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BPJS Kesehatan Cab.

KUDUS
FORMULIR PENGAJUAN KLAIM TINGKAT PERTAMA

Nomor FPK : P2003000020551

Provider : Rejosari
Bulan Pelayanan : March 2020

Pelayanan : RJTP

Total Data : 76

Total Tagihan : Rp. 4.450.000

NoKunjungan NAMA TANGGAL TINDAKAN HASIL TENAGA MEDIS BIAYA

015909320320P000045 KUSMIATI 02/03/2020 Pelayanan ANC 3 (Tiga) dr. KRISTIANA PRASETYOWATI Rp. 50.000

015909320320P000077 INDAH SUPRIYANA 02/03/2020 Pelayanan ANC 1 (Satu) dr. KRISTIANA PRASETYOWATI Rp. 50.000

015909320320P000110 SULASTRI 03/03/2020 Evakuasi medis / Ambulans Darat 0.00 dr. KRISTIANA PRASETYOWATI Rp. 90.000

015909320320P000111 KURYANI 03/03/2020 Evakuasi medis / Ambulans Darat 0.00 dr. KRISTIANA PRASETYOWATI Rp. 90.000

015909320320P000134 KUSWANTO 04/03/2020 Evakuasi medis / Ambulans Darat 0.00 dr. ACHMAT LUTHFI YAKIM Rp. 90.000

015909320320P000275 JASMI 07/03/2020 Evakuasi medis / Ambulans Darat 0.00 dr. ACHMAT LUTHFI YAKIM Rp. 90.000

015909320320P000304 SITI ZULAEKAH 08/03/2020 Evakuasi medis / Ambulans Darat 0.00 dr. KRISTIANA PRASETYOWATI Rp. 90.000

015909320320P000305 HUSNUL CHOTIMAH 09/03/2020 Evakuasi medis / Ambulans Darat 0.00 dr. KRISTIANA PRASETYOWATI Rp. 90.000

015909320320P000351 DEWI SUSANTI 09/03/2020 Pelayanan ANC 3 (Tiga) dr. ACHMAT LUTHFI YAKIM Rp. 50.000

015909320320P000390 SUSILOWATI 09/03/2020 Evakuasi medis / Ambulans Darat 0.00 Isna Noor Khilda Rp. 60.000

015909320320P000392 JASMIN 09/03/2020 Evakuasi medis / Ambulans Darat 0.00 dr. KRISTIANA PRASETYOWATI Rp. 60.000

015909320320P000394 SUMARTO KASBU 10/03/2020 Evakuasi medis / Ambulans Darat 0.00 Isna Noor Khilda Rp. 90.000

015909320320P000433 SILVIA RAHMAWATI 10/03/2020 Evakuasi medis / Ambulans Darat 0.00 Isna Noor Khilda Rp. 90.000

015909320320P000435 SYAROFAH 10/03/2020 Evakuasi medis / Ambulans Darat 0.00 dr. KRISTIANA PRASETYOWATI Rp. 90.000

015909320320P000437 BAGUS ANDRYAN 10/03/2020 Evakuasi medis / Ambulans Darat 0.00 Isna Noor Khilda Rp. 90.000

015909320320P000569 NOOR HIDAYAH 05/03/2020 Pelayanan PNC 1 (Satu) dr. ACHMAT LUTHFI YAKIM Rp. 25.000
NoKunjungan NAMA TANGGAL TINDAKAN HASIL TENAGA MEDIS BIAYA

015909320320P000571 TETI KURNIA 05/03/2020 Pelayanan PNC 1 (Satu) Isna Noor Khilda Rp. 25.000

015909320320P000572 TETI KURNIA 08/03/2020 Pelayanan PNC 2 (Dua) Isna Noor Khilda Rp. 25.000

015909320320P000573 HARTINAH 11/03/2020 Pelayanan PNC 1 (Satu) dr. KRISTIANA PRASETYOWATI Rp. 25.000

015909320320P000574 PRILLI YATININGSIH 08/03/2020 Pelayanan PNC 1 (Satu) Isna Noor Khilda Rp. 25.000

015909320320P000575 PRILLI YATININGSIH 11/03/2020 Pelayanan PNC 2 (Dua) dr. ACHMAT LUTHFI YAKIM Rp. 25.000

015909320320P000663 ULFA DIANI 12/03/2020 Evakuasi medis / Ambulans Darat 0.00 dr. KRISTIANA PRASETYOWATI Rp. 90.000

015909320320P000669 ERINA ARI SUSANA 13/03/2020 Evakuasi medis / Ambulans Darat 0.00 dr. KRISTIANA PRASETYOWATI Rp. 90.000

015909320320P000670 SUNTARI 13/03/2020 Evakuasi medis / Ambulans Darat 0.00 dr. KRISTIANA PRASETYOWATI Rp. 90.000

