Jasa Pelayanan 1999 OKE JAN - AGST

REKAPITULASI HASIL PELAYANAN PASIEN RAWAT JALAN (NON PENJAMINAN)
KABUPATEN BANYUWANGI TAHUN 2021
PUSKESMAS : TEMBOKREJO
BULAN : Januari s/d Maret 2021
Pengujian
Pelayanan Medik Pelayanan Penunjang Medik Kunjungan ∑ RETRIBUSI
Kesehatan
& rujukan
Pelayanan ANC/KB/
No. Nama Pasien Tgl Kunj. Diagnosa/ Gejala TMNO-Kecil Pelayanan Pelayanan Pemeriksaan spesimen
Umum/ Gigi Imunisasi TMNO Radiologi & Kesehatan dan laborat
Ringan II/ Medik Gigi- patologi Rp.
Kebidanan elektro-medik medis
Sedang Mulut klinik Catin
1 2 3 4 5 6 7 8 9 10 11 12 13
1 Siamera Yunita 2/1/2021 Catin 10,000 10,000
2 Dico Ade Evy P Catin 10,000 10,000
3 Desi Arin K. Catin 10,000 10,000
4 Puguh Prayoga Catin 10,000 10,000
5 Mustakbirin Kir Kesehatan 10,000 10,000
6 Hadi Santoso Kir Kesehatan 10,000 10,000
7 Moh. Raihan Kir Kesehatan 10,000 10,000
8 Sunatin Kir Kesehatan 10,000 10,000
9 Suwarni Koles, UA 40,000 40,000
10 Nela Soraya 4/1/2021 Catin 10,000 10,000
11 Ahmad Efendi Catin 10,000 10,000
12 Reni Ramadani 5/1/2021 Catin 10,000 10,000
13 Ronald Inofi Catin 10,000 10,000
14 Martiningsih Kir Kesehatan 10,000 10,000
15 A'an Randa A. 6/1/2021 Catin 10,000 10,000
16 Diah Pitaloka Catin 10,000 10,000
17 Moh. Nur Cahyadi Catin 10,000 10,000
18 Neneng Septa Catin 10,000 10,000
19 Sofyan Nasrullah 7/1/2021 Catin 10,000 10,000
20 Anggi Silvi Maulida Catin 10,000 10,000
21 Nadiana Salsa Kir Kesehatan 10,000 10,000
22 Zaenal Kir Kesehatan 10,000 10,000
23 Gigih Agung Golda 15,000 15,000
24 Ahmad Suparta UA 15,000 15,000
25 Agung wijaya Golda 15,000 15,000
26 Gede Sadru 8/1/2021 Koles, UA 40,000 40,000
27 Asiyanto Koles, UA 40,000 40,000
28 Dini Rizkiyanti 9/1/2021 Catin 10,000 10,000
29 Moh. Tegar Catin 10,000 10,000
30 Nurul PP TEST 10,000 10,000
31 Yogi Prastian 11/1/2021 Catin 10,000 10,000
32 Divia Febrianti Catin 10,000 10,000
33 Khulatil Lutfi Catin 10,000 10,000
34 Sabrila Indah Catin 10,000 10,000
Pengujian
Pelayanan Medik Pelayanan Penunjang Medik Kesehatan Kunjungan ∑ RETRIBUSI
& rujukan
Pelayanan ANC/KB/
No. Nama Pasien Tgl Kunj. Diagnosa/ Gejala Umum/ Gigi Imunisasi TMNO-Kecil Pelayanan Pelayanan Pemeriksaan spesimen
TMNO Radiologi & laborat
Ringan II/ Medik Gigi- patologi Kesehatan dan Rp.
1 2 3 4 5 6 7 8 9 10 11 12 13
35 Nova Agustina 12/1/2021 Catin 10,000 10,000
36 Dedi giovani Catin 10,000 10,000
37 Luh Surya W 13/01/2021 Catin 10,000 10,000
38 Yayan Iswandi Catin 10,000 10,000
39 Ita Mustafa Koles, UA 40,000 40,000
40 Siti Manisah 14/01/2021 Catin 10,000 10,000
41 Moh. Zaini Catin 10,000 10,000
42 Gendis Tindik 15,000 15,000
43 Iga Kurniawan DL, WIDAL 70,000 70,000
44 Sukirah 15/01/2021 Koles 25,000 25,000
45 Yani Cantika 18/01/2021 Catin 10,000 10,000
46 M. Wahyu K Catin 10,000 10,000
47 Yuni Puspitasari Catin 10,000 10,000
48 A. Faisol Catin 10,000 10,000
49 M. Nur Fuady 21/01/2021 Kir Kesehatan 10,000 10,000
50 Indah Novalia Kir Kesehatan 10,000 10,000
51 Ika Faila Tindik 15,000 15,000
52 Suwaris Kolesterol 25,000 25,000
53 Ratna Puspitasari 22/01/2021 Catin 10,000 10,000
54 Alvian Wilva Catin 10,000 10,000
55 Muslimin 23/01/2021 Catin 10,000 10,000
56 Dewi Sumarni Catin 10,000 10,000
57 Anggraini Ayu Catin 10,000 10,000
58 Dika Ristanto Catin 10,000 10,000
59 Novita Sari Kir Kesehatan 10,000 10,000
60 Slamet Riyanto Kir Kesehatan 10,000 10,000
61 Tri Agustina 25/01/2021 Catin 10,000 10,000
62 Teguh Pribadi Catin 10,000 10,000
63 Rhofit Kursantana Catin 10,000 10,000
64 Mila Dwi Okti Catin 10,000 10,000
65 Novi Ayu Zakia 26/01/2021 Catin 10,000 10,000
66 Anadian Tindik 15,000 15,000
67 Wahyu Febrianto Catin 10,000 10,000
68 Katrin Secarani Catin 10,000 10,000
69 M. Affan Kir Kesehatan 10,000 10,000
70 Suminah UA, Koles 40,000 40,000
71 Novitasari 27/01/2021 Catin 10,000 10,000
72 M. Aris Toteles Catin 10,000 10,000
73 Desi Lestianingrum 28/01/2021 Catin 10,000 10,000
74 Yasin arafat Catin 10,000 10,000
