STRUK PEMBAYARAN DI UGD STRUK PEMBAYARAN DI UGD

Nama Pasien : Tanggal : Nama Pasien : Tanggal :

Nomor RM : Status: Umum/BPJS/...... Nomor RM : Status : Umum/BPJS/.....

No Jenis Pelayanan Tarif Ket No Jenis Pelayanan Tarif Ket

1 Administrasi (loket)
2 Pemeriksaan umum
3 Obat Suntikan
1..................................
2..................................
3..................................
4..................................
5..................................
6..................................
Rp. .......................... 1 Administrasi (loket)
Rp. 15.000 2 Pemeriksaan umum
3 Obat Suntikan
Rp............................ 1..................................
Rp. .......................... 2..................................
Rp. .......................... 3..................................
Rp. .......................... 4..................................
Rp. .......................... 5..................................
Rp. .......................... 6..................................
Rp. ..........................
Rp. 15.000
Rp...........................
Rp. ..........................
Rp. ..........................
Rp. ..........................
Rp. ..........................
Rp. ..........................

4 Surat ket. Pemeriksaan 4 Surat ket. Pemeriksaan

1. Surat Ket. Kematian
2. Surat. Rujukan
3. Surat Ket. Visum
4. Surat Ket. sakit
Rp. ..........................
Rp. ..........................
Rp. ..........................
Rp. ..........................
Rp. ..........................
1. Surat Ket. Kematian
Rp. ..........................
2. Surat. Rujukan Rp. ..........................
3. Surat Ket. Visum Rp. ..........................

5 Perawatan gigi 4. Surat Ket. sakit

1.................................. Rp. ..........................
2.................................. Rp. .......................... 5 Perawatan gigi
3.................................. Rp............................ 1.................................. Rp. ..........................
2.................................. Rp. ..........................
7 Konsultasi/ visit Dokter 3.................................. Rp............................
1.................................. Rp. ..........................
2.................................. Rp. .......................... 7 Konsultasi/ visit Dokter
1.................................. Rp. ..........................
8 Jasa pelayanan 2.................................. Rp. ..........................
8 Jasa pelayanan
9 Tindakan medis
1. Debridemen Rp. ..........................
2 Jahit Luka Rp. .......................... 9 Tindakan medis
3. Lepas jahitan Rp. .......................... 1. Debridemen Rp. ..........................
4. Sirkumsisi Rp. .......................... 2 Jahit Luka Rp. ..........................
5. Insisi Abses Rp. .......................... 3. Lepas jahitan Rp. ..........................
6. Ganti Perban Rp. .......................... 4. Sirkumsisi Rp. ..........................
7. Ekstraksi Kuku Rp. .......................... 5. Insisi Abses Rp. ..........................
8. Pasang infus Rp. .......................... 6. Ganti Perban Rp. ..........................
9. Lepas infus Rp. .......................... 7. Ekstraksi Kuku Rp. ..........................
10. Ganti infus Rp. .......................... 8. Pasang infus Rp. ..........................
11. Nebulizer Rp. .......................... 9. Lepas infus Rp. ..........................
12. Oksigen permenit Rp. .......................... 10. Ganti infus Rp. ..........................
13. Pasang Spalak Rp. .......................... 11. Nebulizer Rp. ..........................
14. Pasang Kateter Rp. .......................... 12. Oksigen permenit Rp. ..........................
15. Lepas Kateter Rp. .......................... 13. Pasang Spalak Rp. ..........................
14. Pasang Kateter Rp. ..........................
10 Visum et repertum 15. Lepas Kateter Rp. ..........................
1 Orang hidup Rp . ..........................
2. Orang mati Rp. .......................... 10 Visum et repertum
a. v. Luar Rp. .......................... 1 Orang hidup Rp . ..........................
b. v. Dalam Rp. .......................... 2. Orang mati Rp. ..........................
a. v. Luar Rp. ..........................
9 Pemeriksaan laboratorium Rp. ..........................
b. v. Dalam
1.................................. Rp. ..........................
2.................................. Rp. .......................... 9 Pemeriksaan laboratorium
3.................................. Rp. .......................... 1.................................. Rp. ..........................
4.................................. Rp............................ 2.................................. Rp. ..........................
3.................................. Rp. ..........................
10 UGD
4.................................. Rp............................
13 Tindakan Obstetri
Gynekolog Rp........................... 10 UGD
1.................................. Rp........................... 13 Tindakan Obstetri Gynekolog
2.................................. 1.................................. Rp...........................
14 BHP Rp........................... 2.................................. Rp...........................
15 Biaya Rujukan Rp...........................
Total Rp.......................... 14 BHP Rp...........................
15 Biaya Rujukan Rp...........................
Total Rp..........................
 STRUK PEMBAYARAN DI RAWAT INAP STRUK PEMBAYARAN DI RAWAT INAP

Nama Pasien : Tanggal : Nama Pasien : Tanggal :

Nomor RM : Status: Umum/BPJS/...... Nomor RM : Status : Umum/BPJS/.....

