BPJS Kesehatan Cab.

MALANG
FORMULIR PENGAJUAN KLAIM

Nomor FPK : L1903000005559

Provider : RS BEN MARI
Bulan Pelayanan : March, 2019
Pelayanan : Rawat Jalan Tingkat Lanjut

Total Data : 14

Total Tagihan : 2,136,000

NO TRANSAKSI TANGGAL NAMA PESERTA JENIS KLAIM Biaya

0187R015L1903151279 24/03/2019 MAHMUDA Ambulans 156,000
0187R015L1903151280 08/03/2019 M KOSIM Ambulans 150,000
0187R015L1903151281 05/03/2019 ERNI DWI SAFITRI Ambulans 156,000
0187R015L1903151282 22/03/2019 PONI Ambulans 150,000
0187R015L1903151283 21/03/2019 FILA WIDAYANTI Ambulans 156,000
0187R015L1903151284 20/03/2019 BEJO Ambulans 150,000
0187R015L1903151285 12/03/2019 ALI SUTIKMAN Ambulans 150,000
0187R015L1903151286 09/03/2019 HERI SUBAGYO Ambulans 156,000
0187R015L1903151287 15/03/2019 BAYI NYONYA WAGINI Ambulans 150,000
0187R015L1903151288 10/03/2019 MUHAMMAD VARIL AFANDI Ambulans 150,000
0187R015L1903151289 13/03/2019 widyawati Ambulans 150,000
0187R015L1903151290 26/03/2019 TUMINI Ambulans 150,000
0187R015L1903151291 18/03/2019 SUMI Ambulans 156,000
0187R015L1903151292 09/03/2019 SUMARLAN Ambulans 156,000
 Tanggal,
Pengaju Klaim,

20/08/2019 15.20.39