75 Linda Herlina Catin 10,000 10,000
76 Hamim Tohari Catin 10,000 10,000
Pengujian
& rujukan
Pelayanan ANC/KB/
1 2 3 4 5 6 7 8 9 10 11 12 13
77 Fera Fernanda 2/2/2021 Catin 10,000 10,000
78 Ifan Afandi Catin 10,000 10,000
79 Evi Dian Saputra 3/2/2021 Catin 10,000 10,000
80 Angkasa Tanzil Catin 10,000 10,000
81 Husnul Hotimah Catin 10,000 10,000
82 Slamet Hariyadi Catin 10,000 10,000
83 Andi P 4/2/2021 Kir Kesehatan 10,000 10,000
84 Kunthi Sanid Kir Kesehatan 10,000 10,000
85 Suci Aprilia 5/2/2021 Catin 10,000 10,000
86 Nur Ahmad Catin 10,000 10,000
BULAN : JUNI 2021
Pengujian
Kesehatan
& rujukan
Pelayanan ANC/KB/
1 2 3 4 5 6 7 8 9 10 11 12 13
1 Fitriatul Hasanah 1/4/2021 Catin 10,000 10,000
2 Afan Wahyu Catin 10,000 10,000
3 Rico Pramono Catin 10,000 10,000
4 Mita Agustin Catin 10,000 10,000
5 Ramadan Yanuar Kir Kesehatan 10,000 10,000
6 Arif Abdillah Kir Kesehatan 10,000 10,000
7 Mundiyah 3/4/2021 Koles, UA 40,000 40,000
8 Sukirah Koles 25,000 25,000
9 Suryadi 5/4/2021 Kir Kesehatan 10,000 10,000
10 Syaiful Hak Kir Kesehatan 10,000 10,000
11 Samsul Arifin Kir Kesehatan 10,000 10,000
12 Supriyanto Catin 10,000 10,000
13 Hayati Desi Catin 10,000 10,000
14 Dian Anggraini Catin 10,000 10,000
15 Supriyono Catin 10,000 10,000
16 Afkarina Catin 10,000 10,000
17 M. Mirzha Catin 10,000 10,000
18 Suyanto 6/4/2021 Kir Kesehatan 10,000 10,000
19 Sukirno Sunoto 8/4/2021 Kir Kesehatan 10,000 10,000
20 Wahyu S 9/4/2021 Kir Kesehatan 10,000 10,000
21 Arfita A 10/4/2021 Kir Kesehatan 10,000 10,000
22 Edi Eko Kir Kesehatan 10,000 10,000
23 Yudha Dwi Kir Kesehatan 10,000 10,000
24 St. Latifah Kir Kesehatan 10,000 10,000
25 Hartono Kir Kesehatan 10,000 10,000
26 Ahmad Suprapto Kir Kesehatan 10,000 10,000
27 Iqbal K 12/4/2021 Kir Kesehatan 10,000 10,000
28 Indah Anggraini 13/4/2021 Catin 10,000 10,000
29 Muksitullah Catin 10,000 10,000
30 Retno E. Catin 10,000 10,000
31 Iwan P Catin 10,000 10,000
32 Jamiah 14/4/2021 135,000 135,000
Pengujian
& rujukan
Pelayanan ANC/KB/
1 2 3 4 5 6 7 8 9 10 11 12 13
33 Waginem 15/4/2021 Catin 10,000 10,000
34 Hasan Catin 10,000 10,000
35 Khusnul Khotimah 16/4/2021 Catin 10,000 10,000
36 Ilham Santoso Catin 10,000 10,000
37 Nurhayati Kir Kesehatan 10,000 10,000
38 Vinky Putri 17/4/2021 Kir Kesehatan 10,000 10,000
39 Ike Permatasari Kir Kesehatan 10,000 10,000
40 Bambang Riyanto Kir Kesehatan 10,000 10,000
41 Ponidi Kir Kesehatan 10,000 10,000
42 Nouval 19/4/2021 Kir Kesehatan 10,000 10,000
43 Fairus Kir Kesehatan 10,000 10,000
44 Novia Kir Kesehatan 10,000 10,000
45 Rian Kir Kesehatan 10,000 10,000
46 Dian Oktaviana Kir Kesehatan 10,000 10,000
47 Suyono 21/4/2021 Kir Kesehatan 10,000 10,000
48 Bagus Kir Kesehatan 10,000 10,000
49 Vina Kir Kesehatan 10,000 10,000
50 M. Zainullah 22/4/2021 Catin 10,000 10,000
51 Istiqomah Catin 10,000 10,000
52 Agus Supriyono Kir Kesehatan 10,000 10,000
53 Jaswadi Kir Kesehatan 10,000 10,000
54 Putri Anita 23/4/2021 Kir Kesehatan 10,000 10,000
55 Sutarto Kir Kesehatan 10,000 10,000
56 Sukirno Kir Kesehatan 10,000 10,000
57 Riski Wahyu Kir Kesehatan 10,000 10,000
58 Didik Winarto 24/4/2021 Kir Kesehatan 10,000 10,000
59 Lia Ari Kir Kesehatan 10,000 10,000
60 Supiyah 26/4/2021 Kir Kesehatan 10,000 10,000
61 Lukman Kir Kesehatan 10,000 10,000
62 Tiara Dewi Golda 10,000 10,000
63 Qoriatul 27/4/2021 Kir Kesehatan 10,000 10,000
64 Supi Rahayu 29/4/2021 Catin 10,000 10,000
65 Sacara Alexandru Catin 10,000 10,000
66 Tri Isna Golda 10,000 10,000
67 Raka Sadewa DL 45,000 45,000
68 Dianita 3/5/2021 Catin 10,000 10,000
69 Dias Febri Catin 10,000 10,000
70 Sudartik Kir Kesehatan 10,000 10,000
71 Hariyati Kir Kesehatan 10,000 10,000
Pengujian
& rujukan
Pelayanan ANC/KB/
1 2 3 4 5 6 7 8 9 10 11 12 13
72 Bella Riza 4/5/2021 Catin 10,000 10,000
73 Charisma Arzaqi Catin 10,000 10,000
74 Indayani Catin 10,000 10,000
75 Galung Kukuh Catin 10,000 10,000
