suntik 3 bln 2,500 2,500 10,000 15,000
Kb suntik 3 bln 2,500 2,500 10,000 15,000
Kb suntik 3 bln 2,500 2,500 10,000 15,000
Kb suntik 3 bln 2,500 2,500 10,000 15,000
Kb suntik 3 bln 2,500 2,500 10,000 15,000
Kb suntik 3 bln 2,500 2,500 10,000 15,000
Kb suntik 3 bln 2,500 2,500 10,000 15,000
385,000 385,000 #REF! 363,000 1,463,000
385,000 385,000 330,000 0 1,100,000
Kb suntik 3 bln 2,500 2,500 10,000 15,000
Kb suntik 3 bln 2,500 2,500 10,000 15,000
Kb suntik 3 bln 2,500 2,500 10,000 15,000
Kb suntik 3 bln 2,500 2,500 10,000 15,000
Kb suntik 3 bln 2,500 2,500 10,000 15,000
Kb suntik 3 bln 2,500 2,500 10,000 15,000
Kb suntik 3 bln 2,500 2,500 10,000 15,000
Kb suntik 3 bln 2,500 2,500 10,000 15,000
Kb suntik 3 bln 2,500 2,500 10,000 15,000
Kb suntik 3 bln 2,500 2,500 10,000 15,000
Kb suntik 3 bln 2,500 2,500 10,000 15,000
Kb suntik 3 bln 2,500 2,500 10,000 15,000
Kb suntik 3 bln 2,500 2,500 10,000 15,000
Kb suntik 3 bln 2,500 2,500 10,000 15,000
Kb suntik 3 bln 2,500 2,500 10,000 15,000
Kb suntik 3 bln 2,500 2,500 10,000 15,000
Kb suntik 3 bln 2,500 2,500 10,000 15,000
Kb suntik 3 bln 2,500 2,500 10,000 15,000
Kb suntik 3 bln 2,500 2,500 10,000 15,000
Kb suntik 3 bln 2,500 2,500 10,000 15,000
Kb suntik 3 bln 2,500 2,500 10,000 15,000
Kb suntik 3 bln 2,500 2,500 10,000 15,000
Kb suntik 3 bln 2,500 2,500 10,000 15,000
Kb suntik 3 bln 2,500 2,500 10,000 15,000
Kb suntik 3 bln 2,500 2,500 10,000 15,000
Kb suntik 3 bln 2,500 2,500 10,000 15,000
Kb suntik 3 bln 2,500 2,500 10,000 15,000
Kb suntik 3 bln 2,500 2,500 10,000 15,000
Kb suntik 3 bln 2,500 2,500 10,000 15,000
Kb suntik 3 bln 2,500 2,500 10,000 15,000
Kb suntik 3 bln 2,500 2,500 10,000 15,000
Kb suntik 3 bln 2,500 2,500 10,000 15,000
Kb suntik 3 bln 2,500 2,500 10,000 15,000
467,500 467,500 660,000 0 1,595,000
DAFTAR TAGIHAN KLAIM RAWAT JALAN PASIEN UMUM DALAM DA
TAHUN 2017

KAB / KOTA : Gresik
Kepada Yth
Di. Tempat
Umur Jenis Tanggal

NO NAMA PASIEN Alamat (Thn) Kelamin Kunjungan Diagnosa
(L/P)
1 By ny maria Bolo 1 bln p 12/04/2018 BCG, P1
2 izad Bolo 3 bln L 12/04/2018 D2, P3
3 juna Bolo 4 bln L 12/04/2018 D3, P4
4 almas Bolo 9 bln L 12/04/2018 MR
5 rasya Bolo 9 bln L 12/04/2018 MR
6 faza Bolo 2 bln P 12/04/2018 D1, P2
7 khoyumah Bolo 2 bln P 12/04/2018 D1, P2
8 nazwa Bolo 3 bln P 12/04/2018 D2, P3
9 musa Bolo 4 bln L 12/04/2018 D3, P4
10 gilang Bolo 10 bln L 12/04/2018 MR
11 faza Bolo 12 bln L 12/04/2018 MR
12 febriansah Bolo 4 bln L 12/04/2018 MR
13 azad Bolo 5 bln L 12/04/2018 IPV
14 ah.syaka Bolo 5 bln L 12/04/2018 IPV
15 m.hafizah Bolo 5 bln L 12/04/2018 IPV
16 arista Bolo 4 bln P 12/04/2018 D3, P4
17 Bilqis K.A 5 bln P 12/04/2018 D2, P3
18 alfira K.A 18 bln P 12/04/2018 MR
19 qeronada K.A 4 bln P 12/04/2018 D3, P4
20 almaidatul K.A 18 bln P 12/04/2018 MR
21 putri K.A 2 bln L 12/04/2018 BCG, P1
22 gibran K.A 2 bln L 12/04/2018 BCG, P1
jumlah
Umur Jenis Tanggal

