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PURWOKERTO
FORMULIR PENGAJUAN KLAIM TINGKAT PERTAMA

Nomor FPK : P1901000028012

Provider : II Sumpiuh

Bulan Pelayanan : January 2019

Pelayanan : RITP

Total Data : 17

Total Tagihan : 11,400,000

NO KUNJUNGAN NAMA PESERTA TGL MASUK TGL PULANG TINDAKAN TENAGA MEDIS BIAYA

111107020119P000744 REMBUN (0002483441752) 02/01/2019 03/01/2019 Paket Persalinan per Vaginam normal (oleh Bidan) dr.NONI MINTY BELANTRIC 700,000

111107020119P000746 NOVI TALENI (0001695140188) 04/01/2019 04/01/2019 Paket Persalinan per Vaginam normal (oleh Bidan) dr.NONI MINTY BELANTRIC 700,000

111107020119P000750 SULASTRI (0000525501292) 07/01/2019 08/01/2019 Paket Persalinan per Vaginam normal (oleh Bidan) dr.NONI MINTY BELANTRIC 700,000

111107020119P000751 RIYASIH (0001378254971) 09/01/2019 10/01/2019 Paket Persalinan per Vaginam normal (oleh Bidan) dr.NONI MINTY BELANTRIC 700,000

111107020119P000753 NURHASANAH (0000526028692) 11/01/2019 11/01/2019 Paket Persalinan per Vaginam normal (oleh Bidan) dr.NONI MINTY BELANTRIC 700,000

ANGGI BEKTI PUSPITA SARI

111107020119P000754 11/01/2019 12/01/2019 Paket Persalinan per Vaginam normal (oleh Bidan) dr.NONI MINTY BELANTRIC 700,000
(0002477415137)

111107020119P000756 YUNIATI (0000525992398) 13/01/2019 14/01/2019 Paket Persalinan per Vaginam normal (oleh Bidan) dr.NONI MINTY BELANTRIC 700,000

111107020119P000757 nur rohmah (0002476734513) 14/01/2019 15/01/2019 Rawat Inap di R. Perawatan Biasa dr.NONI MINTY BELANTRIC 200,000

111107020119P000758 RINI LATIFAH (0001549272835) 11/01/2019 13/01/2019 Paket Persalinan per Vaginam normal (oleh Bidan) dr.NONI MINTY BELANTRIC 700,000

111107020119P000759 ARI FAJARSETIAWAN (0000526526199) 09/01/2019 10/01/2019 Paket Persalinan per Vaginam normal (oleh Bidan) dr.NONI MINTY BELANTRIC 700,000

111107020119P000760 TRI YULIANTI (0000525306486) 05/01/2019 06/01/2019 Paket Persalinan per Vaginam normal (oleh Bidan) dr.NONI MINTY BELANTRIC 700,000

111107020119P000761 PARSILAH (0000525894658) 05/01/2019 06/01/2019 Paket Persalinan per Vaginam normal (oleh Bidan) dr.NONI MINTY BELANTRIC 700,000

TRI AJENG MERDEKAWATI

111107020119P000762 04/01/2019 05/01/2019 Paket Persalinan per Vaginam normal (oleh Bidan) dr.NONI MINTY BELANTRIC 700,000
(0001373763947)

111107020119P000763 HARTATI (0002006785888) 17/01/2019 18/01/2019 Paket Persalinan per Vaginam normal (oleh Bidan) dr.NONI MINTY BELANTRIC 700,000
111107020119P000764 KOMALAWATI (0000525956883) 23/01/2019 24/01/2019 Paket Persalinan per Vaginam normal (oleh Bidan) dr.NONI MINTY BELANTRIC 700,000

111107020119P000765 MUHIMATUL LAELI (0001851478648) 26/01/2019 26/01/2019 Paket Persalinan per Vaginam normal (oleh Bidan) dr.NONI MINTY BELANTRIC 700,000

111107020119P001148 MURTIANAWATI (0002006850317) 28/01/2019 28/01/2019 Paket Persalinan per Vaginam normal (oleh Bidan) dr.NONI MINTY BELANTRIC 700,000

Tanggal Terima FPK, Tanggal 08/02/2019

Verifikator Pengaju Klaim

Tanggal terima FPK,
Tanggal, 08/02/2019
Verifikator
Pengaju Klaim