Klaim RS Budi Rahayu

Pekalongan, 15 Januari 2013
No : : BA0003307A/ADM/BR/I/2013 Kepada Yth

Lamp : 16 ( Enam belas ) Kwitansi PT.Administrasi Medika
Hal : : Tagihan Biaya Perawatan Up. Manajer Klaim
Gedung Telkom STO Gambir
Jl. Medan merdeka Selatan No.12
JAKARTA PUSAT
JENIS PEMERIKSAAN Tindakan dibayar

NO NAMA PASIEN JUMLAH
Dr. Umum Lab RontgeDokter pasien
1 Grania Sabililah arraya 35,000 93,200 widya
2 Alesandro araya 35,000 121,700 widya
3 Faizal riza 35,000 550,000 (4,200) 600,000 agus
4 Lucky Arsanta pangestu 75,000 134,500 wayan
5 Agus Hamzah 35,000 174,800 emy
6 Lucky Arsanta pangestu 40,000 224,100 emy
7 Terry Sianipar 35,000 199,500 monika
8 Gembong Paulus 40,000 215,000 ### 519,300 monika
9 Andriana Wulan Stefany 35,000 ### (53,000) 214,400 monika
10 Gembong Paulus 80,000 160,000 ### 947,100 hp winanta
11 Asep Prasetyo 40,000 274,700 emy
12 Gembong Paulus 80,000 239,700 sukartono
13 Deshinta rahayuningtyas 20,000 20,000 bidan
14 Jeri Wijoyo lelono 35,000 (6,100) 54,700 emy
15 Ali Purman 35,000 190,300 monika
16 Kiana Khansa Queena 50,000 106,700 radjin
17
18
TOTAL 4,114,700
Terbilang : # Enam juta seratus empat puluh lima ribu sembilan ratus rupiah #
Adapun pembayarannya, dapat menstranfer ke rekening kami di
Bank BTN Cab.Pekalongam

No.Rek: 00032.01.55.000007.4
an. RS BUDI RAHAYU
mohon bukti transfernya di fax ke (0285) 432002
Demikian pemberitahuan kami, atas perhatian dan kerjasama yang baik diucapkan terima kasih
RSU Budi Rahayu Pekalongan
Sr.M.Yohana SND
Ka.Bag. Keuangan
Kepada Yth
PT. Administrasi Medika
Up. Manajer Klaim
Gedung Telkom STO Gambir (Gedung C, Lt 3.4.5)
JAKARTA PUSAT 10110
RSU BUDI RAHAYU
Jl. Barito 5 PEKALONGAN
RSU BUDI RAHAYU

Kepada Yth :
Health Insurance Claim Dept
PT. Asuransi Sinar Mas
Plaza Simas Gedung II Lt. 3
Jl KH. Fachrudin No.18
JAKARTA PUSAT 10250
Kepada Yth
BRI PT.Cab Pekaongan
U.P.Bagian SDM
JL.WR Supratman No.6
Pekalongan
Kepada Yth
PT ASURANSI ALLIANZ LIFE INDONESIA
U.P Bagian Klaim Kesehatan
JL.HR RASUNA SAID KAWASAN KUNINGAN
PERSADA SUPER BLOK 2
JAKARTA 12980

Up. Manajer Klaim
JAKARTA PUSAT 10110
Kepada Yth
LEMBAGA PERLINDUNGAN SAKSI DAN KORBAN
GEDUNG PERINTIS KEMERDEKAAN
(Gedung Pola) Lt.1 dan Lt.14
Jl Proklamasi No.56
JAKARTA PUSAT 10301
RSU BUDI RAHAYU
RSU BUDI RAHAYU

Kepada Yth
MANAJER YAKES PT TELKOM
Area Jateng dan DIY
JL,Sriwijaya No 3
SEMARANG
Kepada Yth RSU BUDI RAHAYU
PT Asuransi Astra Buana Jl. Barito 5 PEKALONGAN
Up.Manajer Claim
Graha Asuransi Astra
Jl. TB Simatupang Kav.15
JAKARTA 12430
Kepada Yth RSU BUDI RAHAYU

Astra International,Tbk Jl. Barito 5 PEKALONGAN
Kantor Cabang Pekalongan
Jl. Dr.Sutomo No.12-14
PEKALONGAN
Kepada PT. Administrasi Medika

BRI PT.Cab.Pekalongan Up. Manajer Klaim
Up. Bagian SDM Gedung Telkom STO Gambir (Gedung C, Lt 3.4.5
Jl. WR.Supratman Jl. Medan merdeka Selatan No.12
PEKALONGAN JAKARTA PUSAT 10110
Kepada Yth
Bank Mandiri Syariah
Up. Bagian SDI dan Umum
Jl.KH Wahid Hasyim No.11A
PEKALONGAN
Kepada Yth
Up. Manajer Klaim
JAKARTA PUSAT 10110
RSU BUDI RAHAYU

RSU BUDI RAHAYU

Kepada Yth :
Health Insurance Claim Dept
PT. Asuransi Sinar Mas
Plaza Simas Gedung II Lt. 3
Jl KH. Fachrudin No.18
JAKARTA PUSAT 10250
Kepada Yth
BAGIAN CUSTOMER SERVICE
PT. ASURANSI JIWA TUGU MANDIRI
Wisma Tugu Raden Saleh Lt.1,2 & 5
Jl. Raden Saleh No.44
JAKARTA 10330
Kepada Yth
PT. Avrist Asurance
Up. Claim Departmen
Gedung Panin Bank Lantai 3
Jl. Jenderal Sudirman
Jakarta Pusat 10270
Kepada Yth
PT. Asuransi Bina dana Artha,Tbk
Up. Bagian Klaim
PLAZA ABDA 27 th Floor
Jl. Jend. Sudirman Kav.59
JAKARTA 12190
Kepada Yth
BAGIAN CUSTOMER SERVICE
PT. ASURANSI JIWA TUGU MANDIRI
Wisma Tugu Raden Saleh Lt.1,2 & 5
Jl. Raden Saleh No.44
JAKARTA 10330
RSU BUDI RAHAYU

Kepada Yth Kepada Yth

HEALTH INSURANCE CLAIM DEPT PLN(Persero),PT,
PT.ASURANSI SINAR MAS Bagian SDM dan ADM
PLAZA SIMAS GEDUNG II LT .3 Jl.Manggis No.2
JL.KH.FAKHRUDIN NO.18 PEKALONGAN
JAKARTA 10250
RSU BUDI RAHAYU PEKALONGAN
Kepada Yth
KEPALA DINAS KESEHATAN Kab. BATANG
Jl. Jend Sudirman No.17
BATANG
RSU BUDI RAHAYU PEKALONGAN
Kepada Yth
Up. Manajer Klaim
JAKARTA PUSAT 10110
Kepada Yth
PT. Avrist Asurance
Up. Claim Department
Gedung Panin Bank Lantai 3
Jl. Jenderal Sudirman
Jakarta Pusat 10270
Pekalongan, 1 Februari 2013
No : Kepada Yth
Lamp PT.Administrasi Medika
Hal Tagihan Biaya Perawatan Up. Manajer Klaim
Gedung Arthaloka Lt.15 Suite 1508
Jl.Jend Sudirman Kav.2
JAKARTA 10220

NO
NAMA PASIEN
Dr. Umum Dr. Spesialis Resep Lab Rontgen Dokter pasien
1 Agus wah 35,000 176,700
2 Apriliana wahyu harta 75,000
3 Jihan a 35,000 400,000
4 Aulia at 35,000 99,900
5 Paramit 35,000 18,100
6 Listyo 35,000 400,000
7 Moch ir 40,000 7,200
8 Welly budiman 75,000 14,500
9 Handoyo desianto 75,000 11,300
10 Pradhita 40,000 184,100
11 Nur shi 35,000 71,900
12 Suharni 35,000 237,900
13 Edi Sup 35,000 124,600
14 Ninit Sumsunadewi 75,000 40,000
15 Rizki Sh 35,000
16 Pratika adi nugraheni 75,000 9,700
17 Rieza se 35,000 173,900
18 Muhama 35,000 130,800 215,000
19 Gumilan 40,000 168,100
20 Salsabil 50,000 49,400
21 Edy pu 35,000 138,800
22 Paramit 40,000 114,400
23 Anifah 75,000 92,400 40,000
24 Alesand 35,000 68,400
25 Imam ku 40,000 175,400
26 Rieza se 35,000 55,500
27 Alessan 35,000 93,300 110,000 55,000
28 Nofiana Ratna Sumin 75,000 40,000
29 Ira Kurn 55,000 34,900 (9,000)
30 Rudi H 35,000 197,900
31 Fathima 35,000 260,800
32 Zerlina 35,000 76,000
33 Supriadi Simanjutak 75,000 34,500 875,000
34 Prahoro 35,000 104,000
35 Silvian 35,000 14,500 140,000 (19,000)
36 Lusiana 35,000 257,300
37 Nofiana Ratna Sumin 75,000 165,000 40,000 (119,000)
38 Supriad 35,000
39
40
41
42
TOTAL
Terbilang : #Tiga juta dua ratus dua puluh delapan ratus ribu tujuh ratus rupiah #

No.Rek: 00032.01.55.000007.4
an. RS BUDI RAHAYU
Sr.M.Yohana SND
Ka.Bag. Keuangan
4.5)
JUMLAH
211,700 monika
75,000 edy
435,000 agus
134,900 monika
53,100 monika
435,000 agus
47,200 monika
89,500 bima
86,300 pradipto
224,100 monika
106,900 widya
272,900 emy
159,600 emy
115,000 lafran
35,000 widya
84,700 wayan
208,900 monika
380,800 monika
208,100 widya
99,400 marsono
173,800 widya
154,400 monika
207,400 lafran
103,400 widya
215,400 emy
90,500 widya
293,300 widya
115,000 lafran
80,900 emilia
232,900 emilia
295,800 widya
111,000 emy
984,500 fajar
139,000 emy
170,500 monika
292,300 monika
161,000 lafran
35,000 emilia
7,319,200
Pekalongan, 1 Maret 2013
No : Kepada Yth
Hal : Up. Manajer Klaim
JAKARTA 10220
JENIS PEMERIKSAAN dibayar Tindakan