(L/P)
Jumlah Pindahan
Luluk Bolo 27 P 4/2/2018 Kb suntik 3 bln
Musriati Bolo 45 P 4/2/2018 Kb suntik 3 bln
Nurul Bolo 36 P 4/3/2018 Kb suntik 3 bln
Sikiyah Bolo 46 P 4/3/2018 Kb suntik 3 bln
Zahrotul Bolo 25 P 4/3/2018 Kb suntik 3 bln
Sumaibah Bolo 40 P 4/4/2018 Kb suntik 3 bln
Mimbaul Bolo 32 P 4/8/2018 Kb suntik 3 bln
Ramiyati Bolo 21 P 4/8/2018 Kb suntik 3 bln
Fitri Bolo 27 P 4/8/2018 Kb suntik 3 bln
Isnanik Bolo 31 P 4/8/2018 Kb suntik 3 bln
Ruqoiyah Bolo 38 P 4/8/2018 Kb suntik 3 bln
Nazikha Bolo 40 P 4/8/2018 Kb suntik 3 bln
Isnanik Bolo 40 P 4/9/2018 Kb suntik 3 bln
Machsunah Bolo 31 P 4/9/2018 Kb suntik 3 bln
Alfi Bolo 32 P 4/12/2018 Kb suntik 3 bln
siti Khodijah Bolo 36 P 4/12/2018 Kb suntik 3 bln
titin Bolo 27 P 4/12/2018 Kb suntik 3 bln
khoiroh Bolo 45 P 4/12/2018 Kb suntik 3 bln
eli Bolo 31 P 1/13/2018 Kb suntik 3 bln
dawanah Bolo 43 P 1/14/2018 Kb suntik 3 bln
watul Bolo 27 P 1/14/2018 Kb suntik 3 bln
ronayatul Bolo 24 P 4/16/2018 Kb suntik 3 bln
ma'rifah Bolo 39 P 4/16/2018 Kb suntik 3 bln
rohmaniningsih Bolo 32 P 4/16/2018 Kb suntik 3 bln
mustalifah Bolo 39 P 4/16/2018 Kb suntik 3 bln
mufarikha Bolo 45 P 4/16/2018 Kb suntik 3 bln
ninik Bolo 30 P 4/17/2018 Kb suntik 3 bln
mahmudah Bolo 46 P 4/18/2018 Kb suntik 3 bln
siti muarifah Bolo 39 P 4/18/2018 Kb suntik 3 bln
husnul Bolo 46 P 4/18/2018 Kb suntik 3 bln
suamah Bolo 37 P 4/19/2018 Kb suntik 3 bln
cicik Bolo 47 P 4/19/2018 Kb suntik 3 bln
nurul Bolo 46 P 4/22/2018 Kb suntik 3 bln
Jumlah
Umur Jenis Tanggal

