PERHITUNGAN JASA PELAYANAN JKN BULAN MEI TAHUN 2020

Nama Puskesmas PUSKESMAS KEMANTAN FORMULIR 2

Jumlah Peserta JKN 17,779,350
Jumlah besaran Kapitasi 4,500 5,926,450
Jumlah Kapitasi 23,705,800 23,705,800

Jumlah Jumlah JASA PELAYANAN

Point Persentase Total PENERIMAAN KAPITASI DENGAN YANG DITERIMA
KEHADIRAN
Variabel Kehadiran Seluruh JUMLAH PESERTA 8.176 DENGAN PESERTA
TANG Ketenagaan Point 8117
RANGKAP
JENIS GUNG
Pendi MASA TUGAS JUMLAH TANDA
No. Nama Pegawai Jabatan Pangkat/Gol KETENAG JAWAB PAJAK 5 %
dikan KERJA ADMINIS (Perkalian (Kolom 9 dikali Kolom TERIMA TANGAN
AAN PROGRA
Jumlah TRATIF
M Kolom 8 x Jasa Pelayanan 75 Biaya Operasional 25
10 dibagi jumlah
% Pembagian kolom 7) % %
Hari Jumlah (= Kolom 1 kolom 9)
Kolom 3 dibagi
Masuk Hari Kerja + 2 + 5 + 6)
kolom 4)
Kerja

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
1 ARLON, SKM Kepala Puskesmas Penata Tk.I / III D S1 80 10 22 22 100 190 100 190 17,779,350 5,926,450 1,614,373
6 80,719 1,533,655 1
### 2 ERIFIANTI, AMd.Kep Perawat/KTU Penata Tk.I / III D D3 60 25 22 22 30 115 100 115 17,779,350 5,926,450 977,121 48,856 928,265 2
3 HAYADI Sanitarian Penata Tk.I / III D D1 50 25 19 22 75 86 65 17,779,350 5,926,450 550,355 27,518 522,837 3
4 LISNAWATI. S.ST Bidan Penata Tk.I / III D D3 60 25 20 22 85 91 77 17,779,350 5,926,450 656,563 32,828 623,735 4
5 YESI CITRA DEWI, AM.Keb Bidan Penata / III C D3 60 10 20 22 70 91 64 17,779,350 5,926,450 540,699 27,035 513,664 5
- - -
7 Dr. WINDA SASTRI HANDAYANI Dokter Umum Penata / III C S1 150 5 14 22 10 165 64 105 17,779,350 5,926,450 892,154 44,608 847,546 6
8 Ns. H. RONI SAPUTRA, S. Kep Perawat Penata Muda Tk.I / III B S1
9 RINA SOFYARTI. AM. Farm Asisten Apoteker Penata / III C D3 60 20 22 22 80 100 80 17,779,350 5,926,450 679,736 33,987 645,749 7
10 TUTI SUMIATI. AMK Perawat Penata / III C D3 60 10 19 22 70 86 60 17,779,350 5,926,450 513,664 25,683 487,981 8
11 FITRI DONA, Skep.M.Kep Perawat Penata Muda Tk.I / III B S1 100 5 19 22 105 86 91 17,779,350 5,926,450 770,496 38,525 731,972 9
12 TATI YULIA RAHMI, AMK Perawat Penata Muda Tk.I / III B D3 60 10 21 22 70 95 67 17,779,350 5,926,450 567,734 28,387 539,348 10
13 22 0 0 0 - - -
14 SRI DASMIATI, AMd.Keb Bidan Penata Muda / III A D3 60 10 22 22 70 100 70 17,779,350 5,926,450 594,769 29,738 565,031 11
15 ALI SADIKIN, S.ST Analis Penata Muda Tk.I / III B S1 80 10 20 22 30 120 91 109 17,779,350 5,926,450 926,913 46,346 880,567 12
16 REKI ARDIANTI, AM. KL Sanitarian Penata Muda Tk.I / III B D3 60 5 21 22 65 95 62 17,779,350 5,926,450 527,182 26,359 500,823 13
17 FIRDA IRNA DEWI, AM, Kep Perawat Penata Muda Tk.I / III B D3 60 5 21 22 10 75 95 72 17,779,350 5,926,450 608,287 30,414 577,872 14
18 TITIN FITRIANI, AM. Kep Perawat Penata Muda / III A D3 60 5 19 22 65 86 56 17,779,350 5,926,450 476,974 23,849 453,125 15
19 DIRA FITRIANI PRATAMA, AM. Farm Asisten Apoteker Penata Muda / III A D3 60 5 20 22 65 91 59 17,779,350 5,926,450 502,078 25,104 476,974 16