Dr. Umum Dr. Spesialis Resep Lab Rontgen pasien Dokter
1 Sarorah 75,000 40,000 115,000 lafran
2 Allesandro araya gibran 35,000 101,200 136,200 widya
3 Callysta putri 75,000 135,500 340,000 550,500 sugiyanto
4 Ratna Dewi Hartati 50,000 44,900 94,900 marsono
5 Ayu kusuma dewi 75,000 198,500 273,500 edy
6 Soeparno 35,000 45,500 315,000 395,500 monika
7 Hadi prayitno 35,000 141,500 (97,900) 78,600 widya
8 Soeparno 35,000 219,100 254,100 monika
9 Bening Kirana Rizzuqie 35,000 105,100 140,100 monika
10 Aulia Atha Richi 35,000 157,700 (67,400) 125,300 monika
11 Ayu Kusuma Dewi 75,000 198,500 273,500 edy
12 Anifah M Maskurrah 75,000 16,000 40,000 131,000 lafran
13 Siska Oktavia Rina 35,000 46,400 110,000 191,400 emilia
14 Zandi Fairi 40,000 198,100 238,100 emy
15 Deshinta Rahayuningtyas 25,000 25,000 bidan
16 Satiti handayani 40,000 101,800 141,800 emy
17 Ninit Sumsunadewi 35,000 95,100 130,100 widya
18 Dinnie legawati 50,000 162,300 212,300 monika
19 Lucky arsanta 40,000 100,300 140,300 emy
20 Adriana wulan stefany 35,000 35,000 radjin
21 Adriana wulan stefany 35,000 900,000 935,000 monika
22 Sodiq Arifin 35,000 277,100 312,100 radjin
23 Adriana wulan stefany 75,000 120,800 100,000 295,800 bair
24 Sekar ayu Kinasih 50,000 186,900 25,000 261,900 radjin
25 Alesandro Gibran 35,000 88,100 123,100 widya
26 Fakhrudin 50,000 258,700 308,700 radjin
27 Ninit Sumsunadewi 75,000 40,000 115,000 lafran
28 Wachida 40,000 183,500 223,500 widya
29 Nanda Bina Prasetya 35,000 171,500 206,500 emy
30 Pradianto Adi Setiawan 35,000 220,100 25,000 280,100 widya
31 Fitrinada 35,000 35,000 emy
32 Bening Kirana Rizzuqie 35,000 35,000 emy
33 Alina Cahya kartika 50,000 56,400 5,000 111,400 emilia
34 Hanung Bagus 75,000 309,800 200,000 584,800 rosik
35 Fathimah 35,000 43,700 110,000 188,700 widya
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
Pekalongan, 15 Maret 2013
No : : Kepada Yth
Lamp : PT.Administrasi Medika
Hal : : Up. Manajer Klaim
JAKARTA 10220
JUMLAH Tindakan dibayar

Dr. Umum Dr. Spesialis Resep Lab Rontgen Dokter Pasien
1 Lilis Husniyati 35,000 48,400 265,000 348,400 dodi
2 Mohamad Rizki Safarizal 75,000 81,800 156,800 bima
3 Ristianingsih 35,000 111,400 146,400 monika
4 Listyo Herlambang 35,000 167,700 202,700 monika
5 Raole Rigo Berta sinaga 50,000 66,200 116,200 monika
6 Jeri Wijoyo lelono putro 35,000 108,500 (14,300) 129,200 monika
7 Ninit Susunadewi 75,000 40,000 115,000 lafran
8 Wachida 40,000 183,500 223,500 widya
9 Nanda Bina Prasetia 35,000 171,500 206,500 emy
10 Pradianto Adi Setiawan 35,000 220,100 25,000 280,100 widya
11 Fitrada 35,000 35,000 emy
12 Bening Kirana Rizzuqie 35,000 35,000 emy
13 Alina Cahya Kartika 55,000 56,400 111,400 emilia
14 Hanung Bagus P 75,000 309,800 200,000 584,800 rosik
15 Fathimah Az Zahra 35,000 43,700 60,000 50,000 188,700 widya
16 Novi Esterina 75,000 40,000 115,000 lafran
17 Raole Berta 35,000 113,100 65,000 213,100 monika/8/thora
18 Arsya Queen 35,000 12,900 47,900 emilia
19 Dini Mareta 50,000 45,300 95,300 monika
20 Hermawan 50,000 288,500 15,000 353,500 emy
21 Miftahul jannah 40,000 104,100 144,100 monika
22 Nathan sianipar 35,000 36,000 71,000 monika
23 Fajar ferdinand 35,000 119,400 154,400 monika
24 Gembong Paulus 35,000 143,100 178,100 emilia
25 Agus Hamzah 35,000 89,600 124,600 widya
26 Tery Sianipar 35,000 123,400 158,400 emilia
27
28
29
30
32
33
34
48 4,535,100
Terbilang : # Empat juta sembilan ratus tujuh puluh dlapan ribu lima ratus rupiah #

No.Rek: 00032.01.55.000007.4
an. RS BUDI RAHAYU
Demikian pemberirahuan kami, atas perhatian dan kerjasama yang baik diucapkan terima kasih
Sr.M.Yohana SND
Ka.Bag. Keuangan
Pekalongan, 1 Mei 2013
No : : 00012A/ADM/BR/V/2013 Kepada Yth

Lamp : 19 ( Sembilan belas ) Kwitansi PT.Administrasi Medika
JAKARTA 10220
JENIS PEMERIKSAAN Tindakan Dibayar

1 Novi esterina utami 75,000 180,800 40,000 (39,800) 256,000 lafran
2 Dinnie Legawati 50,000 525,000 575,000 radjin
3 Tunirah 75,000 40,000 115,000 lafran
4 Mochamad Irwan 40,000 113,500 153,500 monika
5 Wijarofah 75,000 40,000 115,000 lafran
6 Muhamad Raffa 35,000 98,300 133,300 widya
7 Nurhayati 35,000 120,800 155,800 widya
8 Iklas Setia Mau 35,000 157,100 192,100 monika
9 Paramitha 35,000 166,400 201,400 monika
10 Hery Junianto 35,000 158,200 193,200 monika
11 Adi Prajoko 50,000 80,900 130,900 monika
12 Pradianto Adi SE 35,000 111,100 170,000 316,100 widya
13 Pradianto Adi SE 35,000 35,000 monika
14 aulia atha 35,000 90,000 50,000 175,000 marsono
15 Pradianto Adi SE 80,000 79,800 159,800 widya
16 Roymahal Agung 50,000 37,300 87,300 dodi
17 Mochamad Irwan 40,000 93,900 133,900 monika
18 Ninit sumsunadewi 75,000 40,000 115,000 lafran
19 Edy purnomo 35,000 152,100 187,100 monika
20 -
21 -
22 -
23 -
24 -
25 -
26 -
27 -
28 -
29 -
30
31 -
32 -
33 -
34 -
35 -
36 -
TOTAL 3,430,400
Terbilang : # Lima juta empat ratus sembilan puluh sembilan ribu enam ratus rupiah#

No.Rek: 00032.01.55.000007.4
an. RS BUDI RAHAYU
Sr.M.Yohana SND
Ka.Bag. Keuangan
Pekalongan, 1 Juni 2013
No : Kepada Yth
JAKARTA 10220
JENIS PEMERIKSAAN dibayar Tindakan

NO NAMA PASIEN
Dr. Umum Dr. Spesialis Resep/BHP Lab Rontgen pasien Dokter
1 Raole Rigo Berta 35,000 53,200
2 Silvianca Era Rahmawati 35,000 185,400 (22,000)
3 Fajar Ferdinand 35,000 78,100
4 Syaifudin 35,000 188,300
5 Gembong Paulaus 80,000 742,200
6 Satiti Handayani 75,000 142,300
7 Siska Arum Kusuma 35,000 76,900
8 Kiana Khansa Queena 35,000 83,900
9 Ariyanti 35,000 209,800 305,000
10 Alina Cahya 35,000 112,200
11 M Saiful 35,000 186,900
12 Edy Purnomo 35,000 512,000
13 Nurhayati 35,000 15,900
14 Ristianingsih 75,000 184,300
15 Felix 35,000 107,500
16 Endang susanti 35,000 103,100
17 Hermawan 35,000 243,200 30,000
18 Dahlia Nur 35,000 30,400
19 Riza setiawan 35,000 31,200
20 Zandi 35,000 24,500
21 Andika pratama 35,000 415,000
22 Moch Irwansyah 35,000 103,600
23 Ery wibowo 75,000 123,500
25 Nia Nisrina 50,000 268,400
26 Muhammad Rafy Fu 35,000 53,800
27 Ratna Dewi Harta 35,000
28 Irfanisa Haqi Ka 75,000 411,700
29 Dania Kurniawati 35,000
30 Zandi Fairi 35,000 122,800
31 Aura cinta 35,000 90,400
32 Mudji santoso 75,000 43,600
33 Erva nuryanti 35,000 272,900
35 Dian Tauchida 35,000 32,500
36 ariestiana 75,000 92,400 40,000
37 Febriana mayang 35,000
38
39
40
TOTAL
Terbilang : # Enam juta empat ratus delapan puluh ribu dua ratus rupiah #
JUMLAH
88,200 monika
198,400 widya
113,100 monika
223,300 monika
822,200 soekartono
217,300 emy
111,900 marsono
118,900 marsono
549,800 emy
147,200 marsono
221,900 emy
547,000 radjin
50,900 radjin
259,300 bambang
142,500 marsono
138,100 marsono
308,200 monika
65,400 emy
66,200 radjin
59,500 radjin
450,000 widya
138,600 emy
198,500 wayan
184,400 bambang
318,400 radjin
88,800 monika
35,000 emy
486,700 boedi
35,000 emy
157,800 radjin
125,400 emy
118,600 wayan
307,900 radjin
125,900 emy
67,500 widya
207,400 lafran
35,000 marsono
-
-
-
7,530,200
Pekalongan, 1 Juli 2011
No : : BA0002003A/ADM/BR/VII/2011 Kepada Yth

