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FORMULIR PENGAJUAN KLAIM TINGKAT PERTAMA

Nomor FPK : P1902000010658

Provider : PADONGKO
Bulan Pelayanan : February 2019

Pelayanan : Promotif

Total Data : 8

Total Tagihan : 80,000

NoKunjungan NAMA TANGGAL TINDAKAN TENAGA MEDIS BIAYA

180605020219P000983 IR.HJ.MUSNIAR SELOMO 15/02/2019 Gula Darah Puasa (GDP) - PRB/Prolanis NOVIA 10,000

180605020219P000984 BATNAH BULU 15/02/2019 Gula Darah Puasa (GDP) - PRB/Prolanis NOVIA 10,000

180605020219P000985 NY.MARDAWIAH 15/02/2019 Gula Darah Puasa (GDP) - PRB/Prolanis NOVIA 10,000

180605020219P000986 ATIRAH SAKKA,HJ. 15/02/2019 Gula Darah Puasa (GDP) - PRB/Prolanis NOVIA 10,000

180605020219P000987 DRS. H.MUH.SOFYAN WAHAB 15/02/2019 Gula Darah Puasa (GDP) - PRB/Prolanis NOVIA 10,000

AMIRUDDIN
180605020219P000988 15/02/2019 Gula Darah Puasa (GDP) - PRB/Prolanis NOVIA 10,000
BENGNGA,S.PD.M.PD.H

180605020219P000994 NORMAH SOHRA 15/02/2019 Gula Darah Puasa (GDP) - PRB/Prolanis NOVIA 10,000

180605020219P000995 SUMIATI 15/02/2019 Gula Darah Puasa (GDP) - PRB/Prolanis NOVIA 10,000

Tanggal terima FPK, Tanggal, 01/03/2019

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