20 BUJANG Adminitrasi Kesehatan Penata Muda Tk.I / III B SMA 25 25 21 22 50 95 48 17,779,350 5,926,450 405,524
20,276 385,248 17
21 EKA.S PUSPAYANTI, AMKG Perawat Gigi Penata Muda / III A D3 60 5 20 22 65 91 59 17,779,350 5,926,450 502,078 25,104 476,974 18
22 DINA OKTA SAVITRI, AM.Keb Bidan Penata Muda / III A D3 60 5 18 22 65 82 53 17,779,350 5,926,450 451,870 22,594 429,277 19
23 DESI SARTIKA, Amd.Keb Bidan Pengatur Tk I / II D D3 60 5 18 22 65 82 53 17,779,350 5,926,450 451,870 451,870 20
24 NETRA, AMK Perawat Pengatur / II C D3 60 5 20 22 65 91 59 17,779,350 5,926,450 502,078 502,078 21
25 DIAN NOFRITA, AM. Kep Perawat Pengatur / II C D3 60 5 21 22 20 85 95 81 17,779,350 5,926,450 689,392 689,392 22
26 NUZUL CHAIRA. AM.Keb Bidan Pengatur / II C D3 60 5 21 22 65 95 62 17,779,350 5,926,450 527,182 527,182 23
27 WIJAYANTI. AM. Keb Bidan Pengatur / II C D3 60 5 21 22 65 95 62 17,779,350 5,926,450 527,182 527,182 24
28 ELFIANTI, AM.Keb Bidan Pengatur / II C D3 60 5 20 22 65 91 59 17,779,350 5,926,450 502,078 502,078 25
29 SHINTA NAFIA P. AM.Keb Bidan Pengatur / II C D3 60 5 21 22 65 95 62 17,779,350 5,926,450 527,182 527,182 26
30 ELIFIA MARLIZA, Am.Keb Bidan Pengatur / II C D3 60 5 20 22 65 91 59 17,779,350 5,926,450 502,078 502,078 27
31 IQRA RAMADHAN, Amd.GZ GIZI Pengatur / II C D3 60 5 18 22 65 82 53 17,779,350 5,926,450 451,870 451,870 28
32 NENG YETMIR Adminitrasi Kesehatan Pengatur Muda / II A SMA 25 5 22 22 10 40 100 40 17,779,350 5,926,450 339,868 339,868 29
2093 17,779,350 637,929 17,141,421 17,779,350

Diketahui Oleh Kemantan, Mei 20 20

Kepala Puskesmas Kemantan Kepala Tata Usaha Bendahara JKN

ARLON, SKM ERIFIANTI, AM.Kep ALI SADIKIN, S.ST

NIP. 19800927 200701 1 00 1 NIP. 197309261992032001 NIP. 19770521 200901 1 005
 PERHITUNGAN JASA PELAYANAN JKN BULAN JUNI TAHUN 2020
Nama Puskesmas PUSKESMAS KEMANTAN FORMULIR 2
Jumlah Peserta JKN 17,946,413
Jumlah besaran Kapitasi 4,500 5,982,138
Jumlah Kapitasi 23,928,550 23,928,550

Jumlah Jumlah JASA PELAYANAN

Point Persentase Total PENERIMAAN KAPITASI DENGAN YANG DITERIMA
KEHADIRAN
Variabel Kehadiran Seluruh JUMLAH PESERTA 8.176 DENGAN PESERTA
TANG Ketenagaan Point 8117
RANGKAP
JENIS GUNG
Pendi MASA TUGAS JUMLAH TANDA
No. Nama Pegawai Jabatan Pangkat/Gol KETENAG JAWAB PAJAK 5 %
dikan KERJA ADMINIS (Perkalian (Kolom 9 dikali Kolom TERIMA TANGAN
AAN PROGRA
Jumlah TRATIF
M Kolom 8 x Jasa Pelayanan 75 Biaya Operasional 25
10 dibagi jumlah
% Pembagian kolom 7) % %
Hari Jumlah (= Kolom 1 kolom 9)
Kolom 3 dibagi
Masuk Hari Kerja + 2 + 5 + 6)
kolom 4)
Kerja