Lamp : 36 ( Tiga puluh enam ) Kwitansi PT.Administrasi Medika
JAKARTA 10220
JENIS PEMERIKSAAN Tindakan Dibayar

NO NAMA PASIEN
1 Miftahul Janah 35,000 78,600
2 Fransiska Kriswidiyati 35,000 62,900 470,000
3 Nofiana ratna Sumipar 35,000 297,400
4 Febriani Tri Kurnianingsih 40,000 122,800
5 Zaenal Arifi 75,000 190,800
6 Nathan Sianipar 35,000 73,300
7 Fajar Ferdinand Sianipar 75,000 193,500
8 Terry Sianipar 35,000 151,300
9 Fransiska Kriswidiyati 35,000 166,400
10 Aprilia Elahayu 40,000 358,000
11 Nofiana ratna Sumipar 75,000 22,800 40,000 (22,800)
12 Vista Yanu Mardiati 40,000 152,700
13 Aulia Atha Richi 35,000 92,500
14 Roymahal Agung Santoso 35,000 151,300
15 Anggara Wahyu Setia Aji 35,000 139,000
16 Vista Yanu Mardiati 35,000 185,800
17 Dyah ayu suryaning utami 35,000 66,100
18 Rina agustina Handayani 35,000 81,800
19 Ardhyaga wahyu setya bima 35,000 12,800
20 Zaenal Arifi 75,000 118,200 140,000
21 Kirmiati 50,000 60,300
22 Nita Vaniatur 35,000 215,100
23 Listyo Herlambang 75,000 52,200
25 Harun 35,000 96,200
26 Hermawan 35,000 86,200 15,000
27
28
34
35
36
Total Keseluruhan
Terbilang : # Enam juta empat puluh dua ribu delapan ratus rupiah #

No.Rek: 00032.01.55.000007.4
an. RS BUDI RAHAYU
Sr.M.Yohana SND
Ka.bag.Keuangan
JUMLAH
113,600
567,900
332,400
162,800
265,800
108,300
268,500
186,300
201,400
398,000
115,000
192,700
127,500
186,300
174,000
220,800
101,100
116,800
47,800
333,200
110,300
250,100
127,200
117,300
131,200
136,200
-
-
-
-
5,092,500
Pekalongan,16 Juli 2013
No : Kepada Yth
JAKARTA 10220

1 F Kriswidiyanti 35,000 261,500 296,500
2 Arskha Virendra 75,000 117,200 192,200
3 Putri Ratna H 35,000 92,400 (3,600) 123,800
4 Jauzaa Fakhrizki 35,000 92,900 127,900
5 Izmi Faizah 35,000 93,600 (64,600) 64,000
6 Sakinah 35,000 201,500 236,500
7 M fakhri 75,000 69,600 144,600
8 Izmi Faizah 35,000 12,100 200,000 247,100
9 Herly santoso 40,000 17,900 57,900
10 Muhamad rafy 35,000 206,000 241,000
11 Ery wibowo 75,000 119,600 194,600
12 Siska arum 35,000 276,300 311,300
13 Nanda bina 35,000 224,700 259,700
14 Dian tauchida 35,000 225,400 260,400
15 M fakhri 75,000 95,300 170,300
16 Ariestiana 75,000 40,000 115,000
17 Kiwin Sulis 75,000 40,000 115,000
18 Wijarofah 75,000 40,000 115,000
19 Novi Esterina 75,000 107,400 40,000 (15,000) 207,400
20 Kusnaeni Dwi 40,000 182,400 222,400
21 Azka Faiz Ahbar 50,000 154,200 204,200
22 Satiti Handayani 40,000 54,000 (12,900) 81,100
23 Moch Ronny Harta 35,000 133,600 168,600
24 -
25 -
26 -
27 -
Total Keseluruhan 4,156,500
Terbilang : # Lima juta tiga ratus empat puluh delapan ribu lima ratus rupiah #

No.Rek: 00032.01.55.000007.4
an. RS BUDI RAHAYU
Sr.M.Yohana SND
Ka.Bag keuangan
radjin
sugiyanto
emy
widya
monika
widya
wayan
monika
monika
monika
wayan
radjin
emy
widya
wayan
lafran
harsono
lafran
lafran
monika
radjin
radjin
emy
Pekalongan, 01 Agustus 2013
No : 00305A/ADM/BR/VIII/2013 Kepada Yth

Lamp: 21 ( Dua puluh satu ) Kwitansi PT.Administrasi Medika
Hal : Tagihan Biaya Perawatan Up. Manajer Klaim
JAKARTA 10220
JENIS PEMERIKSAAN Tindakan

Dr. Umum Dr. Spesial Resep Lab Rontgen Dokter
1 Muhammad Raffi 35,000 96,200 131,200
2 Anifah M Masykur 75,000 40,000 115,000
3 Kurnia Achmaddin 35,000 100,800 135,800
4 Umayra Zahra T 75,000 94,600 169,600
5 Fendy Dwi Hartadi 35,000 116,400 151,400
6 Arsya queen 35,000 56,600 91,600
7 Syaefudin 35,000 66,800 101,800
8 Deshinta Rahayuningtyas 75,000 126,100 40,000 241,100
9 Syaefudin 75,000 90,000 165,000
10 Miftahul janah 35,000 80,600 115,600
11 Dian Tauchida 35,000 233,700 268,700
12 Kirmiati 75,000 174,100 249,100
13 Putri Ratna 35,000 140,800 175,800
14 M fakhri 75,000 77,800 152,800
15 Novi Esterina 75,000 92,400 40,000 207,400
16 Nofiana Ratna 35,000 113,700 148,700
17 Aditya Nugroho 35,000 71,500 15,000 121,500
18 muhammad Rizki 50,000 40,600 90,600
19 Hilmawan 35,000 68,000 103,000
20 Marvelo Gibran 35,000 128,800 163,800
21 Nuridin 35,000 203,900 238,900
22 -
23 -
24 -
25
TOTAL TAGIHAN 3,338,400
monika
lafran
monika
sugiyanto
monika
radjin
radjin
lafran
wayan
monika
widya
bima
emy
wayan
lafarn
widya
monika
dodi
monika
emy
emy
TOTAL TAGIHAN
Pekalongan, 16 september 2013
No :: 00472A/ADM/BR/IX/2013 Kepada Yth

Lamp: 28 ( Dua puluh delapan ) Kwitansi PT.Administrasi Medika
JAKARTA 10220
JENIS PEMERIKSAAN Dibayar Tindakan

NO NAMA PASIEN
Dr. Umum Dr. Spesialis Resep Lab Rontgen Pasien Dokter
1 Joko prasetyo 50,000 269,100
2 Nofiana ratna 35,000 37,300 415,000 65,000
3 Kenzie arkana 75,000 87,900
4 Gembong Paulus 80,000 563,600
5 Kiwin Sulis 35,000 114,100
6 Welly budiman 35,000 360,500
7 Ratih Damayanti 35,000 419,700
8 Sri rahajeng 35,000 58,900 (23,800)
9 Raole rigo 35,000 24,200 400,000
10 Listyo herlambang 75,000 39,400
11 Donny Suwandhi 35,000 (3,500)
12 Dyah suryani 35,000
13 Fahrul satya 35,000 235,100
14 Elida Ulfi 35,000 203,200
15 Muhamad rafy 35,000 129,600
16 Grania sabilila 35,000 77,300
17 Rafael Fazle 35,000 86,000 (24,200)
18 Fagrul Satya 35,000 60,800 15,000
19 Ahmad Guntoro 35,000 234,600
20 Bunga Asdianti 35,000 5,800 (438,000) 800,000
21 Eryck Suprichati 40,000 73,000
22 novi Esterina 75,000 40,000
23 Agus wahyudi 35,000 175,500
24 Suratman 35,000 106,500 25000
25 Ratih damayanti 75,000 144,000 105,000
26 Imam Kurnialam 35,000 224,300
27 Salsabila Putri
28 Kiana Khansa
29
TOTAL TAGIHAN
JUMLAH
319,100 radjin
552,300 widya
162,900 sukartono
643,600 bima
149,100 widya
395,500 widya
454,700 radjin
70,100 monika
459,200 agus
114,400 wayan
31,500 widya
35,000 angelina
270,100 monika
238,200 monika
164,600 monika
112,300 monika
96,800 monika
110,800 widya
269,600 radjin
402,800 agus
113,000 monika
115,000 lafran
210,500 monika
166,500 emy
324,000 lauren
259,300 emy
279,400
162,900
6,683,200
Pekalongan, 16 oktober 2013
No : Kepada Yth
JAKARTA 10220

NO NAMA PASIEN
Dr. Umum Dr. Spesialis Resep Lab Rontgen Dokter
1 Fathimah 75,000 151,600
2 Ery wibowo 75,000 81,000
3 Febriana wulanda 75,000 59,400 40,000
4 Rafael Fazle 35,000 134,900
5 Moch Irwan 40,000 71,800
6 Fakhrudin 75,000 224,800
7 Erva Nuryanti 50,000 539,100
8 M.Tohorin 35,000 72,100
9 Dinie legawati 75,000 40,000

10 Muhamad Raffi 35,000 74,800
11 Niska Dwi 75,000 92,400 40,000
12 Veronika Aprilia 35,000 129,300
13 Erva Nuryanti 35,000 336,700
14 Nurhayati 50,000 12,900
15 Hermawan 50,000 213,800 15,000
16 Raole Rigo Berta 35,000 137,300
18 Linawati Waluyo 35,000 89,800
19 Rieza Setiabela 35,000 181,500
20 Bening Kirana 35,000 104,500
21 Ari Sigit Cahyono 40,000 153,300
22 Deshinta Rahayuningtyas 75,000 106,200 40,000
23 Moch Irwan 35,000 265,000