76 Sindy Viola Catin 10,000 10,000
77 Dimas Prasetyo Catin 10,000 10,000
78 Eka Wulandari Catin 10,000 10,000
79 Nur Khoiri 5/05/2021 Kir Kesehatan 10,000 10,000
80 Dian Aditya 6/05/2021 Catin 10,000 10,000
81 Mistikah Catin 10,000 10,000
82 Binti Rokhaitul Catin 10,000 10,000
83 Khoirul Anam Catin 10,000 10,000
84 Lusi Puspita Catin 10,000 10,000
85 M. Sholahuddin Catin 10,000 10,000
86 Edy Kir Kesehatan 10,000 10,000
87 Lukman Kir Kesehatan 10,000 10,000
88 Suyadi 7/5/2021 Kir Kesehatan 10,000 10,000
89 Nuryanto Kir Kesehatan 10,000 10,000
90 Nur Yasin Kir Kesehatan 10,000 10,000
91 Mustamat 8/5/2021 Kir Kesehatan 10,000 10,000
92 Ruslan Wahyu Kir Kesehatan 10,000 10,000
93 Ridwan Kir Kesehatan 10,000 10,000
94 Suryani 11/5/2021 Catin 10,000 10,000
95 Ahmad Sukandar Catin 10,000 10,000
96 Wahyu Kir Kesehatan 10,000 10,000
97 Endang 15/5/2021 Kir Kesehatan 10,000 10,000
98 Lutvi Nur Kir Kesehatan 10,000 10,000
99 Tumini Kir Kesehatan 10,000 10,000
100 Sumiyati Kir Kesehatan 10,000 10,000
101 Reivan Ahmad Kir Kesehatan 10,000 10,000
102 Nadia Kir Kesehatan 10,000 10,000
103 Sutiwi 17/5/2021 Chol 25,000 25,000
104 Sukarni Chol 25,000 25,000
105 Hariyati 18/5/2021 Kir Kesehatan 10,000 10,000
106 Hermin Dwi 20/5/2021 Catin 10,000 10,000
107 Edi Purnawan Catin 10,000 10,000
108 Lusena Gater Catin 10,000 10,000
109 M. Ardy Catin 10,000 10,000
110 Vina erni Catin 10,000 10,000
111 M. Fiki Catin 10,000 10,000
Pengujian
& rujukan
Pelayanan ANC/KB/
1 2 3 4 5 6 7 8 9 10 11 12 13
112 Riyan Baskoro Catin 10,000 10,000
113 Arifatus sholeha Catin 10,000 10,000
114 Iswanto Kir Kesehatan 10,000 10,000
115 Luluk Kir Kesehatan 10,000 10,000
116 Suwarno Kir Kesehatan 10,000 10,000
117 Wafisyah Kir Kesehatan 10,000 10,000
118 Iis S Kir Kesehatan 10,000 10,000
119 Nur Azizah Kir Kesehatan 10,000 10,000
120 Ahmad Saiful 21/5/2021 Catin 10,000 10,000
121 Toina Catin 10,000 10,000
122 St. Nur Kir Kesehatan 10,000 10,000
123 Alfian Afif Kir Kesehatan 10,000 10,000
124 Sadi Kir Kesehatan 10,000 10,000
125 Suharto Kir Kesehatan 10,000 10,000
126 Sugiatin Kir Kesehatan 10,000 10,000
127 Ahmad Akbar Kir Kesehatan 10,000 10,000
128 Ruslan Kir Kesehatan 10,000 10,000
129 Poniyah Kir Kesehatan 10,000 10,000
130 Karina 22/5/2021 Catin 10,000 10,000
131 Roni Agus Catin 10,000 10,000
132 Asmaul Husna Kir Kesehatan 10,000 10,000
133 Komarudin Kir Kesehatan 10,000 10,000
134 Islamiyah Kir Kesehatan 10,000 10,000
135 M. sokeh Kir Kesehatan 10,000 10,000
136 M. Taufik Kir Kesehatan 10,000 10,000
137 Edo Ergi Kir Kesehatan 10,000 10,000
138 Tri Ambarwati 24/5/2021 Catin 10,000 10,000
139 Jaelani Catin 10,000 10,000
140 Abd. Rofik Catin 10,000 10,000
141 Desi Wulandari Catin 10,000 10,000
142 Ayu Wandira Catin 10,000 10,000
143 Putra Kristiawan Catin 10,000 10,000
144 Imroatun Wafiah Catin 10,000 10,000
145 M. Arifin Catin 10,000 10,000
146 Husnul Khotimah Catin 10,000 10,000
147 Nur hidayanto Catin 10,000 10,000
148 Mas'ud Kir Kesehatan 10,000 10,000
149 Khusnul Khotimah 25/5/2021 Catin 10,000 10,000
Pengujian
& rujukan
Pelayanan ANC/KB/
1 2 3 4 5 6 7 8 9 10 11 12 13
150 Ari Wibowo Catin 10,000 10,000
151 St. Nur Farida Catin 10,000 10,000
152 Mistina 27/5/2021 Catin 10,000 10,000
153 Purwanto Catin 10,000 10,000
154 St. romlah Koles, UA 40,000 40,000
155 Surahman Koles, UA 40,000 40,000
156 Budiyanto 28/5/2021 Catin 10,000 10,000
157 Eni Mardiana Catin 10,000 10,000
158 Rohma Santika 29/5/2021 Catin 10,000 10,000
159 M. Aswar Catin 10,000 10,000
160 Narto Irawan Kir Kesehatan 10,000 10,000
161 Chamin Tohari Kir Kesehatan 10,000 10,000
162 Erna Kir Kesehatan 10,000 10,000
163 Warsono Kir Kesehatan 10,000 10,000
164 Ega Anggi Kir Kesehatan 10,000 10,000
165 Sigit Wahyudi Kir Kesehatan 10,000 10,000
166 Budiyono Kir Kesehatan 10,000 10,000
167 Sumadi Kir Kesehatan 10,000 10,000
TOTAL 135,000 - - - - 1,765,000 65,000 1,965,000
Pejabat Pelaksana teknis Kegiatan