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
1 ARLON, SKM Kepala Puskesmas Penata Tk.I / III D S1 80 10 25 25 100 190 100 190 17,946,413 5,982,138 1,851,954 1
6 92,598 1,759,357
### 2 ERIFIANTI, AMd.Kep Perawat/KTU Penata Tk.I / III D D3 60 25 23 25 30 115 92 106 17,946,413 5,982,138 1,031,246 51,562 979,684 2
3 HAYADI Sanitarian Penata Tk.I / III D D1 50 25 17 25 75 68 51 17,946,413 5,982,138 497,104 24,855 472,248 3
4 LISNAWATI. S.ST Bidan Penata Tk.I / III D D3 60 25 23 25 85 92 78 17,946,413 5,982,138 762,225 38,111 724,114 4
5 YESI CITRA DEWI, AM.Keb Bidan Penata / III C D3 60 10 17 25 70 68 48 17,946,413 5,982,138 463,963 23,198 440,765 5

6 Dr. LENI MARLENI Dokter Umum Penata / III C S1 150 5 17 25 155 68 105 17,946,413 5,982,138 1,027,347 51,367 975,980 6
8 Ns. H. RONI SAPUTRA, S. Kep Perawat Penata Muda Tk.I / III B S1 25 0 0
7 RINA SOFYARTI. AM. Farm Asisten Apoteker Penata / III C D3 60 20 22 25 80 88 70 17,946,413 5,982,138 686,198 34,310 651,888 7
8 TUTI SUMIATI. AMK Perawat Penata / III C D3 60 10 21 25 70 84 59 17,946,413 5,982,138 573,131 28,657 544,475 8
9 FITRI DONA, Skep.M.Kep Perawat Penata Muda Tk.I / III B S1 100 5 16 25 105 64 67 17,946,413 5,982,138 655,007 32,750 622,257 9
10 TATI YULIA RAHMI, AMK Perawat Penata Muda Tk.I / III B D3 60 10 23 25 70 92 64 17,946,413 5,982,138 627,715 31,386 596,329 10

11 SRI DASMIATI, AMd.Keb Bidan Penata Muda / III A D3 60 10 23 25 70 92 64 17,946,413 5,982,138 627,715 31,386 596,329 11
12 ALI SADIKIN, S.ST Analis Penata Muda Tk.I / III B S1 80 10 21 25 30 120 84 101 17,946,413 5,982,138 982,511 49,126 933,385 12
13 REKI ARDIANTI, AM. KL Sanitarian Penata Muda Tk.I / III B D3 60 5 18 25 65 72 47 17,946,413 5,982,138 456,166 22,808 433,357 13
14 FIRDA IRNA DEWI, AM, Kep Perawat Penata Muda Tk.I / III B D3 60 5 18 25 10 75 72 54 17,946,413 5,982,138 526,345 26,317 500,028 14
15 TITIN FITRIANI, AM. Kep Perawat Penata Muda / III A D3 60 5 19 25 65 76 49 17,946,413 5,982,138 481,508 24,075 457,433 15
16 DIRA FITRIANI PRATAMA, AM. Farm Asisten Apoteker Penata Muda / III A D3 60 5 21 25 65 84 55 17,946,413 5,982,138 532,193 26,610 505,584 16

17 BUJANG Adminitrasi Kesehatan Penata Muda Tk.I / III B SMA 25 25 23 25 50 92 46 17,946,413 5,982,138 448,368 17
22,418 425,950
18 EKA.S PUSPAYANTI, AMKG Perawat Gigi Penata Muda / III A D3 60 5 21 25 65 84 55 17,946,413 5,982,138 532,193 26,610 505,584 18
19 DINA OKTA SAVITRI, AM.Keb Bidan Penata Muda / III A D3 60 5 16 25 65 64 42 17,946,413 5,982,138 405,481 20,274 385,207 19
20 DESI SARTIKA, Amd.Keb Bidan Pengatur Tk I / II D D3 60 5 8 25 65 32 21 17,946,413 5,982,138 202,740 202,740 20
21 NETRA, AMK Perawat Pengatur / II C D3 60 5 17 25 65 68 44 17,946,413 5,982,138 430,823 430,823 21
22 DIAN NOFRITA, AM. Kep Perawat Pengatur / II C D3 60 5 24 25 20 85 96 82 17,946,413 5,982,138 795,366 795,366 22
23 NUZUL CHAIRA. AM.Keb Bidan Pengatur / II C D3 60 5 21 25 65 84 55 17,946,413 5,982,138 532,193 532,193 23
24 WIJAYANTI. AM. Keb Bidan Pengatur / II C D3 60 5 20 25 65 80 52 17,946,413 5,982,138 506,851 506,851 24
25 ELFIANTI, AM.Keb Bidan Pengatur / II C D3 60 5 16 25 65 64 42 17,946,413 5,982,138 405,481 405,481 25
26 SHINTA NAFIA P. AM.Keb Bidan Pengatur / II C D3 60 5 22 25 65 88 57 17,946,413 5,982,138 557,536 557,536 26
27 ELIFIA MARLIZA, Am.Keb Bidan Pengatur / II C D3 60 5 20 25 65 80 52 17,946,413 5,982,138 506,851 506,851 27
28 IQRA RAMADHAN, Amd.GZ GIZI Pengatur / II C D3 60 5 19 25 65 76 49 17,946,413 5,982,138 481,508 481,508 28