24 Indah Siswati 50,000 9,400
25 Toyibah 75,000 104,300
26 Rahajeng M 35,000 40,400 265,000
27 Widiarti 35,000 600,000
28 Amalia Ulfah 35,000 102,800 100,000
29 Moch Irwan 40,000 257,400
30 Roymahal Agung 35,000 191,300
31 Nabila Aulia P 35,000 137,300
32 Paramitha Safitri 35,000 172,000
33 Ray Raditya Edriano 35,000 165,300

TOTAL TAGIHAN
Terbilang: # Enam juta enam ratus tiga puluh dua ribu lima ratus rupiah #

No.Rek: 00032.01.55.000007.4
an. RS BUDI RAHAYU
e 1508
dibayar
JUMLAH
pasien
226,600 mulyadi
156,000 wayan
174,400 lafran
(81,700) 88,200 monika
111,800 monika
299,800 emy
589,100 radjin
107,100 monika
115,000 lafran
109,800 monika
207,400 lafran
164,300 radjin
371,700 radjin
62,900 angelina
278,800 angelina
172,300 monika
136,500 monika
(7,200) 117,600 monika
216,500 monika
139,500 monika
193,300 monika
221,200 lafran
300,000 monika
59,400 angelina
179,300 kukuh
(6,100) 334,300 monika
(183,000) 452,000 ilham
237,800 ilham
(17,600) 279,800 monika
226,300 monika
172,300 emy
(59,600) 147,400 monika
(59,600) 140,700 radjin

6,789,100
Pekalo ngan 1 November 2013
No : Kepada Yth
JAKARTA 10220

Dr. Umum Dr. Spesial Resep Lab Rontgen Dokter pasien
1 Mudji Santoso 50,000 163,300 (10,000) 203,300
2 Aulia Artha Richi 35,000 59,900 94,900

3 Munawar 35,000 89,300 124,300
4 Toyibah 75,000 42,600 (6,100) 111,500
5 Hanum Restu 50,000 145,400 (52,600) 142,800
6 Jeanca Jadaa 75,000 115,600 (19,100) 171,500
7 Silvianca Era 67,500 67,500
8 Ariyanti 75,000 89,200 75,000 65,000 304,200
9 Zerlina Putri 35,000 137,700 172,700
10 Ariyanti 75,000 131,700 206,700

11 Kenzie Arkana 35,000 106,000 141,000
12 Ike Ristiana 35,000 290,400 (7,500) 317,900
13 Fakrudin 35,000 220,100 65,000 320,100
14 Jeanca Jadaa 75,000 230,400 (30,500) 274,900
15 Silvianca Era 75,000 134,300 (20,900) 188,400
16 Novi Indarti 50,000 316,600 366,600
17 Riza Setiawan 35,000 134,000 169,000
18 Kusnaeni Dwi 35,000 308,000 343,000

19 Jeanca Jadaa 75,000 399,800 (47,500) 427,300
20 -
21 -
22 -
23 -
24 -
25 -
26 -
27 -
28 -
29 -
30
TOTAL TAGIHAN 4,147,600
Terbilang: # Lima juta tiga ratus enam puluh sembilan ribu tujuh ratus rupiah #

Bank BTN Cab.Pekalongan
No.Rek: 00032.01.55.000007.4
an. RS BUDI RAHAYU
Sr.M.Yohana SND
Ka.Bag keuangan
32 Nur Ikmah 75,000 317,600
33 Agus Wahyudi 50,000 258,000
34 Anisa Rizki 50,000 102,000
Bank BTN Cab.Pekalongan

No.Rek: 00032.01.55.000007.4
Sr.M.Y an. RS BUDI RAHAYU
Ka.Bag keuangan
392,600
308,000
152,000
6,760,050
-
Pekalongangan 1 Januari 2014
No : Kepada Yth
JAKARTA 10220
JENIS PEMERIKSAAN
NO NAMA PASIEN
Dr. Umum Dr. Spesialis Resep Lab Rontgen
1 Anang Budiharto 40,000 122,900
2 Alfina Umayya 60,000 293,700
3 Fathimah AZ Zahra 35,000
4 Hanum Restu A 35,000 95,900 365,000
5 Oktavia Caesar 75,000 63,100
7 Desi Ariyani 35,000 94,700 200,000
8 Musaadatul Khaki 35,000 160,300
9 Ariestiana Karti 75,000 40,000
11 Hermawan 35,000 243,200 15,000
12 Muhammad Rafy 35,000 247,300
13 Dian Nita 75,000 172,000
15 Fajar Ferdinad 35,000 141,900
16 Aulia Nurmala 75,000 525,000
17 Nurul Naswaa 35,000 191,800
18 Anang Budiharto 35,000 139,500

19 Ritzki Yunia 35,000 282,700
20 Desiyana Dewayani 40,000 193,800
21 Satiti Handayani 75,000 35,100 860,000
22 Satyahadi rakha 75,000 53,300
23 Chiquita edel 75,000 67,300
24 anis Safitri 35,000 138,900 550,000

26 Sekar ayu 50,000 116,300
27 Kusnaeni Dwi 55,000 364,900
28 Irfanisa Haqi K 75,000 106,200 40,000
29 Galuh Atika Ratna 75,000 40,000
30 Wisnu lazuardi 35,000 319,300
31 Hermawan 35,000 290,000
32 Nanda Bina 35,000 173,200
33 Adriana wulan 35,000 197,900
34
35
36
37
38
39
40
41
42
875,000 4,885,500
Pekalongan 1 Januari 2014
No :
Lamp
Hal :
ka Lt.15 Suite 1508
Tindakan dibayar JENIS PEMERI

JUMLAH NO NAMA PASIEN
Dokter pasien Dr. Umum
162,900 widya 1 Dian Nita
353,700 emy 2 Abdul Haris 35,000
35,000 emy 3 Elly Ermawati 35,000
(59,500) 436,400 monika 4 Satiti handayani
138,100 bhima 5 Dian Nita 35,000
329,700 emy 6 Nurul Naswaa
195,300 emy 7 Freddy candra 35,000
115,000 lafran 8 Ariestiana
224,600 emy 9 Novita Shafia 35,000
293,200 monika 10 Ritzki Yunia 35,000
282,300 monika 11 Andarini septian 40,000
247,000 boedi 12 Andarini septian 35,000
96,300 monika 13 Dian Nita 35,000
176,900 monika 14 Novita Shafira 35,000
600,000 laurenz 15 Aura cinta 50,000
226,800 monika 16 Ery Wibowo
174,500 emy 17 Ahmad efendi

317,700 emy 18 Hilmawan 35,000
233,800 emy 19 Soeparno 50,000
970,100 emy 20 Febriana wulandari
128,300 bima 21 Istin Rezekiana 40,000
142,300 sugiyanto 22 Siti Dwi Asih 50,000
723,900 emy 23 Grania Sabililla 50,000

129,400 emy 24
166,300 emy 25
419,900 radjin 26
(79,400) 141,800 lafran 27
115,000 lafran 28
(35,600) 318,700 widya 29
325,000 monika 30
208,200 emy 31
232,900 32
33
8,661,000 34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
Kepada Yth
PT.Administrasi Medika
Up. Manajer Klaim
JAKARTA 10220

JUMLAH
Dr. Spesialis Resep Lab Rontgen Dokter pasien
75,000 283,700 358,700
265,000 300,000
113,200 25,000 (26,200) 147,000
75,000 92,400 167,400
350,000 385,000
75,000 207,200 110,000 392,200
110,900 145,900
75,000 79,400 40,000 194,400
279,100 314,100
192,500 227,500
189,700 229,700
35,000
172,100 360,000 567,100
384,500 419,500
167,000 217,000
75,000 201,100 276,100
75,000 17,700 92,700

77,900 125,000 237,900
23,700 73,700
75,000 40,000 115,000
84,800 200,000 324,800
66,000 116,000
40,200 90,200
5,426,900
rosik
emy
widya
rosik
ilham
mulyadi
radjin
lafran
widya
emy
emy
emy
putri
widya
savero
wayan
wayan
angelina
savero
lafran
emy
putri
putri
Pekalonngan 1 Januari 2014
No : Kepada Yth
Gedung Arthaloka Lt.15 Su
JAKARTA 10220
JENIS PEMERIKSAAN
NO NAMA PASIEN
1 Restu Kurniawan 75,000 242,500
2 Alfa Khasanah 75,000 40,000
3 Edi Supriyanto 40,000 294,700
4 Ariestiana Karti 75,000 40,000
5 Ririn Pujianti 75,000 40,000
6 Rakha Soepanjalu 35,000 40,500
7 Rafael Fazle 35,000 99,800
8 Muhammad Rizki 35,000 133,400
9 Wdi Supriyanto 35,000
11 Mirza Gulant 35,000 363,100
12 Agus Wahyudi Iri 35,000 181,500
13 M Fakhri H 75,000 47,200
14 Musadatul Khaki 35,000 150,600
15 Gita Ratna F 75,000 77,100
16 Kurnia Achmaddin 35,000 202,400 65,000
17 Nur Syifa Ramadhina 50,000 36,900
18 Rizki Septiana 50,000 363,100
19 Sekar ayu kinasih 50,000 56,900
21 Is Sabari 35,000 177,500
22 Welly Budiman 35,000 223,600 330,000
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
Pekalongan 16 Februari 2014
No :
Administrasi Medika Lamp
Manajer Klaim Hal :
ung Arthaloka Lt.15 Suite 1508
nd Sudirman Kav.2
ARTA 10220
Tindakan dibayar
JUMLAH NO NAMA PASIEN
Dokter pasien
317,500 boedi 1 Fajar Ferdinand
115,000 lafran 2 Nathan Sianipar
334,700 widya 3 Alesandro araya
115,000 lafran 4 Imam Kurnialam
115,000 lafran 5 Putri ratna
75,500 widya 6 Satiti handayani
(27,000) 107,800 monika 7 Fathimah az zahra
168,400 emy 8 Nurul naswa kamila
35,000 widya 9 Fathimah az zahra
188,100 emy 10 Faisal Riza
398,100 radjin 11 Irfanisa haqi
216,500 monika 12 Grania Sabilla
122,200 mulyadi 13 Alesandro araya
185,600 widya 14 Galuh AtikaRatna
(44,400) 107,700 bhima 15 Febriana Wulandari
302,400 monika 16 Iqbal Ashari Fai
86,900 Savero 17 Salwa Aulia R
413,100 radjin 18 Putr Ratna
106,900 Savero 19 Ririn Pijianti
131,700 widya 20 Javier Wiryamanta
212,500 monika 21 Umayra Zahra
588,600 monika 22 Welli Budiman
- 23 Hermawan
- 24 Javier Wiryamanta
- 25 Ummi Umairoh
- 26 Fakhrudin
- 27 Prahoro Badai
- 28 Munawar
- 29 Adriana Wulan
- 30 Respati
- 31 Lusiana
- 32 Muhammad Chaeron
- 33 Niska Dwi
- 34
- 35
- 36
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
Kepada Yth
Up. Manajer Klaim
JAKARTA 10220