Puskesmas Tembokrejo
drg.SRI ISTYANTINI
NIP. 19730811 200604 2 010
BULAN : JUNI 2021
Pengujian
Kesehatan
& rujukan
Pelayanan ANC/KB/
1 2 3 4 5 6 7 8 9 10 11 12 13
1 Diki Ahmad 2/6/2021 30,000 30,000
2 Rozza Devina 2/6/2021 Catin 10,000 10,000
3 M. Lutfi Amin Catin 10,000 10,000
4 Ilvas Yuniarto Catin 10,000 10,000
5 Bella Putri A Catin 10,000 10,000
6 Andi Lala Catin 10,000 10,000
7 Husnul Khotimah Catin 10,000 10,000
8 Nurhadi Catin 10,000 10,000
9 Uswatun Hasanah Catin 10,000 10,000
10 Siska Dwi Catin 10,000 10,000
11 Yunus Eko Catin 10,000 10,000
12 Sauki Muhammad Catin 10,000 10,000
13 Sukamto Kir Kesehatan 10,000 10,000
14 Dullah Kir Kesehatan 10,000 10,000
15 Savira 3/6/2021 Kir Kesehatan 10,000 10,000
16 Suwaji Kir Kesehatan 10,000 10,000
17 Putri 4/6/2021 Kir Kesehatan 10,000 10,000
18 Matori Kir Kesehatan 10,000 10,000
19 Muhlis 5/6/2021 Kir Kesehatan 10,000 10,000
20 Juli Agustono Kir Kesehatan 10,000 10,000
21 M. Thoha Kir Kesehatan 10,000 10,000
22 Sugiono Kir Kesehatan 10,000 10,000
23 Sumaji Kir Kesehatan 10,000 10,000
24 Iwan Wahyudi Kir Kesehatan 10,000 10,000
25 Beni Supriyadi Kir Kesehatan 10,000 10,000
26 Agus Widayanto Kir Kesehatan 10,000 10,000
27 Bagus Priambudi Kir Kesehatan 10,000 10,000
28 Suyanto Kir Kesehatan 10,000 10,000
29 Chichi Christias 8/6/2021 Catin 10,000 10,000
30 Yoga Pratama Catin 10,000 10,000
31 Halimatus Sakdiyah Catin 10,000 10,000
32 Nur Aini Chol, UA 40,000 40,000
33 Mulyati Chol, UA 40,000 40,000
34 M. Hariyanto Catin 10,000 10,000
35 Agus Wata 11/6/2021 Catin 10,000 10,000
Pengujian
& rujukan
Pelayanan ANC/KB/
1 2 3 4 5 6 7 8 9 10 11 12 13
36 Fitriatus Sakadah Catin 10,000 10,000
37 Irfan Kir Kesehatan 10,000 10,000
38 Elok Dwi Catin 10,000 10,000
39 Viru Alvino Nita Sari 12/6/2021 Catin 10,000 10,000
40 Indra Wahyudi Catin 10,000 10,000
41 Dewi Supriyani Catin 10,000 10,000
42 Alex Widodo Catin 10,000 10,000
43 St. Maysyaroh Catin 10,000 10,000
44 Nunjia Marita 14/6/2021 Catin 10,000 10,000
45 Indra Eka Catin 10,000 10,000
46 Nadela Catin 10,000 10,000
47 M. Sutris Catin 10,000 10,000
48 Jamila Chol, UA 40,000 40,000
49 Denny Yoga 16/6/2021 Catin 10,000 10,000
50 Dita Nurhidayah Catin 10,000 10,000
51 Desyana Retno 17/6/2021 Catin 10,000 10,000
52 M. Bilal Catin 10,000 10,000
53 Mega Dwi Catin 10,000 10,000
54 Abd. Azis Catin 10,000 10,000
55 Bella Dwi P Catin 10,000 10,000
56 Nur Wahidin Kir Kesehatan 10,000 10,000
57 Aisa Kir Kesehatan 10,000 10,000
58 Delina Dwi Kir Kesehatan 10,000 10,000
59 Agus Epiyanto Kir Kesehatan 10,000 10,000
60 Zahra Trisna Kir Kesehatan 10,000 10,000
61 Tutik Budi Kir Kesehatan 10,000 10,000
62 Sukirah Chol, UA 40,000 40,000
63 Suharyoto Chol, UA 40,000 40,000
64 Dio Pienta 18/6/2021 Catin 10,000 10,000
65 Ayun Naylafar 19/6/2021 Catin 10,000 10,000
66 Edi sasmito Catin 10,000 10,000
67 Abu Amin Kir Kesehatan 10,000 10,000
68 Hariyanto 21/6/2021 Catin 10,000 10,000
69 Kholifah Catin 10,000 10,000
70 Sugiati Catin 10,000 10,000
71 Ah. Khoirul Huda Catin 10,000 10,000
72 Diana Dewi Kir Kesehatan 10,000 10,000
73 Ruminto 22/6/2021 Kir Kesehatan 10,000 10,000
74 Jesendryn Muria 23/6/2021 Catin 10,000 10,000
75 Grestyan Filda Catin 10,000 10,000
76 Alwin Zakaria Catin 10,000 10,000
77 Anggri Witriana Catin 10,000 10,000
Pengujian
& rujukan
Pelayanan ANC/KB/
1 2 3 4 5 6 7 8 9 10 11 12 13
78 Kasiyan Kir Kesehatan 10,000 10,000
79 Nada Elok Golda 10,000 10,000
80 Alfan Golda 10,000 10,000
81 Luluk Mariatus DL, WIDAL 70,000 70,000
82 Deby Luis 24/6/2021 Catin 10,000 10,000
83 Cindy Nur Indah Catin 10,000 10,000
84 Eko Kusnanto 25/6/2021 Kir Kesehatan 10,000 10,000
85 Supiyan Kir Kesehatan 10,000 10,000
86 Budianto Kir Kesehatan 10,000 10,000
87 Kiki Aprina 26/6/2021 Catin 10,000 10,000
88 Supriyanto Catin 10,000 10,000
89 Dedi Febriantillah Catin 10,000 10,000
90 St. Nurma Yunita Catin 10,000 10,000
91 Fandri 28/6/2021 Kir Kesehatan 10,000 10,000
92 Ilham Dul Fitri 29/6/2021 Catin 10,000 10,000
93 Dina Nur I Catin 10,000 10,000
94 Sofia Andriyono Catin 10,000 10,000
95 Aldi Pratama Catin 10,000 10,000
96 Agus Adi Catin 10,000 10,000
97 Adinda Sri Catin 10,000 10,000
98 Kiki Wahyu Catin 10,000 10,000
99 Dian Okvendra Catin 10,000 10,000
100 M. Agus Kir Kesehatan 10,000 10,000
101 Hidayatur Kir Kesehatan 10,000 10,000
102 Najwa Sila Kir Kesehatan 10,000 10,000
103 Natanael Dwi Chol, UA 40,000 40,000
104 Nilla Wahyuni Golda 10,000 10,000
105 M. Enggal Wahyudi 1/7/2021 Catin 10,000 10,000
106 Ratnasari Catin 10,000 10,000
107 Alda Yulistira Catin 10,000 10,000
108 M. Hairul Catin 10,000 10,000
109 Fitri Alfiyatur Catin 10,000 10,000
110 Edi Prasetyo Catin 10,000 10,000
111 Septa Mansha Catin 10,000 10,000
112 A'af Hari Catin 10,000 10,000
113 Yaris Agustin Catin 10,000 10,000
114 Ahmadi DL 45,000 45,000
115 Irawan Catin 10,000 10,000
116 Siti Munayaroh 2/7/2021 Kir Kesehatan 10,000 10,000
117 Jonsori 3/7/2021 Catin 10,000 10,000
118 St. Mutmainah Catin 10,000 10,000
119 Ika Sartika Catin 10,000 10,000
Pengujian
& rujukan