29 NENG YETMIR Adminitrasi Kesehatan Pengatur Muda / II A SMA 25 5 23 25 10 40 92 37 17,946,413 5,982,138 358,694 29
358,694
1841 5,982,138 17,946,413 658,419 17,287,994 17,946,413

Diketahui Oleh Kemantan, juni 2020

Kepala Puskesmas Kemantan Kepala Tata Usaha Bendahara JKN

ARLON, SKM ERIFIANTI, Amd.Kep ALI SADIKIN, S.ST

NIP. 19800927 200701 1 00 1 197309261992032000 NIP. 19770521 200901 1 005
 PERHITUNGAN JASA PELAYANAN JKN BULAN JULI TAHUN 2020
Nama Puskesmas PUSKESMAS KEMANTAN FORMULIR 2
Jumlah Peserta JKN 17,970,713
Jumlah besaran Kapitasi 4,500 5,990,238
Jumlah Kapitasi 23,960,950 23,960,950

Jumlah Jumlah JASA PELAYANAN

Point Persentase Total PENERIMAAN KAPITASI DENGAN YANG DITERIMA
KEHADIRAN
Variabel Kehadiran Seluruh JUMLAH PESERTA 8.176 DENGAN PESERTA
TANG Ketenagaan Point 8117
RANGKAP
JENIS GUNG
Pendi MASA TUGAS JUMLAH TANDA
No. Nama Pegawai Jabatan Pangkat/Gol KETENAG JAWAB PAJAK 5 %
dikan KERJA ADMINIS (Perkalian (Kolom 9 dikali Kolom TERIMA TANGAN
AAN PROGRA
Jumlah TRATIF
M Kolom 8 x Jasa Pelayanan 75 Biaya Operasional 25
10 dibagi jumlah
% Pembagian kolom 7) % %
Hari Jumlah (= Kolom 1 kolom 9)
Kolom 3 dibagi
Masuk Hari Kerja + 2 + 5 + 6)
kolom 4)
Kerja

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
1 ARLON, SKM Kepala Puskesmas Penata Tk.I / III D S1 80 10 25 26 100 190 96 183 17,970,713 5,990,238 1,712,355
6 85,618 1,626,737 1
### 2 ERIFIANTI, AMd.Kep Perawat Penata Tk.I / III D D3 60 25 16 26 30 115 62 71 17,970,713 5,990,238 663,312 33,166 630,147 2
3 HAYADI Sanitarian Penata Tk.I / III D D1 50 25 24 26 75 92 69 17,970,713 5,990,238 648,892 32,445 616,448 3
4 LISNAWATI. S.ST Bidan Penata Tk.I / III D D3 60 25 25 26 85 96 82 17,970,713 5,990,238 766,053 38,303 727,751 4
5 YESI CITRA DEWI, AM.Keb Bidan Penata / III C D3 60 10 22 26 70 85 59 17,970,713 5,990,238 555,163 27,758 527,405 5