(L/P)
Jumlah Pindahan
Nur halimah Bolo 32 P 4/22/2018 Kb suntik 1 bln
Fajriyah Bolo 47 P 4/22/2018 Kb suntik 3 bln
Mansuriyah Bolo 44 P 4/23/2018 Kb suntik 3 bln
Ma'rifah Bolo 40 P 4/24/2018 Kb suntik 3 bln
Nafiatin Bolo 40 P 4/25/2018 Kb suntik 3 bln
Muliyati Bolo 41 P 4/25/2018 Kb suntik 3 bln
Zumrotul K.A 38 P 4/2/2018 Kb suntik 1 bln
muarofah K.A 41 P 4/3/2018 Kb suntik 3 bln
azidah K.A 39 P 4/4/2018 Kb suntik 3 bln
nuzula K.A 33 P 4/4/2018 Kb suntik 3 bln
Kunaidah K.A 40 P 4/5/2018 Kb suntik 3 bln
syafaatun K.A 38 P 4/6/2018 Kb suntik 3 bln
khilma K.A 43 P 4/6/2018 Kb suntik 3 bln
supening K.A 44 P 4/7/2018 Kb suntik 3 bln
aminah K.A 39 P 4/11/2018 Kb suntik 1 bln
shaliha K.A 45 P 4/15/2018 Kb suntik 3 bln
soman K.A 43 P 4/20/2018 Kb suntik 3 bln
armona K.A 40 P 4/20/2018 Kb suntik 3 bln
ririn K.A 37 P 4/21/2018 Kb suntik 3 bln
siti yatima K.A 40 P 4/21/2018 Kb suntik 3 bln
ayus K.A 29 P 4/22/2018 Kb suntik 3 bln
sualik K.A 37 P 4/22/2018 Kb suntik 3 bln
nailis K.A 33 P 4/23/2018 Kb suntik 3 bln
khilma K.A 22 P 4/23/2018 Kb suntik 3 bln
khotimah K.A 40 P 4/23/2018 Kb suntik 3 bln
fauziah K.A 29 P 4/24/2018 Kb suntik 3 bln
mardiyah K.A 37 P 4/25/2018 Kb suntik 3 bln
dyah K.A 33 P 4/25/2018 Kb suntik 3 bln
sania K.A 22 P 4/25/2018 Kb suntik 3 bln
warti K.A 40 P 4/25/2018 Kb suntik 3 bln
saudah K.A 27 P 4/25/2018 Kb suntik 3 bln
narti K.A 26 P 4/25/2018 Kb suntik 3 bln
ida K.A 27 P 4/25/2018 Kb suntik 3 bln
Jumlah
Umur Jenis Tanggal

(L/P)
Jumlah Pindahan
almas bolo 9 bln L 4/10/2018 DS
syaka bolo 12 bln L 4/10/2018 DS
kirana bolo 30 bln P 4/10/2018 DS
rafa bolo 30 bln L 4/10/2018 DS
aqif bolo 30 bln L 4/10/2018 DS
naura bolo 36 bln P 4/10/2018 DS
akbar bolo 42 bln L 4/10/2018 DS
dafita bolo 48 bln P 4/10/2018 DS
sabrina bolo 60 bln P 4/10/2018 DS
alfad bolo 12 bln L 4/10/2018 DS
faza bolo 3 bln L 4/10/2018 DS
roqi bolo 24 bln L 4/10/2018 DS
ayunda bolo 24 bln P 4/10/2018 DS
akilah bolo 30 bln P 4/10/2018 DS
zaki bolo 30 bln L 4/10/2018 DS
yuda bolo 40 bln L 4/10/2018 DS
arda bolo 60 bln P 4/10/2018 DS
gilang bolo 54 bln L 4/10/2018 DS
salwa bolo P P 4/10/2018 DS
azad bolo 9 bln L 4/10/2018 DS
tiara bolo 12 bln P 4/10/2018 DS
alfaris bolo 24 bln L 4/10/2018 DS
riki bolo 24 bln L 4/10/2018 DS
haidir bolo 24 bln L 4/10/2018 DS
haidzar bolo 24 bln L 4/10/2018 DS
alfa bolo 24 bln L 4/10/2018 DS
ain bolo 30 bln P 4/10/2018 DS
fahri bolo 30 bln L 4/10/2018 DS
embun bolo 42 bln P 4/10/2018 DS
kiran bolo 48 bln P 4/10/2018 DS
mutiara bolo 54 bln P 4/10/2018 DS
dafa bolo 54 bln L 4/10/2018 DS
rara bolo 60 bln P 4/10/2018 DS
Jumlah
Umur Jenis Tanggal