Pelayanan ANC/KB/
1 2 3 4 5 6 7 8 9 10 11 12 13
120 Vikku Riyan Catin 10,000 10,000
121 Kristia Adinda 6/7/2021 Catin 10,000 10,000
122 Deva Bayu Catin 10,000 10,000
123 Henny Setyowati Catin 10,000 10,000
Pengujian
& rujukan
Pelayanan ANC/KB/
1 2 3 4 5 6 7 8 9 10 11 12 13
124 Doddy Suprayogi Catin 10,000 10,000
125 Ita Silvy Catin 10,000 10,000
126 Heru Prasetyo Catin 10,000 10,000
127 Rizza Nur 7/7/2021 Catin 10,000 10,000
128 Elga silvia Catin 10,000 10,000
129 Putri Linda Catin 10,000 10,000
130 Maulana M. Catin 10,000 10,000
131 Dina Norma Catin 10,000 10,000
132 Rafi Arif Catin 10,000 10,000
133 Syahroni Aynun Catin 10,000 10,000
134 Khofifah Novita Catin 10,000 10,000
135 Edi Supriyanto Catin 10,000 10,000
136 Winda Sri Catin 10,000 10,000
137 Kalimah Chol, UA 40,000 40,000
138 Wijiati Indrawati 8/7/2021 Catin 10,000 10,000
139 Retno Rudiyanto Catin 10,000 10,000
140 Kheiren Kir Kesehatan 10,000 10,000
141 Hariono Kir Kesehatan 10,000 10,000
142 Rina Kir Kesehatan 10,000 10,000
143 Reni Metawati 9/7/2021 Catin 10,000 10,000
144 Bagus Bayu Catin 10,000 10,000
145 Heru Kir Kesehatan 10,000 10,000
146 Binti Kir Kesehatan 10,000 10,000
147 Sugiati Chol, UA 40,000 40,000
148 Risky Maulana 12/7/2021 Catin 10,000 10,000
149 Melinia Catin 10,000 10,000
150 Reni Catin 10,000 10,000
151 Fahriza Catin 10,000 10,000
152 Abdillah Catin 10,000 10,000
153 Amalia Riski Catin 10,000 10,000
154 Sulama Catin 10,000 10,000
155 Suprayitno Catin 10,000 10,000
156 Binti Roicatul 13/7/2021 Catin 10,000 10,000
157 Abd. Basil Catin 10,000 10,000
158 Rokayah Catin 10,000 10,000
159 Mesiyah Catin 10,000 10,000
160 Mesidi Catin 10,000 10,000
161 Fahrurizal Catin 10,000 10,000
162 Verana Diana 14/7/2021 Catin 10,000 10,000
163 Puji Setyawan Catin 10,000 10,000
Pengujian
& rujukan
Pelayanan ANC/KB/
1 2 3 4 5 6 7 8 9 10 11 12 13
164 St. Umsiati Catin 10,000 10,000
165 Tori Hudori Catin 10,000 10,000
166 Galuh Kusuma Catin 10,000 10,000
167 Abd. Rizal Catin 10,000 10,000
168 Ratna Wulandari 15/7/2021 Catin 10,000 10,000
169 M. Imron Catin 10,000 10,000
170 M. Riski 17/7/2021 Catin 10,000 10,000
171 Khonita Catin 10,000 10,000
172 Frendi Rico 19/07/2021 Catin 10,000 10,000
173 Intan Saputri Catin 10,000 10,000
174 Resa Afkarina Catin 10,000 10,000
175 Fediyanto Catin 10,000 10,000
176 Sabilla Nur 21/7/2021 Catin 10,000 10,000
177 Ramdan Habibullah Catin 10,000 10,000
178 Rofiat Catin 10,000 10,000
179 Eli Silvia Catin 10,000 10,000
180 Mei Tri Wahyuni Catin 10,000 10,000
181 Dwi Andi Catin 10,000 10,000
182 Laili Kurnianingrum 26/7/2021 Catin 10,000 10,000
183 M. Aji Purnomo Catin 10,000 10,000
184 Dinda Lailiya Catin 10,000 10,000
185 Aldi Kusuma Catin 10,000 10,000
186 Karsini 27/7/2021 Catin 10,000 10,000
187 Dodi Harianto Catin 10,000 10,000
188 Marisa Maharani 28/7/2021 Catin 10,000 10,000
189 Jodi Gusbiawan Catin 10,000 10,000
190 Andito Alvi Catin 10,000 10,000
191 Hamida Safina Catin 10,000 10,000
192 Windriyono Catin 10,000 10,000
193 Moh. Andi Catin 10,000 10,000
194 Herman Adi 70,000 70,000
195 Handoko 2/8/2021 Catin 10,000 10,000
196 Julia salsa Catin 10,000 10,000
197 Muhdi H Kir Kesehatan 10,000 10,000
198 Suyitno Kir Kesehatan 10,000 10,000
199 Heni Mardianita 3/8/2021 Catin 10,000 10,000
200 Anas Bastiar Catin 10,000 10,000
201 St. Alfiah 4/8/2021 Catin 10,000 10,000
202 M. Mustofar Catin 10,000 10,000
203 Lasemi 5/8/2021 Catin 10,000 10,000
204 Agus Purnomo Catin 10,000 10,000
205 Ana Zelviyatin 6/8/2021 Catin 10,000 10,000
Pengujian
& rujukan
Pelayanan ANC/KB/
1 2 3 4 5 6 7 8 9 10 11 12 13
206 Chairul efendi Catin 10,000 10,000
207 Dian 14/8/2021 Kir Kesehatan 10,000 10,000
208 Raditya Kir Kesehatan 10,000 10,000
209 Widuri Widia 18/8/2021 Catin 10,000 10,000
210 Rhendy Asmi Catin 10,000 10,000
211 Marita Catin 10,000 10,000
212 Riyan Hidayat Catin 10,000 10,000
213 Nazila Ari 23/8/2021 Catin 10,000 10,000
214 M. Sofyan Catin 10,000 10,000
215 Evita Sari Catin 10,000 10,000
216 Firgo Sanjaya Catin 10,000 10,000
217 Surya Nur Jannah Catin 10,000 10,000
218 Anzal Fajar Catin 10,000 10,000
219 Hartatik GDA, CHOL, UA 55,000 55,000
220 Ahyatul Jannah 24/8/2021 Catin 10,000 10,000
221 Aris Winanto Catin 10,000 10,000
222 Dian Tobing Catin 10,000 10,000
223 St. Nur Imamah Catin 10,000 10,000
224 Firantika 25/8/2021 Catin 10,000 10,000
225 Danang Catin 10,000 10,000
226 Jawadi Kir Kesehatan 10,000 10,000
227 Meivani 26/8/2021 Catin 10,000 10,000
228 M. Abdul aziz Catin 10,000 10,000
229 Wisnu Wardana Catin 10,000 10,000
230 Ririn Handayani Catin 10,000 10,000
231 Putri Wulandari Catin 10,000 10,000
232 Herman Supriyanto Catin 10,000 10,000
233 Sinta Kasih Catin 10,000 10,000
234 Ramadani Catin 10,000 10,000
235 Elisa Putri Catin 10,000 10,000
236 Aditya Permana Catin 10,000 10,000
237 Sintia Yulian Catin 10,000 10,000
238 Mahfud Bashori Catin 10,000 10,000
239 St. Musyarofah GDA, CHOL 40,000 40,000
240 Nur Dini GDA, UA 30,000 30,000
TOTAL 70,000 - 30,000 - - 2,220,000 590,000 2,910,000
Pejabat Pelaksana teknis Kegiatan