-
6 Dr. LENI MARLENI Dokter Umum Penata / III C S1 150 5 22 26 155 85 131 17,970,713 5,990,238 1,229,290 61,465 1,167,826 6
8 Ns. H. RONI SAPUTRA, S. Kep Perawat Penata Muda Tk.I / III B S1 - - -
7 RINA SOFYARTI. AM. Farm Asisten Apoteker Penata / III C D3 60 20 21 26 80 81 65 17,970,713 5,990,238 605,633 30,282 575,351 7
8 TUTI SUMIATI. AMK Perawat Penata / III C D3 60 10 23 26 70 88 62 17,970,713 5,990,238 580,398 29,020 551,378 8
9 FITRI DONA, Skep.M.Kep Perawat Penata Muda Tk.I / III B S1 100 5 11 26 105 42 44 17,970,713 5,990,238 416,373 20,819 395,554 9
10 TATI YULIA RAHMI, AMK Perawat Penata Muda Tk.I / III B D3 60 10 26 26 70 100 70 17,970,713 5,990,238 656,102 32,805 623,297 10
-
11 SRI DASMIATI, AMd.Keb Bidan Penata Muda / III A D3 60 10 24 26 70 92 65 17,970,713 5,990,238 605,633 30,282 575,351 11
12 ALI SADIKIN, S.ST Analis Penata Muda Tk.I / III B S1 80 10 23 26 30 120 88 106 17,970,713 5,990,238 994,968 49,748 945,220 12
13 REKI ARDIANTI, AM. KL Sanitarian Penata Muda Tk.I / III B D3 60 5 23 26 65 88 58 17,970,713 5,990,238 538,941 26,947 511,994 13
14 FIRDA IRNA DEWI, AM, Kep Perawat Penata Muda Tk.I / III B D3 60 5 21 26 10 75 81 61 17,970,713 5,990,238 567,781 28,389 539,392 14
15 TITIN FITRIANI, AM. Kep Perawat Penata Muda / III A D3 60 5 22 26 65 85 55 17,970,713 5,990,238 515,509 25,775 489,733 15
16 DIRA FITRIANI PRATAMA, AM. Farm Asisten Apoteker Penata Muda / III A D3 60 5 23 26 65 88 58 17,970,713 5,990,238 538,941 26,947 511,994 16

17 BUJANG Adminitrasi Kesehatan Penata Muda Tk.I / III B SMA 25 25 23 26 50 88 44 17,970,713 5,990,238 414,570
20,729 393,842 17
18 EKA.S PUSPAYANTI, AMKG Perawat Gigi Penata Muda / III A D3 60 5 24 26 65 92 60 17,970,713 5,990,238 562,373 28,119 534,255 18
19 DINA OKTA SAVITRI, AM.Keb Bidan Penata Muda / III A D3 60 5 18 26 65 69 45 17,970,713 5,990,238 421,780 21,089 400,691 19
20 DESI SARTIKA, Amd.Keb Bidan Pengatur Tk I / II D D3 60 5 10 26 65 38 25 17,970,713 5,990,238 234,322 234,322 20
21 NETRA, AMK Perawat Pengatur / II C D3 60 5 24 26 65 92 60 17,970,713 5,990,238 562,373 562,373 21
22 DIAN NOFRITA, AM. Kep Perawat Pengatur / II C D3 60 5 24 26 20 85 92 78 17,970,713 5,990,238 735,411 735,411 22
23 NUZUL CHAIRA. AM.Keb Bidan Pengatur / II C D3 60 5 23 26 65 88 58 17,970,713 5,990,238 538,941 538,941 23
24 WIJAYANTI. AM. Keb Bidan Pengatur / II C D3 60 5 23 26 65 88 58 17,970,713 5,990,238 538,941 538,941 24
25 ELFIANTI, AM.Keb Bidan Pengatur / II C D3 60 5 22 26 65 85 55 17,970,713 5,990,238 515,509 515,509 25
### 26 SHINTA NAFIA P. AM.Keb Bidan Pengatur / II C D3 60 5 23 26 65 88 58 17,970,713 5,990,238 538,941 538,941 26
27 ELIFIA MARLIZA, Am.Keb Bidan Pengatur / II C D3 60 5 20 26 65 77 50 17,970,713 5,990,238 468,644 468,644 27
28 IQRA RAMADHAN, Amd.GZ GIZI Pengatur / II C D3 60 5 20 26 65 77 50 17,970,713 5,990,238 468,644 468,644 28

29 NENG YETMIR Adminitrasi Kesehatan Pengatur Muda / II A SMA 25 5 26 26 10 40 100 40 17,970,713 5,990,238 374,916
374,916 29
1917 17,970,713 649,703 17,321,010 17,970,713

Diketahui Oleh Kemantan, Juli 2020

Kepala Puskesmas Kemantan Kepala Tata Usaha Bendahara JKN

ARLON, SKM ERIFIANTI, Amd. Kep ALI SADIKIN, S.ST

NIP. 19800927 200701 1 00 1 NIP. 19730926 199203 2 001 NIP. 19770521 200901 1 005
 DAFTAR TANDA TERIMA DANA JKN
PEGAWAI PUSKESMAS KEMANTAN
BULAN MEI S/D AGUSTUS TAHUN 2020