No Jenis Pelayanan Tarif Ket No Jenis Pelayanan Tarif Ket

1 Administrasi (loket)
2 Pemeriksaan umum
3 Obat Suntikan
1..................................
2..................................
3..................................
4..................................
5..................................
6..................................
Rp. .......................... 1 Administrasi (loket)
Rp. 15.000 2 Pemeriksaan umum
3 Obat Suntikan
Rp.......................... 1..................................
Rp. .......................... 2..................................
Rp. .......................... 3..................................
Rp. .......................... 4..................................
Rp. .......................... 5..................................
Rp. .......................... 6..................................
Rp. ..........................
Rp. 15.000
Rp..........................
Rp. ..........................
Rp. ..........................
Rp. ..........................
Rp. ..........................
Rp. ..........................

4 Surat ket. Pemeriksaan 4 Surat ket. Pemeriksaan

1. Surat Ket. Kematian
2. Surat. Rujukan
3. Surat Ket. Visum
4. Surat Ket. sakit
Rp. ..........................
Rp. ..........................
Rp. ..........................
Rp. ..........................
Rp. ..........................
1. Surat Ket. Kematian
Rp. ..........................
2. Surat. Rujukan Rp. ..........................
3. Surat Ket. Visum Rp. ..........................

5 Perawatan gigi 4. Surat Ket. sakit

1.................................. Rp. ..........................
2.................................. Rp. .......................... 5 Perawatan gigi
3.................................. Rp............................ 1.................................. Rp. ..........................
2.................................. Rp. ..........................
7 Konsultasi/ visit Dokter 3.................................. Rp............................
1.................................. Rp. ..........................
2.................................. Rp. .......................... 7 Konsultasi/ visit Dokter
1.................................. Rp. ..........................
8 Jasa pelayanan Rp 2.................................. Rp. ..........................
8 Jasa pelayanan Rp
9 Tindakan medis
1. Debridemen Rp. ..........................
2 Jahit Luka Rp. .......................... 9 Tindakan medis
3. Lepas jahitan Rp. .......................... 1. Debridemen Rp. ..........................
4. Sirkumsisi Rp. .......................... 2 Jahit Luka Rp. ..........................
5. Insisi Abses Rp. .......................... 3. Lepas jahitan Rp. ..........................
6. Ganti Perban Rp. .......................... 4. Sirkumsisi Rp. ..........................
7. Ekstraksi Kuku Rp. .......................... 5. Insisi Abses Rp. ..........................
8. Pasang infus Rp. .......................... 6. Ganti Perban Rp. ..........................
9. Lepas infus Rp. .......................... 7. Ekstraksi Kuku Rp. ..........................
10. Ganti infus Rp. .......................... 8. Pasang infus Rp. ..........................
11. Nebulizer Rp. .......................... 9. Lepas infus Rp. ..........................
12. Oksigen permenit Rp. .......................... 10. Ganti infus Rp. ..........................
13. Pasang Spalak Rp. .......................... 11. Nebulizer Rp. ..........................
14. Pasang Kateter Rp. .......................... 12. Oksigen permenit Rp. ..........................
15. Lepas Kateter Rp. .......................... 13. Pasang Spalak Rp. ..........................
14. Pasang Kateter Rp. ..........................
10 Ruang rawat inap perhari Rp . .......................... 15. Lepas Kateter Rp. ..........................
Ad. Rekam Medik Rp. ..........................
10 Ruang rawat inap perhari Rp . ..........................
9 Pemeriksaan laboratorium Ad. Rekam Medik Rp. ..........................
1.................................. Rp. ..........................
2.................................. Rp. .......................... 9 Pemeriksaan laboratorium
3.................................. Rp. .......................... 1.................................. Rp. ..........................
4.................................. Rp............................ 2.................................. Rp. ..........................
3.................................. Rp. ..........................
10 UGD 4.................................. Rp............................
13 Tindakan Obstetri
Gynekologi Rp........................... 10 UGD
1.................................. Rp........................... 13 Tindakan Obstetri Gynekologi
2.................................. 1.................................. Rp...........................
14 BHP Rp........................... 2.................................. Rp...........................
15 Biaya Rujukan Rp........................... 14 BHP Rp...........................
Total Rp.......................... 15 Biaya Rujukan Rp...........................
Total Rp..........................