JUMLAH
35,000 114,500 114,500 monika
35,000 109,400 144,400 monika
35,000 127,900 162,900 monika
50,000 204,600 254,600 emy
35,000 126,300 50,000 211,300 emy
40,000 101,800 141,800 emy
35,000 58,000 93,000 widya
35,000 165,100 25,000 225,100 widya
35,000 435,000 470,000 monika
75,000 75,000 haryanto
35,000 219,000 230,000 484,000 angelina
35,000 98,600 133,600 widya
35,000 145,600 180,600 widya
75,000 168,700 40,000 (119,000) 164,700 lafran
75,000 40,000 115,000 lafran
35,000 159,100 194,100 emy
35,000 435,000 470,000 emy
35,000 20,000 55,000 emy
75,000 40,000 115,000 lafran
75,000 65,000 140,000 zainal
75,000 116,200 191,200 iswandi
35,000 355,800 390,800 monika
50,000 194,100 20,000 264,100 emy
75,000 200,000 275,000 zainal
35,000 105,500 200,000 340,500 monika
40,000 267,400 307,400 widya
35,000 317,700 352,700 emy
35,000 321,500 356,500 savero
35,000 276,000 356,000 667,000 emy
35,000 363,100 398,100 radjin
35,000 95,700 130,700 widya
35,000 74,400 109,400 emy
75,000 195,200 40,000 310,200 lafran
-
-
-
Pekalongan 01 Maret 2014
No
Lam
Hal
JENIS PEMERIKSAAN
NO NAMA PASIEN
Dr. Umum Dr. Spesialis Resep Lab
1 Pratika Adhi 35,000 19,800
2 Muhammad Rizki 35,000 68,300
3 Joko Yunantoro 35,000 105,000
5 Ahmad Efendi 35,000 192,000
6 Nofiana Ratna S 35,000 141,600
8 Pratika Adhi 35,000
9 Javier Wiryamanto 75,000 94,200
10 Hadi Prayitno 40,000 164,000
11 Sulthan Dzaki 35,000 166,400 435,000
12 Zelina Putri 35,000 143,700
13 Hery Junianto 75,000 129,100 80,000
14 Hery Junianto 75,000
15 Mirza Gulanzt 35,000 102,200
16 Miftahul jannah 40,000 151,200
17 Andarini Septiyaningrum 35,000 94,200
18 Hadi Prayitno 35,000 435,000
19 Felix failasuf 75,000 117,500
20 Nur ikmah 35,000 82,400
21 Pratika Adhi 35,000
22 Grania sabilila 35,000 86,400
23 Soeparno 35,000 136,000
24 Andriana Wulan 35,000 524,200
25 Romandhona Dwi S 35,000 51,300
26 Berthus Budiman 35,000 218,000 20,000
27 Ratna Dewi Hartati 35,000 102,200
28 Rafael Fazle M 35,000 64,600 455,000
29 Putri Ratna H 35,000 66,800
30 Muhammad Chaeron 35,000 203,300
31 Hadi Prayitno 75,000
32 Adhyastha Zhfran 75,000
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
Pekalongan 17 Maret
Kepada Yth No :
PT.Administrasi Medika Lamp
Up. Manajer Klaim Hal :
JAKARTA 10220
Tindakan dibayar NO
JUMLAH
Rontgen Dokter pasien
54,800 dewi 1
103,300 emy 2
140,000 widya 3
305,000 monika 4
(7,500) 219,500 monika 5
176,600 monika 6
279,100 monika 7
35,000 savero 8
169,200 zainal 9
204,000 emy 10
636,400 emy 11
178,700 emy 12
65,000 349,100 laurenz 13
75,000 laurenz 14
137,200 emy 15
191,200 monika 16
129,200 widya 17
470,000 emy 18
192,500 mulyadi 19
117,400 widya 20
35,000 monika 21
121,400 widya 22
171,000 widya 23
559,200 savero 24
(17,300) 69,000 savero 25
273,000 widya 26
137,200 monika
(111,000) 443,600 savero
101,800 widya
(12,300) 226,000 emy
75,000 haryanto
75,000 wayan
6,450,400
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
Pekalongan 17 Maret 2014
NAMA PASIEN JENIS PEMERIKSAAN

Dr. Umum Dr. Spesialis Resep Lab
Kharisma suzana 75,000 109,100
Hadi Prayitno 50,000 140,600
Javier wiryamant 35,000 100,000
Hadi Prayitno 35,000 102,800 120,000
Kharisma suzana 75,000
Ariyanti 35,000 131,500
Edi susanto 50,000 298,100
Gumilang Teguh 35,000 212,700 330,000
Pratika Adi Nugraha 55,000 77,000
Javier wiryamant 75,000 119,800
Nining atminah 50,000 16,500
Mirza gulant dhona 35,000 313,600
Aprilia 35,000 139,700
Janitra Alessha 20,000
Bening Kirana 35,000 62,500
Ristianingsih 35,000 149,400
Suharni 35,000 151,200
Edi supriyanto 75,000 774,600 65,000
Galuh Atika 75,000
Umayra Zahra 35,000 126,900
Kepada Yth
Up. Manajer Klaim
JAKARTA 10220
Tindakan dibayar
JUMLAH
Rontgen Dokter pasien
40,000 (10,100) 214,000 lafran
190,600 paska
135,000 emy
257,800 widya
40,000 115,000 lafran
166,500 emy
348,100 savero
(55,700) 522,000 widya
132,000 monika
194,800 zainal
66,500 dewi
55,000 403,600 emy
174,700 monika
20,000 bidan
97,500 monika
184,400 monika
186,200 emy
5,000 919,600 sukartono
40,000 115,000 lafran
161,900 widya
-
-
-
-
-
-
-
-
-
-
-
-
4,605,200
Pekalongan 1 April 2014
No Kepada Yth
Lam PT.Administrasi Medika
Hal Up. Manajer Klaim
Gedung Arthaloka Lt.15 Suite
JAKARTA 10220
NO NAMA PASIEN JENIS PEMERIKSAAN Tindakan

1 Marvelyo gibran 35,000 56,400
2 Arya Sultan zaki 35,000 160,200
4 Muhamad adi 35,000 34,100
5 Soeparno 35,000 298,800
7 adriana wulan 40,000 238,000
8 Lisa nurmawati 50,000 248,300
9 Ayu kusuma dewi 75,000
10 Mirza gulant 35,000 194,000
11 Meilia kristanti 35,000 76,200
12 Imama wulandari 35,000 162,600
13 Nur ikmah 75,000 40,000
14 Jauzaa fakhrizki 35,000 169,400
15 Aura Cinta 35,000 89,900
16 Niska dwi anisa 75,000 40,000
17 Nia nisrina 50,000 250,900
18 Irfanisa haqi 75,000 40,000
19 Heru pramono 35,000 58,400
20 Jauzaa fakhrizki 75,000 92,300
21 Edi Supriyanto 80,000 496,100 120,000
22 Ahmad Efendi 35,000 216,000
23 Laila badrin 35,000 220,900
24 ratna puspita sari
25
26
Pekalongan 16 April 2014
No :
T.Administrasi Medika Lamp
p. Manajer Klaim Hal :
edung Arthaloka Lt.15 Suite 1508
Jend Sudirman Kav.2
AKARTA 10220
Tindakan dibayar NO NAMA PASIEN

JUMLAH
Dokter pasien
91,400 angelinA 1 Nabila aulia
195,200 angelinA 2 Sri murtiasih
387,000 sukartono 3 elly Ermawati
69,100 savero 4 Ariyanti
333,800 savero 5 Janitra Alesha
116,400 bima 6 Galuh Atika
278,000 emy 7 Arkan Faeyza
298,300 radjin 8 Sum Indah putri
75,000 bima 9 Rakha
229,000 emy 10 Moch nenda
111,200 emy 11 Hermawan
197,600 widya 12 Ery Wibowo
115,000 lafran 13 Nanang budiyono
204,400 radjin 14 Adityo nugroho
124,900 monika 15 Ratna Puspita
115,000 lafran 16 Erva nuryanti
300,900 radjin 17 Nurul Naswa
115,000 lafran 18 Chusna amaliya
93,400 widya 19 Pratika adi
167,300 mulyadi 20 Arya Sultan Zaki
696,100 sukartono 21 Nur syifa
251,000 monika 22 Sekar ayu kinasih
255,900 monika 23 Atha Harsavadana
179,600 24 Muhamad Rizki
25 Adriana Wulan
26 Adityo nugroho
27 Joko Yunantoro
28
5,000,500
Kepada Yth
Up. Manajer Klaim
JAKARTA 10220