No. Nama Pegawai Pangkat/Gol MEI JUNI JULI TOTAL 5 % DINKES 10% UTK TKS JUMLAH TERIMA TANDA TANGAN
1 2 3 4 5 6 8 9 10 11 12
1 ARLON , SKM Penata Tk.I / III D 1,542,366 1,785,737 1,645,887 4,973,990 248,700 497,399 4,227,892 1
2 ERIFIANTI, AMd.Kep Penata Tk.I / III D 928,265 979,684 630,147 2,538,095 126,905 253,810 2,157,381 2
3 HAYADI Penata Tk.I / III D 522,837 472,248 616,448 1,611,533 80,577 161,153 1,369,803 3
4 LISNAWATI. S.ST Penata Tk.I / III D 623,735 724,114 727,751 2,075,600 103,780 207,560 1,764,260 4
5 YESI CITRA DEWI, AM.Keb Penata / III C 513,664 440,765 527,405 1,481,835 74,092 148,183 1,259,560 5
6 IDA ELIZA. AMK Penata Tk.I / III D - #REF!
7 Dr. WINDA SASTRI HANDAYANI Penata / III C 847,546 975,980 1,167,826 2,991,352 149,568 299,135 2,542,649 7
8 Ns. H. RONI SAPUTRA, S. Kep Penata Muda Tk.I / III B - - - - - - - #REF!
9 RINA SOFYARTI. AM. Farm Penata / III C 645,749 651,888 575,351 1,872,989 93,649 187,299 1,592,040 9
10 TUTI SUMIATI. AMK Penata / III C 487,981 544,475 551,378 1,583,834 79,192 158,383 1,346,259 10
11 FITRI DONA, S.Kep. M.Kep Penata Muda Tk.I / III B 731,972 622,257 395,554 1,749,782 87,489 174,978 1,487,315 11
12 TATI YULITA RAHMI, AMK Penata Muda Tk.I / III B 539,348 596,329 623,297 1,758,974 87,949 175,897 1,495,128 12
#REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF!
14 SRI DASMIATI, AMd.Keb Penata Muda / III A 565,031 596,329 575,351 1,736,711 86,836 173,671 1,476,205 14
15 ALI SADIKIN, S.ST Penata Muda Tk.I / III B 880,567 933,385 945,220 2,759,172 137,959 275,917 2,345,296 15
16 REKI ARDIANTI, AM. KL Penata Muda Tk.I / III B 500,823 433,357 511,994 1,446,174 72,309 144,617 1,229,248 16
17 FIRDA IRNA DEWI, AM, Kep Penata Muda Tk.I / III B 577,872 500,028 539,392 1,617,292 80,865 161,729 1,374,698 17
18 TITIN FITRIANI, AM. Kep Penata Muda / III A 476,974 457,433 489,733 1,424,140 71,207 142,414 1,210,519 18
19 DIRA FITRIANI PRATAMA, AM. Farm Penata Muda / III A 476,974 505,584 511,994 1,494,552 74,728 149,455 1,270,369 19
20 BUJANG Penata Muda Tk.I / III B 385,248 425,950 393,842 1,205,039 60,252 120,504 1,024,283 20
21 EKA.S PUSPAYANTI, AMKG Penata Muda / III A 476,974 505,584 534,255 1,516,812 75,841 151,681 1,289,290 21
22 DINA OKTA SAVITRI, AM.Keb Penata Muda / III A 429,277 385,207 400,691 1,215,174 60,759 121,517 1,032,898 22
23 DESI SARTIKA, Amd.Keb Pengatur Tk I / II D 451,870 202,740 234,322 888,933 44,447 88,893 755,593 23
24 NETRA, AMK Pengatur / II C 502,078 430,823 562,373 1,495,274 74,764 149,527 1,270,983 24
25 DIAN NOFRITA, AM. Kep Pengatur / II C 689,392 795,366 735,411 2,220,169 111,008 222,017 1,887,143 25
26 NUZUL CHAIRA. AM.Keb Pengatur / II C 527,182 532,193 538,941 1,598,316 79,916 159,832 1,358,569 26
27 WIJAYANTI. AM. Keb Pengatur / II C 527,182 506,851 538,941 1,572,974 78,649 157,297 1,337,028 27
28 ELFIANTI, AM.Keb Pengatur / II C 502,078 405,481 515,509 1,423,067 71,153 142,307 1,209,607 28
29 SHINTA NAFIA P. AM.Keb Pengatur / II C 527,182 557,536 538,941 1,623,659 81,183 162,366 1,380,110 29
30 ELIFIA MARLIZA, AM.Keb Pengatur / II C 502,078 506,851 468,644 1,477,573 73,879 147,757 1,255,937 30
31 IQRA RAMADHAN, Amd.Gz Pengatur / II C 451,870 481,508 468,644 1,402,023 70,101 140,202 1,191,719 31
32 NENG YETMIR Pengatur Muda / II A 339,868 358,694 374,916 1,073,478 53,674 107,348 912,456 32
#REF! #REF! #REF! #REF!