(L/P)
Jumlah Pindahan
56 fiza bolo 60 bln L 4/10/2018 DS
57 felin bolo 72 bln P 4/10/2018 DS
58 DS
59 DS
60 DS
61 DS
62 DS
63 DS
64 DS
65 DS
66 DS
67 DS
68 DS
69 DS
70 DS
71 DS
72 DS
73 DS
74 DS
75 DS
76 DS
77 DS
78 DS
79 DS
80 DS
81 DS
82 DS
83 DS
84 DS
85 DS
86 DS
87 DS
88 DS
Jumlah
Umur Jenis Tanggal

NO Nama Alamat (Thn) Kelamin Kunjungan Diagnosa
(L/P)
89 Mazidatul Bolo 17 thn P 4/10/2018 GIIIP20002 UK 39

90 syifrotul Bolo 24 thn P 4/20/2018 GIIP00010 UK 35
91 eti nur Bolo 33 thn P 4/10/2018 GIIPI000I UK 32
92 zulia indah Bolo 20 thn P 4/5/2018 GIIPI000I UK 33
93 zuliatin Bolo 36 thn P 4/10/2018 GIIPI000I UK 28
94 agustina Bolo 25 thn P 4/12/2018 GIIPI000I UK 28
95 suzidta Bolo 19 thn P 4/10/2018 GIP00000 UK 24
96 zuhrotun Bolo 19 thn P 4/18/2018 GIIP00010 UK 36
97 fahimatul Bolo 30 thn P 4/22/2018 GIIIP20002 UK 16
98 ifana Bolo 33 thn P 4/19/2018 GIIPI000I UK 16
99 yatul umamik Bolo 34 thn P 4/17/2018 GIIPI000I UK 12
100 khumaidah Bolo 37 thn P 4/21/2018 GIVPI0021 UK 12
101 fululul Bolo 27 thn P 4/10/2018 GIIPI000I UK 8
102 rafino Bolo 19 thn P 4/24/2018 GIP00000 UK 14
103 umul masita Bolo 24 thn P 4/21/2018 GIIPI000I UK 8
104 ainun Bolo 26 thn P 4/16/2018 GIP00000 UK 8
105 heti kusuma Bolo 36 thn P 4/18/2018 G3P20002 UK 16
106 siti mafrucha Bolo 33 thn P 4/19/2018 G2PI000I UK 12
107 iva nila Bolo 44 thn P 4/21/2018 G4P30003 UK 28
108 taiqotul Bolo 22 thn P 4/5/2018 GIP00000UK 8
109 widiawati Bolo 34 thn P 4/2/2018 G2PI000I UK 8
110 khoridatul Bolo 24 thn P 4/7/2018 G2PI000I UK 6
111 lizaroti Bolo 34 thn P 4/17/2018 G2PI000I UK 6
112 Arina K.A 25 thn P 4/1/2018 GIP00000 UK
113 gita prety K.A 25 thn P 4/3/2018 GIP00000
114 fitri K.A 21 thn P 4/5/2018 GIP00000
115 rofiah K.A 22 thn P 4/7/2018 GIIPI000I
116 uswatun K.A 36 thn P 4/10/2018 GIIPI000I
117 fahliyah K.A 24 thn P 4/13/2018 GIP00000
118 isnanimah K.A 32 thn P 4/15/2018 G3P20002
119 widatul K.A 33 thn P 4/16/2018 G2PI000I
120 qurotul K.A 25 thn P 4/17/2018 G2PI000I
121 wiwin K.A 27 thn P 4/20/2018 G2PI000I
Jumlah
Umur Jenis Tanggal