Dr. Umum Dr. Spesialis Resep ABHP Lab Rontgen Dokter
35,000 42,000 8,600 600,000
50,000 482,200
75,000 40,000
35,000 75,300 130,000
50,000 84,100
75,000 40,000
35,000 142,800
35,000 144,200
35,000 104,800
35,000 154,300
50,000 250,000 20,000
75,000 164,200
35,000 136,300 200,000
50,000 297,800 435,000
75,000 79,400 40,000
75,000
35,000 105,400
35,000 247,200
35,000 233,300
50,000 26,000
35,000 22900 400,000
35,000 12,700 450,000
75,000
75,000 177,900
35,000
35,000 254,600
50,000 460,000
a Lt.15 Suite 1508
dibayar
JUMLAH
pasien
685,600 agus
532,200 angelina
115,000 lafran
240,300 emy
134,100 marsono
115,000 lafran
177,800 widya
179,200 widya
139,800 widya
189,300 widya
320,000 paska
239,200 wayan
371,300 monika
782,800 savero
194,400 lafran
75,000 linda
140,400 widya
282,200 radjin
268,300 radjin
76,000 radjin
457,900 agus
497,700 agus
75,000 sugiyanto
252,900 iswandi
35,000 widya
289,600 widya
510,000
7,376,000
Pekalongan 2 Mei 2014
No :
Lamp
Hal :
NO NAMA PASIEN JENIS PEMERIKSAAN

Dr. Umum Dr. Spesialis Resep ABHP
1 Ummi Umairoh 35,000 208,800
2 Ninit sumsumadewi 35,000 114,200
3 Musaadatul 35,000 202,900
4 Sri Murtiasih 35,000 468,400
5 Abyan Harsha 35,000 103,700
6 Grania Sabilla 35,000 66,500
7 Gery Gredivo 35,000 106,700
8 Callysta putri 35,000 102,700
9 Lia andriani 75,000 328,400
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
Kepada Yth No :
PT.Administrasi Medika Lamp
Up. Manajer Klaim Hal :
JAKARTA 10220
Tindakan dibayar NO
JUMLAH
Lab Rontgen Dokter pasien
243,800 monika 1
149,200 emy 2
237,900 monika 3
503,400 widya 4
138,700 monika 5
101,500 widya 6
141,700 savero 7
137,700 monika 8
403,400 rosik 9
10
11
12
2,057,300 13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
NAMA PASIEN JENIS PEMERIKSAAN

Salsabila putri 50,000 211,100
Aprilia Elahayu 75,000 78,100
Silvianca era 35,000 238,400
Taufiqurohman 35,000 170,100
Fathimah 35,000 49,800
Rosalina 35,000 123,800
Abdullah lubis 35,000 149,900
Mudji Santoso 50,000 112,600
Rafael Fazle 35,000 42,900
Oktavia pusvitas 35,000 193,400
Fatkhul azis 35,000 22,800
Bagus setio 35,000 189,300
Aulia atha 35,000 112,000
Galuh atika 75,000
Adriana wulan 35,000 149,700
Nanda Bina 35,000 100,700
abyan harsha 75,000 147,100
M Adi ristomo 40,000 240,300
Rieza Setiabela 75,000 48,200
Silvianca era 75,000 298,800
Fathimah 35,000 53,400
Ariyanti 35,000 110,200
Musadatul 35,000 169,900
Kepada Yth
Up. Manajer Klaim
JAKARTA 10220
Tindakan dibayar
JUMLAH
261,100 emy
40,000 193,100 lafran
(27,300) 246,100 emy
205,100 monika
84,800 monika
158,800 widya
184,900 widya
(10,000) 152,600 emy
100,000 (35,600) 142,300 ilham
26,000 254,400 emy
57,800 dewi
495,000 719,300 emy
147,000 monika
40,000 115,000 lafran
270,000 454,700 dewi
135,700 widya
222,100 widya
280,300 emy
123,200 widya
(37,400) 336,400 budi
88,400 monika
90,000 235,200 emy
204,900 widya
Pekalongan 2 Juni 2014
No :
Lamp
Hal :

Dr. Umum Dr. Spesialis Resep
1 Nofiana Ratna 35,000 320,800
2 Iif Fatekha 75,000 99,000
3 Witdiarti 35,000
4 Ray Raditya 75,000
5 Kenzie Arkana 75,000 137,000
6 Gregorius Satrio 35,000 126,400
7 Adriana Wulan 35,000 266,600
8 Dewi Agustina 75,000 85,000
10 Muhamad Raffi 35,000 171,600
11 Lukman Nizar 35,000 200,800
12 Octa Paramitha 75,000 40,000
13 Hadi prayitno 35,000 82,500
14 Abyan Harsha 35,000 144,800
15 elly ermawati 75,000
16 Jauza fakhrizki 35,000 141,000
17 Dewi Agustina 75,000 93,500
18 Marvelo Gibran 35,000 173,700
19 Irfanisa Haqi 75,000
20 aprilia Elahayu 75,000
21 Muhamad Rizki 35,000 144,100
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
Kepada Yth
Up. Manajer Klaim
JAKARTA 10220
Tindakan dibayar
JUMLAH
ABHP Lab Rontgen Dokter pasien
355,800
40,000 214,000
60,000 95,000
75,000
212,000
161,400
301,600
160,000
75,000 466,600
206,600
235,800
115,000
(67,100) 50,400
179,800
40,000 115,000
176,000
117,000 285,500
208,700
40,000 115,000
75,000
179,100
-
-
Pekalongan 16 Juni 2014
No :
Lamp
Hal :

Dr. Umum Dr. Spesialis
emy 1 Rieza Setiabela 35,000
lafran 2 Felix Failasuf 35,000
ilham 3 M Adi Ristomo 75,000
sugiyanto 4 Kurnia adhi 35,000
sugiyanto 5 Lusiana dyah 35,000
radjin 6 M Adi Ristomo 75,000
radjin 7 Soeparno 35,000
haryanto 8 Musaadatul 50,000
budi 9 Adriana 35,000
monika 10 Arsatya bima 75,000
monika 11 Atha Harsavadana 75,000
lafran 12 abyan Harsha 75,000
widya 13 Musaadatul 75,000
monika 14 Kusmartina Puspi 35,000
lafran 15 Novita shafira 35,000
radjin 16 Achmad zulfiadi 35,000
haryanto 17 Sri Rochyati 75,000
radjin 18 Juliartanto 75,000
lafran 19
lafran 20
monika 21
22
Kepada Yth
Up. Manajer Klaim
JAKARTA 10220
Tindakan dibayar
Resep ABHP Lab Rontgen Dokter pasien
176,100
156,100 (66,200)
235,300 150,000 65,000
209,200
94,200 270,000
898,100 (425,900)
343,400
236,400 330,000
69,700
208,700
170,700
106,000
2,300
134,000
706,200
251,500
121,900
203,700
JUMLAH
211,100 aji
124,900 widya
525,300 rosik
244,200 emy
399,200 monika
547,200 rosik
378,400 radjin
616,400 monika
104,700 emy
283,700 mulyadi
245,700 mulyadi
181,000 mulyadi
77,300 ken
169,000 emy
741,200 widya
286,500 radjin
196,900 tito
278,700 hermawan
-
-
-
-
5,611,400
Pekalongan 1 Juli 2014
No :
Lamp
Hal :

2 Atha Harsavadana 75,000 192,400
3 Abyan Harsha 75,000 143,300
4 Fatkhul Azis 35,000 281,400
6 Tatik Dwi Lestari 35,000 63,400
8 Ayu Kusuma Dewi 35,000 215,900
9 Satyahadi Rakha 35,000 80,900
10 Galuh Atika 75,000
11 Desiana Ratanani 35,000 181,900
12 Zerlina Putri 35,000 75,200
13 Ariyanti 40,000 222,300
14 Musaadatul 40,000 258,600
15 Sekar ayu Kinasih 50,000 243,400
16 Pratika Adi 50,000 41,500
17 Mirza Gulant 35,000 160,500
18 Andarini Septyani 35,000 171,300
19 Elly Ermawati 75,000
20 Sum Indah Putri 35,000 161,800
21 Andhika Pratama 35,000 146,100
23 Mirza Gulant 35,000 178,700
24 Munasifah 40,000 280,000
25 Suratman 50,000 608,300
26 Wisnu Lazuardi 35,000 116,600
27 Iif Fatekha . 75,000
28
29
30
Kepada Yth
Up. Manajer Klaim
JAKARTA 10220
Tindakan dibayar
JUMLAH
96,300 monika
267,400 mulyadi
218,300 mulyadi
316,400 emy
130,100 bhima
98,400 widya
313,500 radjin
250,900 emy
435,000 550,900 widya
40,000 115,000 lafran
(83,600) 133,300 radjin
110,200 emy
262,300 emy
298,600 emy
293,400 emy
91,500 dewi
195,500 savero
206,300 emy
40,000 115,000 lafran
(16,400) 180,400 widya
181,100 emy
83,100 mulyadi
213,700 emy
320,000 emy
30,000 5,000 693,300 emy
40,000 191,600 ilham
40,000 115,000 lafran
Pekalongan 16 Juli 2014
No :
Lamp
Hal :

Dr. Umum
1 Aulia Nurmala
2 Kusmartina Puspita 40,000
3 Ahmad Guntoro 40,000
4 Moch Nur Fatoni
5 Restu Kurniawan 35,000
6 Ahmad Efendi
7 Arfan Harshapram 35,000
8 Haryono Purwoko 50,000
9 Abyan harsha 35,000
10 Fathimah 35,000
11 Jeanca Jadda
12 Chiquita Edel 50,000
13 Hadi Prayitno 35,000
14 Roymahal Agung 35,000
15 Galuh Atika
16 Mustaminah 50,000
17 Atha Harsavadana 35,000
18 Eryck suprichati
19
20
21
22
23
24
25
26
27
28
29
30
Kepada Yth
Up. Manajer Klaim
JAKARTA 10220