015909320320P000711 SUSIANA 14/03/2020 Pelayanan ANC 3 (Tiga) Isna Noor Khilda Rp. 50.000

015909320320P000712 DWI SUFIANA 14/03/2020 Pelayanan ANC 2 (Dua) dr. ACHMAT LUTHFI YAKIM Rp. 50.000

015909320320P000713 SUSI KUMALASARI 14/03/2020 Pelayanan ANC 2 (Dua) dr. ACHMAT LUTHFI YAKIM Rp. 50.000

015909320320P000714 NOVIYANTI SAFITRI 14/03/2020 Pelayanan ANC 2 (Dua) dr. ACHMAT LUTHFI YAKIM Rp. 50.000

015909320320P000715 SITI MUNDHIROH 14/03/2020 Pelayanan ANC 3 (Tiga) dr. ACHMAT LUTHFI YAKIM Rp. 50.000

015909320320P000716 NUR AISAH 14/03/2020 Pelayanan ANC 3 (Tiga) Isna Noor Khilda Rp. 50.000

015909320320P000812 ANA RAFIKA 17/03/2020 Pelayanan ANC 2 (Dua) dr. KRISTIANA PRASETYOWATI Rp. 50.000

015909320320P000915 SUMARDI 17/03/2020 Evakuasi medis / Ambulans Darat 0.00 dr. ACHMAT LUTHFI YAKIM Rp. 90.000

015909320320P000916 ISMATUL HUSNA 17/03/2020 Pelayanan ANC 3 (Tiga) dr. ACHMAT LUTHFI YAKIM Rp. 50.000

015909320320P000917 NOOR ASIYAH 17/03/2020 Pelayanan ANC 2 (Dua) dr. ACHMAT LUTHFI YAKIM Rp. 50.000

015909320320P000918 CHAFIDHATUN NIKMAH 17/03/2020 Pelayanan ANC 3 (Tiga) dr. ACHMAT LUTHFI YAKIM Rp. 50.000

015909320320P000925 MUHAMMAD AGUD F R 17/03/2020 Evakuasi medis / Ambulans Darat 0.00 Isna Noor Khilda Rp. 90.000

015909320320P000927 SUYATMI 17/03/2020 Evakuasi medis / Ambulans Darat 0.00 dr. ACHMAT LUTHFI YAKIM Rp. 90.000

015909320320P001003 ANIK WAHYUTI 18/03/2020 Evakuasi medis / Ambulans Darat 0.00 Isna Noor Khilda Rp. 90.000

015909320320P001044 RUKI 19/03/2020 Evakuasi medis / Ambulans Darat 0.00 dr. ACHMAT LUTHFI YAKIM Rp. 90.000

015909320320P001146 SUPARMI 20/03/2020 Evakuasi medis / Ambulans Darat 0.00 dr. ACHMAT LUTHFI YAKIM Rp. 90.000

015909320320P001147 EKO PRAYITNO 20/03/2020 Evakuasi medis / Ambulans Darat 0.00 dr. ACHMAT LUTHFI YAKIM Rp. 90.000

015909320320P001238 EMI ERMAWATI 21/03/2020 Evakuasi medis / Ambulans Darat 0.00 Isna Noor Khilda Rp. 90.000

015909320320P001311 FATIMATUZ ZAHRO' 24/03/2020 Evakuasi medis / Ambulans Darat 0.00 dr. KRISTIANA PRASETYOWATI Rp. 90.000

015909320320P001312 FITRI WULANDARI 13/03/2020 Pelayanan PNC 1 (Satu) Isna Noor Khilda Rp. 25.000
NoKunjungan NAMA TANGGAL TINDAKAN HASIL TENAGA MEDIS BIAYA

015909320320P001313 FITRI WULANDARI 16/03/2020 Pelayanan PNC 2 (Dua) Isna Noor Khilda Rp. 25.000

015909320320P001314 RIA MAYASARI 15/03/2020 Pelayanan PNC 1 (Satu) dr. ACHMAT LUTHFI YAKIM Rp. 25.000

015909320320P001315 RIA MAYASARI 18/03/2020 Pelayanan PNC 2 (Dua) dr. ACHMAT LUTHFI YAKIM Rp. 25.000

015909320320P001316 DARMISIH 15/03/2020 Pelayanan PNC 1 (Satu) dr. ACHMAT LUTHFI YAKIM Rp. 25.000

015909320320P001317 DARMISIH 18/03/2020 Pelayanan PNC 2 (Dua) dr. ACHMAT LUTHFI YAKIM Rp. 25.000

015909320320P001320 SITI FATIMAH 15/03/2020 Pelayanan PNC 1 (Satu) dr. ACHMAT LUTHFI YAKIM Rp. 25.000