(L/P)
Jumlah Pindahan
Iis kurniawati Gosari 25 P 4/14/2018 Kb suntik 1 bln
nia karunia Gosari 45 P 4/14/2018 Kb suntik 3 bln
rohmawati Gosari 39 P 4/15/2018 Kb suntik 3 bln
harti Gosari 48 P 4/15/2018 Kb suntik 3 bln
siti kholifah Gosari 48 P 4/15/2018 Kb suntik 3 bln
mukasanah Gosari 38 P 4/15/2018 Kb suntik 3 bln
sukesih Gosari 24 P 4/16/2018 Kb suntik 1 bln
saudah Gosari 40 P 4/18/2018 Kb suntik 3 bln
asroka Gosari 43 P 4/18/2018 Kb suntik 3 bln
adimah Gosari 33 P 4/20/2018 Kb suntik 3 bln
siti muayah Gosari 42 P 4/20/2018 Kb suntik 3 bln
muarifah Gosari 20 P 4/20/2018 Kb suntik 3 bln
reni saidah Gosari 29 P 4/20/2018 Kb suntik 3 bln
zulifah Gosari 35 P 4/21/2018 Kb suntik 3 bln
muafatun Gosari 38 P 4/21/2018 Kb suntik 1 bln
ngattemi Gosari 40 P 4/23/2018 Kb suntik 3 bln
asifatun Gosari 32 P 4/25/2018 Kb suntik 3 bln
miftahul Gosari 21 P 4/28/2018 Kb suntik 3 bln
rohmawati Gosari 37 P 4/29/2018 Kb suntik 3 bln
sumarmi Gosari 45 P 4/29/2018 Kb suntik 3 bln
P Kb suntik 3 bln
P Kb suntik 3 bln
P Kb suntik 3 bln
P Kb suntik 3 bln
P Kb suntik 3 bln
P Kb suntik 3 bln
P Kb suntik 3 bln
P Kb suntik 3 bln
P Kb suntik 3 bln
P Kb suntik 3 bln
P Kb suntik 3 bln
P Kb suntik 3 bln
P Kb suntik 3 bln
Jumlah
Umur Jenis Tanggal

(L/P)
Jumlah Pindahan
sundari Gosari 34 P 4/15/2018 G5P40004
urifah Gosari 32 P 4/10/2018 G3P20002
nur niani Gosari 32 P 4/18/2018 G2PI000I
muntik Gosari 33 P 4/24/2018 G2PI000I
sandra Gosari 32 P 4/24/2018 G2PI000I
evi ludiana Gosari 28 P 4/25/2018 G4P30003
zuliatun Gosari 30 P 4/26/2018 G2PI000I
nur baiti Gosari 32 P 4/15/2018 G2PI000I
latifah Gosari 33 P 4/22/2018 G2PI000I
dina Gosari 26 P 4/22/2018 G2PI000I
nur aini Sekapuk 36 P 4/15/2018 G3P20002
eka sari Sekapuk 29 P 4/12/2018 G3P10011
asmaul husna Sekapuk 26 P 5/2/2018 G3P10011
nikmatul alifah Sekapuk 35 P 5/14/2018 G2PI000I
nur hayati Sekapuk 30 P 4/12/2018 G3P20002
fitri nur Sekapuk 42 P 4/2/2018 G1P00000
yuyun nur Sekapuk 26 P 4/3/2018 G3P20002
mukaromah Sekapuk 26 P 4/3/2018 G3P20002
nikmatul fauzah Sekapuk 37 P 4/12/2018 G2P10001
ratih Sekapuk 25 P 4/2/2018 G2P10001
yati aprilia Sekapuk 32 P 4/5/2018 G1P00000
emi susilowati Sekapuk 19 P 4/5/2018 G2P10001
sri rahayu Sekapuk 34 P 4/9/2018 G2P10001
siti aminah Sekapuk 29 P 4/4/2018 G2P10001
luluk herlina Sekapuk 34 P 4/18/2018 G3P20002
katarina Sekapuk 34 P 4/4/2018 G2P10001
yuni wahyu Sekapuk 18 P 4/8/2018 G1P00000
my ulfa Sekapuk 36 P 4/8/2018 G5P40004
nita iswati Sekapuk 34 P 4/8/2018 G2P10001
ainuriah Sekapuk 40 P 4/10/2018 G3P20002
ita purwati Sekapuk 17 P 4/10/2018 G3P20002
nanik supriati Sekapuk 31 P 4/10/2018 G2P10001
anggelina Sekapuk 20 P 4/4/2018 G1P00000
Jumlah
Umur Jenis Tanggal
(L/P)
Jumlah Pindahan
188 Nur eni Sekapuk 25 P 4/5/2018 G1P00000
189 Suci nur aini Sekapuk 26 P 4/5/2018 G2P10001
190 arifatul makrifah Sekapuk 24 P 4/10/2018 G2P10001
191 rully nisrokah Sekapuk 29 P 4/15/2018 G2P10001
192 wiwin finarni Sekapuk 30 P 4/16/2018 G2P10001
193 mukholifah Sekapuk 32 P 4/11/2018 G2P10001
194 yayuk sugiarti Sekapuk 17 P 4/17/2018 G1P00000
195 vera ida bagus Sekapuk 28 P 5/2/2018 G2P10001
196 emitriana Sekapuk 39 P 4/16/2018 G3P20002
197 tutik linda Sekapuk 35 P 4/20/2018 G2P10001
198 nurul aulia Sekapuk 22 P 4/11/2018 G1P00000
199 wardatul fitriah Sekapuk 28 P 4/21/2018 G1P00000
200 mery ptisca Sekapuk 30 P 4/4/2018 G2P10001
201 nur laila Sekapuk 28 P 4/7/2018 G1P00000
202 sintia novita Sekapuk 22 P 4/8/2018 G1P00000
203 hima suryani Sekapuk 33 P 4/20/2018 G2P10001
204
205
206
207
208
209
210
211
212
213
214
215
216
217
218
219
220
Jumlah
Umur Jenis Tanggal