Pengujian
& rujukan
Pelayanan ANC/KB/
1 2 3 4 5 6 7 8 9 10 11 12 13
drg.SRI ISTYANTINI
NIP. 19730811 200604 2 010
TANDA TERIMA/KUITANSI
TELAH TERIMA DARI : Pengguna Anggaran Dinas Kesehatan Kabupaten Banyuwangi

UANG SEBESAR : Rp 786,000 ( Tujuh Ratus Delapan Puluh Enam Ribu Rupiah)
UNTUK KEPERLUAN : Pembayaran Jasa Pelayanan Kesehatan Rawat Jalan dan Ambulans Transport/Ambulans Rujukan
Pasien Umum Bulan Juni tahun 2021
Kode Kegiatan : 1.02.02.2.02
Nama Kegiatan : Penyediaan Layanan Untuk UKM dan UKP Rujukan Tingkat Daerah
Kabupaten / Kota
Kode Rekening : 5.1.01.03.06.0001
Sub Kegiatan : Operasional Pelayanan Puskesmas (OPP)
Nama Rekening : Belanja Jasa Pelayanan Kesehatan bagi ASN
Tahun Anggaran : 2021
Dengan rincian pengeluaran sebagai berikut:

Pelayanan Rawat Jalan : Rp 1,965,000 x 40% = Rp 786,000
Pelayanan Ambulans : = Rp -
JUMLAH : = Rp 786,000
JUMLAH PPh Pasal 21 JUMLAH JASA

NO. NAMA/NIP GOL JABATAN TANDA TANGAN
JASA (Rp.) (Rp.) DITERIMA (Rp)
1 dr. ERI DWI SUSANTO III B Dokter 267,240 40,086 227,154 1.

