Lampiran : 1 ( satu ) berkas

Perihal : Mohon Transfer

Yth, Pimpinan Bank Mandiri

Cabang Cut Mutia

di -
Bandar Lampung
Dengan ini kami mohon bantuannya untuk mendebit sesuai bilyet No.
Utama Bandar Lampung No. 123.00.0636942.7 sebesar Rp.51.492.000,- (lima puluh
rupiah) dan selanjutnya mengkredit rekening Provider BPJS Kesehatan sebagai berik
Realisasi Biaya
NO Nama Rekening BULAN PELAYANAN Senam
1 2 5

1 dr. Elvira Irianty Jan 300,000

2 Sugiyanto Jan 1,050,000
3 Puskesmas Gadingrejo Jan 980,000
4 Ria Sari Jan 635,000
5 Klinik Sabila Jan 235,000
6 Yayasan Ikatede Jan 585,000
7 Puskesmas Way Halim Jan 2,100,000
8 Puskesmas Rawat Inap Kemiling Jan 2,100,000
9 Dewi Sintawat Jan 150,000
10 Ibu Karlina Sari Jan 506,000
11 Retka Wahyuni Jan 844,000
12 Puskesmas Hanura-Jamkesda Jan 1,400,000
13 BLUD UPTD Puskesmas Kedaloman Jan 350,000
14 BLUD UPTD Puskesmas Rantau Tijang Jan 1,930,000
15 UPT Puskesmas Adiluwih Jan 570,000
16 Klinik Rawat Inap Sae Waras Jan 865,000
17 PT Perkebunan Nusantara VII Jan 1,000,000
18 Ervan Budiawan Jan 1,000,000
19 Dasa Susilawat Jan 700,000
20 Rosdiana Sitanggang Dr JAN 800,000
21 Eni Suhest JAN 230,000
22 Puskesmas Rawat Inap Sukamaju JAN 1,270,000
23 Hernowo Anggoro Warsono H JAN 120,000
24 BP Dira Medika Cq. dr. Sri Rahayu YulianJAN 575,000
25 Hilda Putri JAN 695,000
26 Aila Karyus JAN 750,000
27 Klinik Surya Medika JAN 1,050,000
28 PT Raffasya Sentra Medika JAN 286,000
29 Puskesmas Pringsewu JAN 505,000
30 Puskesmas Ambarawa JAN 100,000
31 Dr. Rahmat Sukoco JAN 152,000
32 Minda Nora JAN 1,000,000
33 Balai Pengobatan Bhakt Kasih JAN 125,000
34 Karang Anyar JAN 455,000
35 Hajimena JAN 250,000
36 Dr. Inten Kumalasari JAN 1,050,000
37 dr Harmaina JAN 200,000
38 Puskesmas Rawat Inap Kedaton JAN 3,900,000
39 Puskesmas Rawat Inap Panjang JAN 1,750,000
40 Puskesmas Satelit JAN 1,650,000
41 Suwanto JAN 950,000
42 Puskesmas Kalirejo JAN 150,000
43 Chinta Ariestassia JAN 239,000

TOTAL 35,552,000

Demikian atas bantuan dan kerjasamanya diucapkan terimakasih.

Bandar Lampung,
Kabid Penagihan &

Edmon
Asisten Man
 Bandar Lampung, 05 April 2019

bilyet No. dari rekening DJS BPJS Kesehatan Cabang

.51.492.000,- (lima puluh satu juta empat ratus sembilan puluh dua ribu
S Kesehatan sebagai berikut :
Realisasi Biaya Pajak Edukasi Biaya Setelah Biaya Diterima
Biaya Diajukan
Edukasi (6%) Pajak FKTP
6 7=(6*50%)*6% 8=5+6-7 9