(L/P)
Jumlah Pindahan
221 M. Saiful Sekapuk 3 bln L 4/9/2018 combo 1, polio 2
222 almira qista Sekapuk 3 bln P 4/9/2018 combo 1, polio 2
223 bunga karisa Sekapuk 5 bln L 4/9/2018 combo 3, polio 4
224 destra Sekapuk 5 bln L 4/9/2018 combo 3, polio 4
225 desinta Sekapuk 5 bln L 4/9/2018 combo 3, polio 4
226 grasella Sekapuk 9 bln L 4/9/2018 campak
227 zahrotul Sekapuk 0 bln P 4/9/2018 hbo
228 alfin Sekapuk 9 bln L 4/9/2018 campak
229 galang Sekapuk 3 bln L 4/11/2018 combo 1, polio 2
230 rayinda Sekapuk 3 bln L 4/11/2018 combo 1, polio 2
231 fauziyah Sekapuk 2 bln P 4/11/2018 combo 1, polio 2
232 domes Sekapuk 4 bln L 4/11/2018 combo 2, polio 3
233 arin najwa Sekapuk 4 bln P 4/11/2018 combo 2, polio 3
234 ravendra Sekapuk 3 bln L 4/11/2018 combo 2, polio 3
235 layedah Sekapuk 7 bln P 4/11/2018 IPV
236 syafea Sekapuk 6 bln P 4/11/2018 IPV
237 raflesia Sekapuk 7 bln P 4/11/2018 IPV
238 hanun Sekapuk 10 bln L 4/11/2018 IPV
239 alfatih Sekapuk 2 bln L 4/8/2018 combo 1, polio 2
240 alya Sekapuk 6 bln P 4/8/2018 Bcg, polio 1
241 fawas Sekapuk 5 bln L 4/8/2018 Bcg, polio 1
242 almeira Sekapuk 6 bln P 4/8/2018 Bcg, polio 1
243 arsya Sekapuk 1 bln L 4/13/2018 Bcg, polio 1
244 vannesa Sekapuk 1 bln P 4/12/2015 Bcg, polio 1
245 faris Sekapuk 1 bln L 4/12/2015 Bcg, polio 1
246 medina Sekapuk 4 bln P 4/12/2015 combo 2, polio 3
247 assyfak Sekapuk 3 bln L 4/12/2015 combo 2, polio 3
248 hanisa Sekapuk 4 bln P 4/12/2015 combo 3, polio 4
249 iqbal Sekapuk 5 bln L 4/12/2015 combo 3, polio 4
250 mareta Sekapuk 5 bln P 4/12/2015 combo 3, polio 4
251 qonita Sekapuk 5 bln P 4/12/2015 combo 3, polio 4
252 arsyfa Sekapuk 10 bln L 4/12/2015 campak
253 asmira Sekapuk 10 bln P 4/12/2015 campak
Jumlah
SIEN UMUM DALAM DAN LUAR GEDUNG
2017
PUSKESMAS : Sekapuk
BULAN : APRIL
Poli KIA Biaya
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
55,000 55,000 0 66,000 176,000
Poli KIA Biaya
302,500 302,500 #REF! #REF! 605,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
385,000 385,000 #REF! #REF! 1,100,000
Poli KIA Biaya
385,000 385,000 330,000 0 1,100,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
467,500 467,500 660,000 0 1,595,000
Poli KIA Biaya
2,500 2,500 10,000 0 15,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
85,000 85,000 10,000 0 180,000
Poli KIA Biaya
85,000 85,000 10,000 0 180,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
167,500 167,500 10,000 0 345,000
Poli KIA Biaya
220,000 220,000 0 0 440,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
302,500 302,500 0 0 605,000
Poli KIA Biaya
302,500 302,500 0 0 605,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
385,000 385,000 330,000 0 1,100,000
Poli KIA Biaya
385,000 385,000 330,000 0 1,100,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
467,500 467,500 0 1,265,000
Poli KIA Biaya
467,500 467,500 660,000 0 1,265,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
2,500 2,500 5,000
550,000 550,000 0 1,430,000
Poli KIA Biaya
550,000 550,000 990,000 0 2,090,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
632,500 632,500 990,000 99,000 2,354,000
DAFTAR TAGIHAN KLAIM RAWAT JALAN PASIEN UMUM DALAM DA
TAHUN 2017