Diketahui Oleh Kemantan, September 2020

Kepala Puskesmas Kemantan Bendahara JKN

ARLON, SKM ALI SADIKIN, S.ST

NIP. 19800927 20070 1 00 1 NIP. 19770521 200901 1 005
 PERHITUNGAN JASA PELAY
Nama Puskesmas PUSKESMAS KEMANTAN
Jumlah Peserta JKN
Jumlah besaran Kapitasi 4,500
Jumlah Kapitasi 24,171,550

JENIS
Pendi
No. Nama Pegawai Jabatan Pangkat/Gol KETENAG
dikan
AAN

1 2 3 4 5 6

6 1 ARLON, SKM Kepala Puskesmas Penata Tk.I / III D S1 80

### 2 ERIFIANTI, AMd.Kep Perawat Penata Tk.I / III D D3 60

3 HAYADI Sanitarian Penata Tk.I / III D D1 50
4 LISNAWATI. S.ST Bidan Penata Tk.I / III D D3 60
5 YESI CITRA DEWI, AM.Keb Bidan Penata / III C D3 60

6 IDA ELIZA. AMK Perawat Penata Tk.I / III D D3 60

7 Dr. WINDA SASTRI HANDAYANI Dokter Umum Penata / III C S1 150
8 Ns. H. RONI SAPUTRA, S. Kep Perawat Penata Muda Tk.I / III B S1 100
9 RINA SOFYARTI. AM. Farm Asisten Apoteker Penata / III C D3 60
10 TUTI SUMIATI. AMK Perawat Penata / III C D3 60
11 FITRI DONA, Skep.M.Kep Perawat Penata Muda Tk.I / III B S1 60
12 TATI YULIA RAHMI, AMK Perawat Penata Muda Tk.I / III B D3 60
13 DODI, SKM KESMAS/ KTU Penata Muda / III A S1 80
14 SRI DASMIATI, AMd.Keb Bidan Penata Muda / III A D3 60
15 ALI SADIKIN, S.ST Analis Penata Muda Tk.I / III B S1 80
16 REKI ARDIANTI, AM. KL Sanitarian Penata Muda Tk.I / III B D3 60
17 FIRDA IRNA DEWI, AM, Kep Perawat Penata Muda Tk.I / III B D3 60
18 TITIN FITRIANI, AM. Kep Perawat Penata Muda / III A D3 60
19 DIRA FITRIANI PRATAMA, AM. Farm Asisten Apoteker Penata Muda / III A D3 60

20 BUJANG Adminitrasi Kesehatan Penata Muda Tk.I / III B SMA 25

21 EKA.S PUSPAYANTI, AMKG Perawat Gigi Penata Muda / III A D3 60

22 DINA OKTA SAVITRI, AM.Keb Bidan Penata Muda / III A D3 60
23 DESI SARTIKA, Amd.Keb Bidan Pengatur Tk I / II D D3 60
24 NETRA, AMK Perawat Pengatur / II C D3 60
25 DIAN NOFRITA, AM. Kep Perawat Pengatur / II C D3 60
26 NUZUL CHAIRA. AM.Keb Bidan Pengatur / II C D3 60
27 WIJAYANTI. AM. Keb Bidan Pengatur / II C D3 60
28 ELFIANTI, AM.Keb Bidan Pengatur / II C D3 60
29 SHINTA NAFIA P. AM.Keb Bidan Pengatur / II C D3 60
30 ELIFIA MARLIZA, Am.Keb Bidan Pengatur / II C D3 60
31 IQRA RAMADHAN, Amd.GZ GIZI Pengatur / II C D3 60

