BPJS Kesehatan Cab.

PALU
FORMULIR PENGAJUAN KLAIM TINGKAT PERTAMA

Nomor FPK : P1510000012711

Provider : KAMONJI
Bulan Pelayanan : October, 2015

Pelayanan : RITP
Total Data : 13

Total Tagihan : 9,750,000

NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG TINDAKAN Biaya

031900051015Y001854 FAHRIA 02/10/201 02/10/2015 Paket persalinan per vaginam normal 600,000
02/10/201 02/10/2015 Pelayanan ANC (FFS) 50,000
02/10/201 02/10/2015 Pelayanan ANC (FFS) 50,000
02/10/201 02/10/2015 Pelayanan ANC (FFS) 50,000
02/10/201 02/10/2015 Pelayanan ANC (FFS) 50,000
031900051015Y001855 ASTANTI 28/10/201 28/10/2015 Paket persalinan per vaginam normal 600,000
031900051015Y001856 LISDAYANTI 05/10/201 05/10/2015 Paket persalinan per vaginam normal 600,000
05/10/201 05/10/2015 Pelayanan ANC (FFS) 50,000
05/10/201 05/10/2015 Pelayanan ANC (FFS) 50,000
05/10/201 05/10/2015 Pelayanan ANC (FFS) 50,000
05/10/201 05/10/2015 Pelayanan ANC (FFS) 50,000
05/10/201 05/10/2015 Pelayanan PNC (FFS) 25,000
05/10/201 05/10/2015 Pelayanan PNC (FFS) 25,000
05/10/201 05/10/2015 Pelayanan PNC (FFS) 25,000

Tanggal terima Tanggal, 10 November 2015

Verifikator, Pengaju Klaim,

10/11/2015 11.38.49
 BPJS Kesehatan Cab. PALU
FORMULIR PENGAJUAN KLAIM TINGKAT PERTAMA

Nomor FPK : P1510000012711

Provider : KAMONJI
Bulan Pelayanan : October, 2015

Pelayanan : RITP
Total Data : 13

Total Tagihan : 9,750,000

NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG TINDAKAN Biaya

031900051015Y001857 SUMARNI 29/10/201 29/10/2015 Paket persalinan per vaginam normal 600,000
29/10/201 29/10/2015 Pelayanan ANC (FFS) 50,000
29/10/201 29/10/2015 Pelayanan ANC (FFS) 50,000
29/10/201 29/10/2015 Pelayanan ANC (FFS) 50,000
29/10/201 29/10/2015 Pelayanan ANC (FFS) 50,000
29/10/201 29/10/2015 Pelayanan PNC (FFS) 25,000
29/10/201 29/10/2015 Pelayanan PNC (FFS) 25,000
031900051015Y001872 MASITA 02/10/201 02/10/2015 Paket persalinan per vaginam normal 600,000
02/10/201 02/10/2015 Pelayanan ANC (FFS) 50,000
02/10/201 02/10/2015 Pelayanan ANC (FFS) 50,000
02/10/201 02/10/2015 Pelayanan ANC (FFS) 50,000
02/10/201 02/10/2015 Pelayanan ANC (FFS) 50,000
02/10/201 02/10/2015 Pelayanan PNC (FFS) 25,000
02/10/201 02/10/2015 Pelayanan PNC (FFS) 25,000

Tanggal terima Tanggal, 10 November 2015

Verifikator, Pengaju Klaim,

10/11/2015 11.38.49
 BPJS Kesehatan Cab. PALU
FORMULIR PENGAJUAN KLAIM TINGKAT PERTAMA

Nomor FPK : P1510000012711

Provider : KAMONJI
Bulan Pelayanan : October, 2015

Pelayanan : RITP
Total Data : 13

Total Tagihan : 9,750,000

NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG TINDAKAN Biaya

02/10/201 02/10/2015 Pelayanan PNC (FFS) 25,000
031900051015Y001873 FIRDAYANTI 07/10/201 07/10/2015 Paket persalinan per vaginam normal 600,000
07/10/201 07/10/2015 Pelayanan ANC (FFS) 50,000
07/10/201 07/10/2015 Pelayanan ANC (FFS) 50,000
07/10/201 07/10/2015 Pelayanan ANC (FFS) 50,000
07/10/201 07/10/2015 Pelayanan ANC (FFS) 50,000
07/10/201 07/10/2015 Pelayanan PNC (FFS) 25,000
07/10/201 07/10/2015 Pelayanan PNC (FFS) 25,000
031900051015Y001874 INE 11/10/201 11/10/2015 Paket persalinan per vaginam normal 600,000
11/10/201 11/10/2015 Pelayanan ANC (FFS) 50,000
11/10/201 11/10/2015 Pelayanan ANC (FFS) 50,000
11/10/201 11/10/2015 Pelayanan ANC (FFS) 50,000
11/10/201 11/10/2015 Pelayanan ANC (FFS) 50,000
11/10/201 11/10/2015 Pelayanan PNC (FFS) 25,000

Tanggal terima Tanggal, 10 November 2015

Verifikator, Pengaju Klaim,

10/11/2015 11.38.49
 BPJS Kesehatan Cab. PALU
FORMULIR PENGAJUAN KLAIM TINGKAT PERTAMA

Nomor FPK : P1510000012711

Provider : KAMONJI
Bulan Pelayanan : October, 2015

Pelayanan : RITP
Total Data : 13

Total Tagihan : 9,750,000

NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG TINDAKAN Biaya

11/10/201 11/10/2015 Pelayanan PNC (FFS) 25,000
031900051015Y001875 LISTIANI 25/10/201 25/10/2015 Paket persalinan per vaginam normal 600,000
25/10/201 25/10/2015 Pelayanan PNC (FFS) 25,000
25/10/201 25/10/2015 Pelayanan PNC (FFS) 25,000
031900051015Y001876 ASNAWATI 10/10/201 10/10/2015 Paket persalinan per vaginam normal 600,000
10/10/201 10/10/2015 Pelayanan ANC (FFS) 50,000
10/10/201 10/10/2015 Pelayanan ANC (FFS) 50,000
10/10/201 10/10/2015 Pelayanan ANC (FFS) 50,000
10/10/201 10/10/2015 Pelayanan ANC (FFS) 50,000
031900051015Y001878 RAHMAWATI. Z 10/10/201 10/10/2015 Paket persalinan per vaginam normal 600,000
031900051015Y001879 RIA 09/10/201 09/10/2015 Paket persalinan per vaginam normal 600,000
031900051015Y001880 INTAN 31/10/201 31/10/2015 Paket persalinan per vaginam normal 600,000
031900051015Y001881 MAWAR 31/10/201 31/10/2015 Paket persalinan per vaginam normal 600,000
31/10/201 31/10/2015 Pelayanan ANC (FFS) 50,000

Tanggal terima Tanggal, 10 November 2015

Verifikator, Pengaju Klaim,

10/11/2015 11.38.49
 BPJS Kesehatan Cab. PALU
FORMULIR PENGAJUAN KLAIM TINGKAT PERTAMA

Nomor FPK : P1510000012711

Provider : KAMONJI
Bulan Pelayanan : October, 2015

Pelayanan : RITP
Total Data : 13

Total Tagihan : 9,750,000

NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG TINDAKAN Biaya

31/10/201 31/10/2015 Pelayanan ANC (FFS) 50,000
31/10/201 31/10/2015 Pelayanan ANC (FFS) 50,000
31/10/201 31/10/2015 Pelayanan ANC (FFS) 50,000

Tanggal terima Tanggal, 10 November 2015

Verifikator, Pengaju Klaim,

10/11/2015 11.38.49