Dr. Spesialis Resep ABHP Lab Rontgen Dokter
75,000 447,600
507,200
200,000 1,100
75,000
88,200
75,000 64,000
127,500
383,500 65,000
118,400
85,900
75,000 192,700 265,000
17,900
168,900
194,200
75,000 40,000
239,800
107,100
80,000 357,500
Suite 1508
dibayar
JUMLAH
pasien
522,600 laurenz
547,200 radjin
241,100 emy
75,000 hermawan
123,200 widya
139,000 bima
162,500 emy
498,500 radjin
153,400 emy
120,900 widya
(53,300) 479,400 sugiyanto
67,900 jefly
203,900 widya
229,200 emy
115,000 lafran
289,800 savero
142,100 widya
437,500 sukartono
-
-
-
-
-
-
-
-
-
Pekalongan 1 Agustus 2014
No :
Lamp
Hal :

1 Aryasatya alvaro 20,000 13,300
2 Shania Paramitha 35,000 568,600
3 Ery Wibowo 75,000 165,800
4 Richo Kurniawan 75,000 179,600
5 Syarifatun nisa 35,000
6 Irfanisa haqi 75,000
7 Galuh Atika Ratna 75,000
8 Rieza setiabela 35,000 195,600
9 Abyan Harsha 35,000 80,700
10 Kurnia Achmaddin 50,000 192,600
11 Elida Ulfi 35,000
12 Gregorius satrio 50,000 239,300
13 Adriana wulan 50,000 150,900
14 Silvianca Era 75,000 108,500
15
16
17
18
19
20
21
22
Kepada Yth
Up. Manajer Klaim
JAKARTA 10220
Tindakan dibayar
JUMLAH
33,300 bidan
603,600 widya
240,800 wayan
(25,500) 229,100 hermawan
400,000 435,000 agus
40,000 115,000 lafran
40,000 115,000 lafran
230,600 emy
115,700 widya
242,600 emy
435,000 470,000 emy
289,300 radjin
230,000 430,900 radjin
(18,400) 165,100 wayan
-
-
-
-
-
-
-
-
Pekalongan 18 Agustus 2014
No :
Lamp
Hal :

1 Nabila Aulia 75,000
2 Ghina anggun 50,000
3 Arkan Faeyza 50,000
4 Erva nuryanti 50,000
7 Satyahadi 35,000
8 Soeparno 40,000
9 Munasifah 35,000
10 Fatkhul Azis 75,000
11 Salwa Aulia 35,000
12 Suharni 80,000
13 Kurnia Achmaddin 35,000
14 Jauzaa Fahrizki 35,000
15 Ariesta Kartikarini 55,000
16 Andarini Septiyaningrum 35,000
17 Adriana Wulan 40,000
18
19
20
21
22
Kepada Yth
Up. Manajer Klaim
JAKARTA 10220
Tindakan dibayar
247,100
44,500
264,400
318,700
208,600 65,000
108,200
559,300 1,900
263,000
96,900
125,000
389,800 1,900 20,000
11,900 700,000
111,400
330,900 1,600
23,200
270,800 1,900
JUMLAH
75,000 bhima
297,100 radjin
94,500 radjin
314,400 radjin
393,700 rosik
348,600 radjin
143,200 widya
601,200 radjin
298,000 radjin
171,900 wayan
160,000 widya
491,700 sukartono
746,900 agus
146,400 widya
387,500 emy
58,200 widya
312,700 emy
-
-
-
-
-
Pekalongan 1 September 2014
No :
Lamp
Hal :

Dr. UmumDr. Spesialis Resep ABHP
1 Panji Santosa 75,000 214,600
2 Jeri Wijoyo Lelo 35,000 282,100
3 Hadi Prayitno 35,000 303,000
4 Panji Santosa 75,000 21,200
5 Galuh Atika 75,000
6 Kayla Selvi 50,000 67,700
8 Kinara Hadi alfa 35,000 64,200
9 Nia Nisrina 50,000 265,400
10 Pratika adi Nugrahaeni 50,000 428,800
11 Muhamad Rizki 35,000 155,400
12 Elly Ermawati 75,000 79,400
13 Tatik Dwi Lestari 35,000 363,500
14 Irfanisa haqi 75,000
15 Callysta Putri 35,000 173,800
16 Suprapto 35,000 222,200
17 Nofiana ratna 75,000 782,600
18 M.Reiyyan najid 35,000 137,400
19 Lusiana 35,000 547,900
20 Arkan Faeyza 35,000 123,800
21 Ata Mahda 35,000 162,000
22 Badai Mutiara 35,000 247,100
23 Sultan Dzaky 50,000 172,000
24 Desiana Ratanani 35,000 46,600
25 Satyahadi rakha 35,000 50,400
26 Hermawan 35,000 303,100
27 lLaeli Amaliyah 35,000 110,000
28 Rizki Norfitrian 35,000 11,400
Kepada Yth
Up. Manajer Klaim
JAKARTA 10220
Tindakan dibayar
JUMLAH
330,000 619,600 rosik
(31,700) 285,400 radjin
338,000 widya
96,200 rosik
40,000 115,000 lafran
117,700 radjin
287,900 radjin
99,200 widya
315,400 radjin
395,000 873,800 radjin
190,400 widya
40,000 194,400 lafran
398,500 radjin
40,000 115,000 lafran
208,800 radjin
290,000 547,200 widya
347,000 1,204,600 sukartono
172,400 radjin
582,900 radjin
158,800 radjin
197,000 radjin
282,100 emy
222,000 emy
81,600 dewi
120,000 50,000 255,400 widya
20,000 358,100 widya
60,000 205,000 ilham
300,000 346,400 ilham
8,868,800
Pekalongan 16 September 2014
No :
Lamp
Hal :

1 Siska Nurmalina 35,000 191,400
2 Andarini Septianingrum 35,000 138,200
3 Bening Kirana 35,000 105,500
5 Rena Purwanignrum 75,000
8 Iff Fatekha 75,000
9 Vivi Milla 35,000 26,800
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
Kepada Yth
Up. Manajer Klaim
JAKARTA 10220
Tindakan dibayar
JUMLAH
226,400 widya
(7,800) 165,400 dewi
140,500 emy
1,900 201,700 emy
40,000 115,000 lafran
40,000 115,000 lafran
75,000 287,900 budi
40,000 115,000 lafran
61,800 jefly
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
###
Pekalongan, 1 OKTOBER 2014
No :
Lamp
Hal :

1 Hermin Indriasari 35,000
3 Dwi setya Nur 35,000 41,000
4 Wulandary gunawan 35,000 112,300
5 Farid Daki Athalah 75,000 107,200
7 Hermin Indriasari 50,000 257,500
8 Edy purnomo 50,000 246,400
9 Aulia atha 50,000 23,600
10 Nurul Naswaa 75,000
11 Panji Santoso 35,000 274,500
12 Jauza Fakhrizki 35,000 107,400
13 Ery wibowo 75,000 208,900
14 Erva Nuryanti 75,000 290,300
15 Hermin Indriasari 75,000
16 Jeri Wijoyo 35,000 155,500
17 Fendy Dwi 35,000
18 Saidatul 75,000 300,200
19 Nurul Naswaa 75,000 207,800
20 Rokhimatun 75,000 243,500
21
22
23
24
25
Kepada Yth
Up. Manajer Klaim
JAKARTA 10220
Tindakan dibayar
JUMLAH
46,000 81,000 emy
244,800 emy
76,000 dodi
147,300 dodi
182,200 sugiyanto
40,000 115,000 lafran
6,400 20,000 333,900 radjin
296,400 emy
73,600 jefly
160,000 235,000 budi
309,500 radjin
142,400 widya
283,900 wayan
75,000 440,300 budi
40000 115,000 lafran
(19,100) 171,400 widya
35,000 emy
75,000 450,200 budi
282,800 budi
75,000 393,500 budi
Pekalongan,16 OKTOBER 2014
No :
Lamp
Hal :

1 Rosalina 40,000
2 Adriana wulan 35,000
3 Adriana wulan 35,000
4 salsabila putri 35,000
ugiyanto 5 Heru pramono 35,000
6 Kurnia Achmadin 75,000
7 wahyu dwi setyaningsih 75,000
8 Siska arum kusuma 50,000
9 Ritzki yunia 35,000
10 Dwi setya 35,000
11 Hadi Prasetyo 35,000
12 satyahadi rakha 35,000
13 Tri Rahayu 35,000
14 anisa rizki 50,000
15 Imam kurnialam 35,000
16 Suprapto 35,000
17 Shania paramitha 35,000
18 felix failasuf 35,000
20 Kayla selvi 35,000
21 Yulianto 35,000
22 Kayla selvi 75,000
23 Chusna amaliya 35,000
24 Siska arum kusuma 35,000
25 Heru pramono 35,000
26 irfanisa haqi 75,000
27 Edi supriyanto 75,000
Kepada Yth
Up. Manajer Klaim
JAKARTA 10220
Tindakan dibayar
202,100
80,300 205,000
16,000 235,000
224,700
104,400
225,000 75,000
40,000
190,600
21,200 340,000
185,300
153,100
101,300
394,300
145,000
228,100 (7,800)
153,700 19,800 25,000
568,600
143,900
201,400
131,400
107,200
107,900
11,500 1,000 850,000 (297,500)
60,600
65,000 45,000
153,700
JUMLAH
242,100 monika
320,300 monika
286,000 emy
259,700 widya
139,400 widya
375,000 budi
115,000 harsono
240,600 emy
396,200 monika
220,300 monika
188,100 widya
136,300 widya
429,300 radjin
195,000 emy
255,300 monika
233,500 widya
603,600 widya
178,900 emy
276,400 budi
131,400 emy
142,200 widya
182,900 zainal
600,000 ilham
95,600 dewi
145,000 widya
75,000 lafran
228,700 laurenz
Pekalongan,1 NOVEMBER 2014
No :
Lamp
Hal :