KAB / KOTA : Gresik
Kepada Yth
Di. Tempat
Umur Jenis Tanggal

(L/P)
1 Izad Bolo 3 bln L 3/10/2018 D2, P3
2 juna Bolo 2 bln L 3/10/2018 D1, P2
3 syaka Bolo 10 bln L 3/10/2018 MR
4 najwa Bolo 1 bln P 3/10/2018 BCG, P1
5 firzan Bolo 3 bln L 3/10/2018 D2, P3
6 shilla Bolo 6 bln P 3/10/2018 IPV
7 azmil Bolo 9 bln L 3/10/2018 MR
8 hafizah Bolo 1 bln P 3/10/2018 BCG, P1
9 sakha Bolo 4 bln L 3/10/2018 D3, P4
10 evano Bolo 4 bln L 3/10/2018 D3,P4
11 by ny khoyumah Bolo 1 bln L 3/10/2018 BCG, P1
12 By ida rifan K.A 0 bln P 3/13/2018 HBO
13 by anik K.A 0 bln P 3/13/2018 HBO
14 bilqis K.A 1 bln P 3/13/2018 BCG, P1
15 by choridul K.A 1 bln L 3/13/2018 BCG, P1
16 qurotun nada K.A 3 bln P 3/13/2018 combo 2, polio 3
17 nur azka K.A 3 bln P 3/13/2018 combo 2, polio 3
18 by yati K.A 5 bln P 3/13/2018 combo 3, polio 4
19 by ayu K.A 5 bln P 3/13/2018 combo 3, polio 4
20 evisa K.A 1 bln P 3/13/2018 BCG, P1
21 miftahul K.A 7 bln L 3/13/2018 IPV
22 iffad K.A 7 bln L 3/13/2018 IPV
jumlah
Umur Jenis Tanggal