32 NENG YETMIR Adminitrasi Kesehatan Pengatur Muda / II A SMA 25

Diketahui Oleh
Kepala Puskesmas Kemantan

ARLON, SKM
NIP. 19800927 200701 1 00 1
PERHITUNGAN JASA PELAYANAN JKN BULAN MEI TAHUN 2020

18,128,663
6,042,888
24,171,550

Jumlah Jumlah
Point Persentase Total PENERIMAAN KAPITASI DENGA
KEHADIRAN
Variabel Kehadiran Seluruh JUMLAH PESERTA 8.176
TANG Ketenagaan Point
RANGKAP
GUNG
MASA TUGAS
JAWAB
KERJA ADMINIS (Perkalian
PROGRA
Jumlah TRATIF
M Kolom 8 x Jasa Pelayanan 75
% Pembagian kolom 7) %
Hari Jumlah (= Kolom 1
Kolom 3 dibagi
Masuk Hari Kerja + 2 + 5 + 6)
kolom 4)
Kerja

7 8 9 10 11 12 13 14 15

10 22 22 100 190 100 190 18,128,663

25 22 22 30 115 100 115 18,128,663

25 19 22 75 86 65 18,128,663
25 20 22 85 91 77 18,128,663
10 20 22 70 91 64 18,128,663

10
5 22 10 165 0 0 18,128,663
10
20 22 22 80 100 80 18,128,663
10 19 22 70 86 60 18,128,663
5 19 22 65 86 56 18,128,663
10 21 22 70 95 67 18,128,663
10
10 22 22 70 100 70 18,128,663
10 22 22 30 120 100 120 18,128,663
5 21 22 65 95 62 18,128,663
5 21 22 10 65 95 62 18,128,663
5 19 22 65 86 56 18,128,663
5 20 22 65 91 59 18,128,663

25 21 22 50 95 48 18,128,663

5 20 22 65 91 59 18,128,663
5 18 22 65 82 53 18,128,663
5 18 22 65 82 53 18,128,663
5 20 22 65 91 59 18,128,663
5 21 22 20 85 95 81 18,128,663
5 21 22 65 95 62 18,128,663
5 20 22 65 91 59 18,128,663
5 20 22 65 91 59 18,128,663
5 21 22 65 95 62 18,128,663
5 20 22 65 91 59 18,128,663
5 18 22 65 82 53 18,128,663

5 22 22 10 30 100 30 18,128,663

1941

Kepala Tata Usaha

ERIFIANTI, Amd. Kep

NIP. 19730926 199203 2 001
 FORMULIR 2

JASA PELAYANAN
ERIMAAN KAPITASI DENGAN YANG DITERIMA
JUMLAH PESERTA 8.176 DENGAN PESERTA
8117
JUMLAH TANDA
PAJAK 5 %
(Kolom 9 dikali Kolom TERIMA TANGAN
Biaya Operasional 25
10 dibagi jumlah
%
kolom 9)

16 17 18 19 20
6,042,888 1,774,240
88,712 1,685,528 1
6,042,888 1,073,882 53,694 1,020,188 2
6,042,888 604,855 30,243 574,612 3
6,042,888 721,581 36,079 685,502 4
6,042,888 594,243 29,712 564,531 5
- - - 6
6,042,888 - - - 7
- - - 8
6,042,888 747,049 37,352 709,696 9
6,042,888 564,531 28,227 536,305 10
6,042,888 524,207 26,210 497,997 11
6,042,888 623,955 31,198 592,758 11
- - - 12
6,042,888 653,668 32,683 620,984 13
6,042,888 1,120,573 56,029 1,064,544 14
6,042,888 579,387 28,969 550,418 15
6,042,888 579,387 28,969 550,418 16
6,042,888 524,207 26,210 497,997 17
6,042,888 551,797 27,590 524,207 18
6,042,888 445,682 22,284 423,398 19

6,042,888 551,797 27,590 524,207 20

6,042,888 496,618 24,831 471,787 21
6,042,888 496,618 496,618 22
6,042,888 551,797 551,797 23
6,042,888 757,660 757,660 24
6,042,888 579,387 579,387 25
6,042,888 551,797 551,797 26
6,042,888 551,797 551,797 27
 6,042,888 579,387 579,387 28
6,042,888 551,797 551,797 29
6,042,888 496,618 496,618 29
6,042,888 280,143 280,143 30

18,128,663 636,583 17,492,080 18,128,663

Kemantan, Mei 2020

Bendahara JKN

ALI SADIKIN, S.ST

NIP. 19770521 200901 1 005