400,000 700,000 700,000 Rp 700,000

400,000 1,450,000 - 1,450,000 Rp 1,450,000
400,000 1,380,000 1,380,000 Rp 1,380,000
400,000 1,035,000 1,035,000 Rp 1,035,000
400,000 635,000 635,000 Rp 635,000
400,000 985,000 985,000 Rp 985,000
400,000 2,500,000 2,500,000 Rp 2,500,000
400,000 2,500,000 2,500,000 Rp 2,500,000
400,000 550,000 12,000 538,000 Rp 538,000
400,000 906,000 12,000 894,000 Rp 894,000
400,000 1,244,000 1,244,000 Rp 1,244,000
400,000 1,800,000 1,800,000 Rp 1,800,000
400,000 750,000 750,000 Rp 750,000
400,000 2,330,000 2,330,000 Rp 2,330,000
400,000 970,000 970,000 Rp 970,000
400,000 1,265,000 1,265,000 Rp 1,265,000
400,000 1,400,000 1,400,000 Rp 1,400,000
400,000 1,400,000 1,400,000 Rp 1,400,000
- 700,000 700,000 Rp 700,000
400,000 1,200,000 12,000 1,188,000 Rp 1,188,000
400,000 630,000 630,000 Rp 630,000
400,000 1,670,000 1,670,000 Rp 1,670,000
400,000 520,000 520,000 Rp 520,000
400,000 975,000 975,000 Rp 975,000
 - 695,000 695,000 Rp 695,000
400,000 1,150,000 1,150,000 Rp 1,150,000
400,000 1,450,000 1,450,000 Rp 1,450,000
400,000 686,000 686,000 Rp 686,000
400,000 905,000 905,000 Rp 905,000
400,000 500,000 500,000 Rp 500,000
- 152,000 152,000 Rp 152,000
400,000 1,400,000 1,400,000 Rp 1,400,000
400,000 525,000 525,000 Rp 525,000
400,000 855,000 855,000 Rp 855,000
400,000 650,000 650,000 Rp 650,000
400,000 1,450,000 12,000 1,438,000 Rp 1,438,000
400,000 600,000 600,000 Rp 600,000
400,000 4,300,000 4,300,000 Rp 4,300,000
400,000 2,150,000 2,150,000 Rp 2,150,000
400,000 2,050,000 2,050,000 Rp 2,050,000
400,000 1,350,000 1,350,000 Rp 1,350,000
400,000 550,000 550,000 Rp 550,000
400,000 639,000 12,000 627,000 Rp 627,000

16,000,000 51,552,000 60,000 51,492,000 51,492,000

rimakasih.

Bandar Lampung, 05 April 2019

Kabid Penagihan & Keuangan

Edmon
Asisten Manager
2,310,034,057.
2,310,034,057
2,309,064,512
969,545
No. Nama Rekening
Branti Raya
RI Tanjung Bintang
RI. Bakauheni
RI. Tanjung Sari Natar
dr. Elvira Irianty / BP Dara Petak
Dua Putri Jaya (Klinik Dua Putri Jaya)
Darmawan / Klinik Choiriah
Puskesmas Sukarame
Puskesmas Rawat Inap Kota Karang
Puskesmas Rawat Inap Panjang

Dasa Susilawati
Rosdiana Sitanggang Dr
 No. Rekening Bank Keterangan
1140012285543 Mandiri KCP Kalianda PKM Branti Raya
1140012284827 Mandiri KCP Kalianda PKM Tanjung Bintang
1140012285386 Mandiri KCP Kalianda PKM Bakauheni
1140012286962 Mandiri KCP Kalianda PKM Tanjung Sari Natar
1140002024175 Mandiri Klinik Dara Petak
1140010635137 Mandiri Klinik Dua Putri Jaya
1140011011486 Mandiri Klinik Choiriah
1140010016718 Mandiri PKM RI Sukarame
1140010027129 Mandiri PKM RI Kota Karang
1140010035940 Mandiri PKM RI Panjang
-
1140010993502 Mandiri Klinik Wede Arrachaman
2940372090 BCA KCP Antasari dr. Rosdiana Sitanggang
 IVA / NAMA PUSKESMAS/KLINIK
NO. NAMA FKTP/BIDAN GDP GDPP BUPEL BUPEL
PAPSMEAR

1 2 6 6 7
PKM Branti Raya 600,000 Jan-19 PKM Branti Raya
PKM Tanjung Bintang 850,000 Des18 PKM Tanjung Bintang
PKM Bakauheni 1,475,000 Jan PKM Bakauheni
PKM Tanjung Sari Natar 1,400,000 Des18 PKM Tanjung Sari Natar
Klinik Dara Petak 210,000 Jan Klinik Dara Petak
Klinik Dua Putri Jaya 100,000 Okt18 Klinik Dua Putri Jaya
Klinik Choiriah 302,500 Nov18, Jan19 Klinik Choiriah
PKM RI Sukarame 150,000 Des PKM RI Sukarame
PKM RI Kota Karang 175,000 Jan PKM RI Kota Karang
PKM RI Panjang 500,000 Des PKM RI Panjang
612,500 2,225,000
Klinik Wede Arrachaman 25,000 Jan Klinik Wede Arrachaman
dr. Rosdiana Sitanggang 25,000 Jan dr. Rosdiana Sitanggang
KET. NPWP