(L/P)
Jumlah Pindahan
122 Asrokah Bolo 45 P 3/1/2018 Kb suntik 1 bln
123 endang Bolo 45 P 3/1/2018 Kb suntik 3 bln
124 erniyati Bolo 36 P 3/1/2018 Kb suntik 3 bln
125 syafaatul Bolo 36 P 3/5/2018 Kb suntik 3 bln
126 leni Bolo 34 P 3/5/2018 Kb suntik 3 bln
127 isnawati Bolo 38 P 3/5/2018 Kb suntik 3 bln
128 nurul Bolo 45 P 3/5/2018 Kb suntik 1 bln
129 maslukha Bolo 36 P 3/5/2018 Kb suntik 3 bln
130 zakiyatul Bolo 28 P 3/6/2018 Kb suntik 3 bln
131 muarifah Bolo 40 P 3/6/2018 Kb suntik 3 bln
132 rohmatul Bolo 45 P 3/6/2018 Kb suntik 3 bln
133 shobaha Bolo 40 P 3/10/2018 Kb suntik 3 bln
134 astiroh Bolo 45 P 3/10/2018 Kb suntik 3 bln
135 likha Bolo 40 P 3/10/2018 Kb suntik 3 bln
136 farida Bolo 30 P 3/10/2018 Kb suntik 1 bln
137 khoirul Bolo 38 P 3/14/2018 Kb suntik 3 bln
138 lianah Bolo 45 P 3/14/2018 Kb suntik 3 bln
139 nur hamimah Bolo 48 P 3/14/2018 Kb suntik 3 bln
140 zianah Bolo 40 P 3/14/2018 Kb suntik 3 bln
141 rifatul Bolo 28 P 3/18/2018 Kb suntik 3 bln
142 wiwin Bolo 25 P 3/19/2018 Kb suntik 3 bln
143 sumadilah K.A 40 P 3/1/2018 Kb suntik 3 bln
144 emi K.A 30 P 3/2/2018 Kb suntik 3 bln
145 ulfah K.A 40 P 3/2/2018 Kb suntik 3 bln
146 nuzulah K.A 36 P 3/7/2018 Kb suntik 3 bln
147 muafilah K.A 40 P 3/10/2018 Kb suntik 3 bln
148 purwani K.A 37 P 3/11/2018 Kb suntik 3 bln
149 ainun K.A 30 P 3/14/2018 Kb suntik 3 bln
150 musaah K.A 37 P 3/14/2018 Kb suntik 3 bln
151 hamami K.A 42 P 3/15/2018 Kb suntik 3 bln
152 siti asiyah K.A 44 P 3/16/2018 Kb suntik 3 bln
153 kunaidah K.A 40 P 3/16/2018 Kb suntik 3 bln
154 afifah K.A 31 P 3/16/2018 Kb suntik 3 bln
Jumlah
Umur Jenis Tanggal

(L/P)
Jumlah Pindahan
155 nurotul K.A 40 P 3/16/2018 Kb suntik 3 bln
156 suharti K.A 30 P 3/16/2018 Kb suntik 3 bln
157 mujiati K.A 40 P 3/17/2018 Kb suntik 3 bln
158 sumikatin K.A 36 P 3/17/2018 Kb suntik 3 bln
159 siti mukromah K.A 40 P 3/19/2018 Kb suntik 3 bln
160 arifah K.A 37 P 3/19/2018 Kb suntik 3 bln
161 romangsah K.A 37 P 3/20/2018 Kb suntik 3 bln
162 wafiroh K.A 42 P 3/20/2018 Kb suntik 3 bln
163 tutik K.A 44 P 3/21/2018 Kb suntik 3 bln
164 lailiyah K.A 31 P 3/21/2018 Kb suntik 3 bln
165 baity K.A 29 P 3/22/2018 Kb suntik 3 bln
166 qomsatun K.A 40 P 3/22/2018 Kb suntik 3 bln
167 mastini K.A 24 P 3/23/2018 Kb suntik 3 bln
168 khofiyah K.A 31 P 3/24/2018 Kb suntik 3 bln
169 masriyani K.A 24 P 3/25/2018 Kb suntik 3 bln
170 P Kb suntik 3 bln
Jumlah
SIEN UMUM DALAM DAN LUAR GEDUNG
2017
PUSKESMAS : Sekapuk
BULAN : Maret
Poli KIA Biaya
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
2,500 2,500 3,000 8,000
55,000 55,000 0 66,000 176,000
Poli KIA Biaya
302,500 302,500 #REF! #REF! 605,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
385,000 385,000 #REF! #REF! 1,100,000
Poli KIA Biaya
385,000 385,000 330,000 0 1,100,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
2,500 2,500 10,000 15,000
467,500 467,500 660,000 0 1,595,000

Jaspel 2017

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89 Mazidatul Bolo 17 thn P 4/10/2018 GIIIP20002 UK 39

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