NIP. 19910727 201903 1 005
2 DWI ACHMAD MUJIARNA II C Perawat 149,340 0 149,340 2.
NIP. 19860907 201903 1 002
3 LILIK SUTANTI II C Bidan 157,200 0 157,200 3.
NIP. 19821212 201704 2 005
4 JULIA PUSPITA SARI - Tenaga Laborat 102,180 0 102,180 4.
NIP. -
5 SHELLA FERISA ALFIAN - Asisten Apoteker 62,880 0 62,880 5.
NIP. -
6 ERWIYATI II C Tenaga Admin 47,160 0 47,160 6.
NIP. 19690329 201001 2 002
JUMLAH 786,000 40,086 745,914
Banyuwangi, 17 Juni 2021
Menyetujui : Disetujui Lunas Dibayar :

Pengguna Anggaran Kuasa Pengguna Anggaran Tgl. :
Kepala Dinas Kesehatan Kepala Bidang Bendahara Pengeluaran
Kab. Banyuwangi Sumber Daya Kesehatan
dr. H WIDJI LESTARIONO M.MKes MUJITO,SKM,M.MKes DIAN PUSPITA, SE

Pembina Utama Muda Pembina Penata
NIP. 19630522 198902 1 002 NIP: 19690524 199203 1 003 NIP. 19760506 200901 2 006

UANG SEBESAR : Rp 791,000 ( Tujuh Ratus Sembilan Puluh Satu Ribu Rupiah)
UNTUK KEPERLUAN : Pembayaran Jasa Pelayanan Kesehatan Puskemas Tembokrejo
Bulan Januari dan Februari 2017

Nama Kegiatan : Dana Operasional Puskesmas (DOP)
Kode Rekening : 5.2.2.03.28
Nama Rekening : Belanja Jasa Pelayanan Kesehatan

Pelayanan Rawat Jalan : Rp 1,977,500 x 40% = Rp 791,000
JUMLAH : = Rp 791,000

1 dr. Mangesti Utami III d Dokter 268,940 13,447 255,493 1.

19730110 200604 2 015
2 Kalung Lutvia K III a Perawat 150,290 7,515 142,776 2.
19830223 200701 2 008
3 Dwi Bekti Andayani III a Bidan 158,200 7,910 150,290 3.
19770524 200701 2 008
4 Erwiyati II a Tenaga Admin 47,460 0 47,460 4.
19690329 201001 2 002
5 Suhartini Tenaga Lab 102,830 0 102,830 5.
6 Sunarlin Tenaga Apotek 63,280 0 63,280 6.
JUMLAH 791,000 28,872 762,129
Banyuwangi,
Menyetujui: Disetujui : Lunas Dibayar:

Pengguna Anggaran Kuasa Pengguna Anggaran Tgl:
Kepala Dinas Kesehatan Kepala Bidang
Kab. Banyuwangi Sumber Daya Kesehatan Bendahara Pengeluaran
dr. WIDJI LESTARIONO MUJITO, SKM DIAN PUSPITASARI, SE

Pembina Tk. I Penata Penata Muda Tk. I
NIP. 19630522 198902 1 002 NIP. 19690524 199203 1 003 NIP. 19760506 200901 2 006

UANG SEBESAR : Rp 1,065,600 ( Tujuh Ratus Sembilan Puluh Satu Ribu Rupiah)
Bulan Maret s.d Mei 2017


Pelayanan Rawat Jalan : Rp 2,664,000 x 40% = Rp 1,065,600
JUMLAH : = Rp 1,065,600


19730110 200604 2 015
19830223 200701 2 008
19770524 200701 2 008
4 Erwiyati II a Tenaga Admin 63,936 0 63,936 4.
19690329 201001 2 002
5 Suhartini Tenaga Lab 138,528 0 138,528 5.
JUMLAH 1,065,600 38,894 1,026,706
Banyuwangi,


NIP. 19630522 198902 1 002 NIP. 19690524 199203 1 003 NIP. 19760506 200901 2 006

UANG SEBESAR : Rp 1,213,000 ( Satu Juta Dua Ratus Tiga Belas Ribu Rupiah)
Bulan Juni s.d Agustus 2017


Pelayanan Rawat Jalan : Rp 3,032,500 x 40% = Rp 1,213,000
JUMLAH : = Rp 1,213,000


19730110 200604 2 015
19830223 200701 2 008
19770524 200701 2 008
4 Erwiyati II c Tenaga Admin 72,780 0 72,780 4.
19690329 201001 2 002
5 Julia Puspita Sari Tenaga Lab 157,690 0 157,690 5.
JUMLAH 1,213,000 44,275 1,168,726
Banyuwangi,