1 Munasifah 40,000 309,300
2 Imam kurnialam 35,000
3 Rena Purwaningrum 75,000 58,200
4 Rohimatun 75,000 178,500
5 Imam kurnialam 35,000 501,200
6 Hermawan 35,000 258,600
7 jauza fakhrizi 35,000 99,600
8 Moch Irwan 35,000 249,300
9 Aris Sudarmanto 55,000 151,400
10 Choirunisa 75,000 213,100
11 Hadi Prayitno 40,000 111,700
12 Felix failasuf 35,000 58,800
13 Endang susanti 35,000 130,800
14 Rena Purwaningrum 75,000
15 Anisa Rizki 50,000 113,600
16 Nuzul Nur hikmah 75,000 49,500
19 Ghailan Abid 50,000 311,600
20 Jeri Wijoyo 35,000 173,700
21 Adi Ginanjar 35,000 157,400
22 Erva Nuryanti 75,000 278,400
25 Niken Kusumaningrum 35,000 190,700
Kepada Yth
Up. Manajer Klaim
JAKARTA 10220
Tindakan dibayar
JUMLAH
2,000 351,300
270,000 305,000
(13,400) 119,800
75,000 328,500
536,200
20,000 313,600
134,600
284,300
68,800 110,000 385,200
288,100
2,000 153,700
93,800
165,800
40,000 115,000
163,600
124,500
112,300
134,000
(69,500) 292,100
(20,900) 187,800
90,000 282,400
353,400
100,000 65,000 292,900
1000 147,800
225,700
Pekalongan,16 NOVEMBER 2014
No :
Lamp
Hal :

Dr. Umum
radjin 1 Evi Nureni 35,000
radjin 2 Desiana Ratnaningtyas 35,000
budi 3 adriana Wulan
budi 4 Satyahadi Rakha 35,000
radjin 5 Musaadatul Khakimah
radjin 6 Niken Kusumaningtyas
widya 7 Arishinta afryan
radjin 8 Febriani kartika
radjin 9 Heri Setio ardianto 35,000
iswandi 10 Siska Nurmalina
widya 11 Rohimatun wahyuningsih
dewi 12 Indra ratmoko 50,000
dewi 13 Aris Sudarmanto
lafran 14 Edi Supriyanto
emy 15 Rokhimatun Wahyuningsih 35,000
bima 16 Sodiq Arifin 40,000
sugiyanto 17 Edy Purnomo 50,000
monika 18 Thomas wardoyo
emy 19 Siska arum
widya 20 Umi Umairoh 35,000
emy 21 Ristianingsih 35,000
budi 22 Ayu kusuma dewi 35,000
laurenz 23 adriana Wulan
monika 24 Sultan Dzaky
emy 25
Kepada Yth
Up. Manajer Klaim
JAKARTA 10220
ENIS PEMERIKSAAN Tindakan

292,900
183,300
75,000 401,100
103,300
75,000 278,400
75,000 278,400 75,000
75,000 40,000
75,000 278,400
75,000 278,400
75,000 235,400
18,800 21,400
75,000 163,300 6,900
75,000 304,100
75,500
64,000
26,800
75,000 57,000 27,200
75,000 450,900
87,100 1,000 130,000
167,500 40,000
109,600
75,000 175,000 352,000
5 Suite 1508
dibayar
JUMLAH
pasien
327,900 widya
218,300 widya
476,100 rosik
138,300 widya
353,400 budi
428,400 budi
115,000 lafran
353,400 budi
35,000 widya
353,400 budi
310,400 budi
90,200 savero
245,200 bambang
379,100 laurenz
110,500 monika
104,000 savero
76,800 aji
159,200 bhima
525,900 sukartono
253,100 ilham
242,500 ilham
144,600 widya
602,000 rosik
-
-
Pekalongan,1 DESEMBER 2014
No :
Lamp
Hal :

1 Kinara Hadi 35,000
2 Naily Adhiba 35,000
3 Satyahadi 75,000
5 Musadatul 75,000
6 Satyahadi 75,000
7 Siska arum 35,000
8 Rohimatun wahyuningsih 75,000
9 Mustaminah 40,000
11 Dedy Yulianto 75,000
12 Kurnia achmadin 35,000
13 Saidatul Istiqomah 35,000
14 Abdulah Lubis 35,000
15 Jauza Fahrizki 35,000
16 Fathimah Az Zahra 35,000
17 Aditya wibisono 35,000
18 Rozikin 75,000
19 Saidatul Istiqomah 35,000
20
21
22
Kepada Yth
Up. Manajer Klaim
JAKARTA 10220
Tindakan dibayar
JUMLAH
94,000 129,000
395,700 430,700
150,000 225,000
75,000 150,000
27,800 75,000 177,800
134,800 75,000 284,800
217,600 250,000 502,600
75,000 150,000
225,800 50,000 315,800
177,500 212,500
12,100 87,100
31,300 66,300
64,200 80,000 179,200
180,300 215,300
91,600 126,600
117,200 152,200
149,400 184,400
75,000
5,700 100,000 (78,000) 62,700
-
-
-
Pekalongan,16 Desember 2014
No :
Lamp
Hal :

Dr. Umum
widya 1 Muhamad Raffi 35,000
widya 2 Heru Pramono 35,000
budi 3 Ira Kurniadewi 35,000
budi 4 Eko Prasetyo
budi 5 Nabila Aulia
budi 6 Gita Ratna Fuada 40,000
emy 7 Rafael Fazle 35,000
budi 8 Arishinta
emy 9 Hermawan 35,000
widya 10 Vivi milla 35,000
bima 11 Ayu Pratiwi
jefly 12 Shania Paramitha 35,000
ilham 13 Anisa Rziki 50,000
monika 14 Restu Kurniawan 50,000
widya 15 Nurul Naswa 50,000
widya 16 Moch Irwan 35,000
widya 17 Hanum restu 35,000
wayan 18 Munasifah 40,000
ilham 19 Alesandro 35,000
20 Siska Arum
21 Saidatul 35,000
22
Kepada Yth
Up. Manajer Klaim
JAKARTA 10220
NIS PEMERIKSAAN Tindakan

51,100 300,000
50,500
475,000
75,000 207,100 80,000
75,000
228,600
138,100 10,500 200,000
75,000 40,000
216,300 20,000
115,500 40,000
75,000 49,100
568,600
149,200
32,200 325,000
159,700
195,900
58,500 22,800
212,500 15,900
122,800
80,000 478,300 1,900
320,100
15 Suite 1508
dibayar
JUMLAH
pasien
386,100 agus
85,500 widya
510,000 dewi
362,100 laurenz
75,000 bhima
268,600 monika
(208,000) 175,600 emy
115,000 lafran
271,300 emy
190,500 ilham
124,100 wayan
603,600 monika
199,200 radjin
407,200 ipul
209,700 emy
230,900 radjin
116,300 emy
268,400 emy
157,800 widya
560,200 widya
355,100 emy

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Pekalongan, 15 Januari 2013

No : : BA0003307A/ADM/BR/I/2013 Kepada Yth

JENIS PEMERIKSAAN Tindakan dibayar

Adapun pembayarannya, dapat menstranfer ke rekening kami di

Bank BTN Cab.Pekalongam

mohon bukti transfernya di fax ke (0285) 432002

RSU Budi Rahayu Pekalongan

RSU BUDI RAHAYU

PT. Administrasi Medika

RSU BUDI RAHAYU

Kepada Yth RSU BUDI RAHAYU

Kepada PT. Administrasi Medika

RSU BUDI RAHAYU

RSU BUDI RAHAYU

RSU BUDI RAHAYU

Kepada Yth Kepada Yth

RSU BUDI RAHAYU PEKALONGAN

JENIS PEMERIKSAAN Tindakan dibayar

Adapun pembayarannya, dapat menstranfer ke rekening kami di

an. RS BUDI RAHAYU

mohon bukti transfernya di fax ke (0285) 432002

RSU Budi Rahayu Pekalongan

JENIS PEMERIKSAAN dibayar Tindakan

JUMLAH Tindakan dibayar

Adapun pembayarannya, dapat menstranfer ke rekening kami di

Bank BTN Cab.Pekalongam

RSU Budi Rahayu Pekalongan

No : : 00012A/ADM/BR/V/2013 Kepada Yth

JENIS PEMERIKSAAN Tindakan Dibayar

Adapun pembayarannya, dapat menstranfer ke rekening kami di

Bank BTN Cab.Pekalongam

mohon bukti transfernya di fax ke (0285) 432002

RSU Budi Rahayu Pekalongan

JENIS PEMERIKSAAN dibayar Tindakan

No : : BA0002003A/ADM/BR/VII/2011 Kepada Yth

JENIS PEMERIKSAAN Tindakan Dibayar

Adapun pembayarannya, dapat menstranfer ke rekening kami di

Bank BTN Cab.Pekalongam

mohon bukti transfernya di fax ke (0285) 432002

RSU Budi Rahayu Pekalongan

JENIS PEMERIKSAAN Tindakan dibayar

Adapun pembayarannya, dapat menstranfer ke rekening kami di

Bank BTN Cab.Pekalongam

mohon bukti transfernya di fax ke (0285) 432002

RSU Budi Rahayu Pekalongan

No : 00305A/ADM/BR/VIII/2013 Kepada Yth

JENIS PEMERIKSAAN Tindakan

No :: 00472A/ADM/BR/IX/2013 Kepada Yth

JENIS PEMERIKSAAN Dibayar Tindakan

JENIS PEMERIKSAAN Tindakan

2 Ery wibowo 75,000 81,000

3 Febriana wulanda 75,000 59,400 40,000

4 Rafael Fazle 35,000 134,900

5 Moch Irwan 40,000 71,800

6 Fakhrudin 75,000 224,800

7 Erva Nuryanti 50,000 539,100

8 M.Tohorin 35,000 72,100

9 Dinie legawati 75,000 40,000

11 Niska Dwi 75,000 92,400 40,000

12 Veronika Aprilia 35,000 129,300

13 Erva Nuryanti 35,000 336,700

14 Nurhayati 50,000 12,900

15 Hermawan 50,000 213,800 15,000