015909320320P001321 SITI FATIMAH 18/03/2020 Pelayanan PNC 2 (Dua) dr. ACHMAT LUTHFI YAKIM Rp. 25.000

015909320320P001322 DWI INDRAYANI 17/03/2020 Pelayanan PNC 1 (Satu) dr. KRISTIANA PRASETYOWATI Rp. 25.000

015909320320P001323 DWI INDRAYANI 20/03/2020 Pelayanan PNC 2 (Dua) dr. KRISTIANA PRASETYOWATI Rp. 25.000

015909320320P001324 ERINA ARI SUSANA 15/03/2020 Pelayanan PNC 1 (Satu) Isna Noor Khilda Rp. 25.000

015909320320P001325 ERINA ARI SUSANA 18/03/2020 Pelayanan PNC 2 (Dua) Isna Noor Khilda Rp. 25.000

015909320320P001327 YOGA ALDI SAPUTRA 24/03/2020 Evakuasi medis / Ambulans Darat 0.00 Isna Noor Khilda Rp. 90.000

015909320320P001332 SLAMET 25/03/2020 Evakuasi medis / Ambulans Darat 0.00 dr. KRISTIANA PRASETYOWATI Rp. 90.000

015909320320P001347 ADELIA MEYCHA PUTRI WIBOWO 26/03/2020 Evakuasi medis / Ambulans Darat 0.00 dr. KRISTIANA PRASETYOWATI Rp. 90.000

015909320320P001442 NA'IMATUN MUSFIROH 26/03/2020 Evakuasi medis / Ambulans Darat 0.00 Isna Noor Khilda Rp. 90.000

015909320320P001569 AHMAD USMAN KHANAFI 27/03/2020 Evakuasi medis / Ambulans Darat 0.00 Isna Noor Khilda Rp. 90.000

015909320320P001619 AFRINA LAILA SYIFA 28/03/2020 Evakuasi medis / Ambulans Darat 0.00 dr. KRISTIANA PRASETYOWATI Rp. 90.000

015909320320P001621 IDA RAHAYU 28/03/2020 Evakuasi medis / Ambulans Darat 0.00 dr. KRISTIANA PRASETYOWATI Rp. 60.000

015909320320P001674 SUNARTI 28/03/2020 Pelayanan ANC 3 (Tiga) Isna Noor Khilda Rp. 50.000

015909320320P001675 RINI MAULIDHA HADI 28/03/2020 Pelayanan ANC 2 (Dua) dr. ACHMAT LUTHFI YAKIM Rp. 50.000

015909320320P001676 SITI AROFAH 28/03/2020 Pelayanan ANC 3 (Tiga) dr. KRISTIANA PRASETYOWATI Rp. 50.000

015909320320P001678 RISTIANAH 28/03/2020 Pelayanan ANC 1 (Satu) dr. KRISTIANA PRASETYOWATI Rp. 50.000

015909320320P001757 MU`ALLIMATUL KHOIRIYAH 31/03/2020 Pelayanan ANC 2 (Dua) dr. ACHMAT LUTHFI YAKIM Rp. 50.000

015909320320P001763 ENDANG SULISTIANI 31/03/2020 Pelayanan ANC 3 (Tiga) dr. ACHMAT LUTHFI YAKIM Rp. 50.000

015909320320P001770 RULIN RULIANA 23/03/2020 Pelayanan PNC 1 (Satu) Isna Noor Khilda Rp. 25.000

015909320320P001771 RULIN RULIANA 26/03/2020 Pelayanan PNC 2 (Dua) Isna Noor Khilda Rp. 25.000

015909320320P001772 SITI KHOTIMAH 27/03/2020 Pelayanan ANC 3 (Tiga) dr. ACHMAT LUTHFI YAKIM Rp. 50.000

015909320320Y000580 KUSTIANA 12/03/2020 Pelayanan ANC 3 (Tiga) Isna Noor Khilda Rp. 50.000
NoKunjungan NAMA TANGGAL TINDAKAN HASIL TENAGA MEDIS BIAYA

015909320320Y000582 UMI LATIFAH 11/03/2020 Pelayanan ANC 2 (Dua) Isna Noor Khilda Rp. 50.000

015909320320Y000586 HARYATI 10/03/2020 Pelayanan ANC 3 (Tiga) Isna Noor Khilda Rp. 50.000

015909320320Y000620 FITRI WULANDARI 09/03/2020 Pelayanan ANC 3 (Tiga) dr. KRISTIANA PRASETYOWATI Rp. 50.000

015909320320Y000656 ISTIANA 13/03/2020 Pelayanan ANC 2 (Dua) Isna Noor Khilda Rp. 50.000

Tanggal terima FPK, Tanggal, 06/04/2020


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