NIP. 19630522 198902 1 002 NIP. 19690524 199203 1 003 NIP. 19760506 200901 2 006
BULAN : JANUARI 2017
Pengujian
Kesehatan
& rujukan
Pelayanan ANC/KB/
1 2 3 4 5 6 7 8 9 10 11 12 13
1 Meseri 01/01/2017 Kolest 9,500 9,500
2 Dwi Anggara 02/01/2017 Catin 7,500 7,500
3 Eva Lestari 02/01/2017 Catin 7,500 7,500
4 Misran 02/01/2017 Catin 7,500 7,500
5 Sainem 02/01/2017 GDA 12,000 12,000
6 Rohadi 04/01/2017 GDA 12,000 12,000
7 Mukhaidori 04/01/2017 Kolest 9,500 9,500
8 Ponijah 05/01/2017 Catin 7,500 7,500
9 Rina Dwi Yanti 05/01/2017 Catin 7,500 7,500
10 Agung Sidayu 05/01/2017 Catin 7,500 7,500
11 Nuryati 05/01/2017 Catin 7,500 7,500
12 Buali 05/01/2017 Catin 7,500 7,500
13 Kopi 06/01/2017 GDA 12,000 12,000
14 Sipon 07/01/2017 Kolest 9,500 9,500
15 Lasiamin 07/01/2017 UA 11,000 11,000
16 Ponijem 09/01/2017 GDA 12,000 12,000
17 Tuminah 09/01/2017 Kolest 9,500 9,500
18 Susi 09/01/2017 Kolest 9,500 9,500
19 Sri Astutik 10/01/2017 Catin 7,500 7,500
20 Samsul Arifin 10/01/2017 Catin 7,500 7,500
21 Andika Arif 10/01/2017 Catin 7,500 7,500
22 Maria Ulva 10/01/2017 Catin 7,500 7,500
23 Tumirin 10/01/2017 Catin 7,500 7,500
24 Nurul Hidayah 10/01/2017 Catin 7,500 7,500
25 Adi Rafli 10/01/2017 Catin 7,500 7,500
26 Putri Khoriyatul 10/01/2017 Catin 7,500 7,500
27 Priyono 10/01/2017 UA 11,000 11,000
28 Oki Felani 11/01/2017 Catin 7,500 7,500
29 Retno Nurhayati 11/01/2017 Catin 7,500 7,500
30 Surip 11/01/2017 UA 11,000 11,000
31 Ria 11/01/2017 AFF IMPLAN 25,000 25,000
32 Jaelani 12/01/2017 Catin 7,500 7,500
33 Jubaidah 12/01/2017 Catin 7,500 7,500
34 Tumiarsih 12/01/2017 Catin 7,500 7,500
Pengujian
& rujukan
Pelayanan ANC/KB/
1 2 3 4 5 6 7 8 9 10 11 12 13
35 Legiono 12/01/2017 Catin 7,500 7,500
36 Purwanto 13/01/2017 GDA 12,000 12,000
37 Yatimin 13/01/2017 Catin 7,500 7,500
38 Ponijem 13/01/2017 Catin 7,500 7,500
39 Sudarsih 13/01/2017 Catin 7,500 7,500
40 Sudarji 13/01/2017 Catin 7,500 7,500
41 Rohman H 14/01/2017 Catin 5,000 5,000
42 Hermin M 14/01/2017 Catin 5,000 5,000
43 Jariyah 16/01/2017 AFF IMPLANT 25,000 25,000
44 Supirah 16/01/2017 HB 5,000 5,000
45 Sriatin 16/01/2017 Kolest 17,000 17,000
46 Sutiana 17/01/2017 Catin 9,500 9,500
47 Ach. Riyadi 17/01/2017 Catin 7,500 7,500
48 Dedi Purwanto 17/01/2017 Catin 7,500 7,500
49 Siti Mutoharoh 17/01/2017 Catin 7,500 7,500
50 Tria Sanjaya 17/01/2017 Catin 7,500 7,500
51 Fila Yunita 17/01/2017 Catin 7,500 7,500
52 Faizin Sofyan 17/01/2017 Catin 7,500 7,500
53 Luluk Ekowati 17/01/2017 Catin 7,500 7,500
54 Kustina Dewi 17/01/2017 Catin 7,500 7,500
55 Rizqi F 17/01/2017 Catin 7,500 7,500
56 Sumani 17/01/2017 GDA+UA 23,000 23,000
57 Fadli 18/01/2017 Catin 7,500 7,500
58 Agus Muthohir 18/01/2017 Catin 7,500 7,500
59 Dedi Purwanto 18/01/2017 Catin 7,500 7,500
60 Lailatul H 18/01/2017 Catin 7,500 7,500
61 Desi Ayu R 18/01/2017 Catin 7,500 7,500
62 Sigit Hadi S 18/01/2017 Catin 7,500 7,500
63 Siti Aisyah 18/01/2017 GDA 12,000 12,000
64 Miski 19/01/2017 GDA 12,000 12,000
65 Djufriadi 20/01/2017 Catin 7,500 7,500
66 Ratna Watini 20/01/2017 Catin 7,500 7,500
67 Siti Aisyah 23/01/2017 Catin 7,500 7,500
68 Luki Prayitno 23/01/2017 Catin 7,500 7,500
69 Suparno 23/01/2017 Catin 7,500 7,500
70 Regi 23/01/2017 Catin 7,500 7,500
71 Ani Asis 23/01/2017 Catin 7,500 7,500
72 M. Johan Syah 23/01/2017 Catin 7,500 7,500
73 Yuliati 23/01/2017 Catin 7,500 7,500
74 Imam Safi'i 23/01/2017 Catin 7,500 7,500
75 Beni Muharom 23/01/2017 Catin 7,500 7,500
76 Kamilia Efendi 23/01/2017 Catin 7,500 7,500
Pengujian
& rujukan
Pelayanan ANC/KB/
1 2 3 4 5 6 7 8 9 10 11 12 13
77 Reza Risti 23/01/2017 Catin 7,500 7,500
79 Tarminah 25/01/2017 GDA 12,000 12,000
80 Suliha 25/01/2017 UA 11,000 11,000
81 H. Siti 26/01/2017 GDA 12,000 12,000
82 Sipon 26/01/2017 GDA 12,000 12,000
83 Sakron 27/01/2017 Catin 7,500 7,500
84 Iis Sugiyarti 27/01/2017 Catin 7,500 7,500
85 Erwan Priyadi 27/01/2017 Catin 7,500 7,500
86 Dyah Ayu P 30/01/2017 Catin 7,500 7,500
87 Galung Yuniarta 30/01/2017 Catin 7,500 7,500
88 Juber 30/01/2017 Catin 7,500 7,500
89 Evitamala 30/01/2017 Catin 7,500 7,500
90 Sukirah 30/01/2017 GDA+KOLEST 21,500 21,500
91 Hartatik 30/01/2017 UA 11,000 11,000
TOTAL - - 499,000 317,000 816,000
Banyuwangi, 31 Januari 2017

Mengetahui,
Kepala UPTD Puskesmas Tembokrejo
dr. MANGESTI UTAMI

Penata Tingkat I
NIP. 19730110 200604 2 015
BULAN : FEBRUARI 2017
Pengujian
Kesehatan
& rujukan
Pelayanan ANC/KB/
1 2 3 4 5 6 7 8 9 10 11 12 13
1 Katiman 01/02/2017 GDA 12,000 12,000
2 M.Ismail 01/02/2017 KIR KES LAIN 5,000 5,000
3 Susiwati 01/02/2017 KIR KES LAIN 5,000 5,000
4 Suwarsono 01/02/2017 KIR KES LAIN 5,000 5,000
5 Nanang Purwos 01/02/2017 KIR KES LAIN 5,000 5,000
6 Bambang C 01/02/2017 KIR KES LAIN 5,000 5,000
7 Siswanto 01/02/2017 KIR KES LAIN 5,000 5,000
8 Agus Amin T 01/02/2017 KIR KES LAIN 5,000 5,000
9 Subakat 01/02/2017 KIR KES LAIN 5,000 5,000
10 Rasminto 01/02/2017 KIR KES LAIN 5,000 5,000
11 Isa Asmaul H 02/02/2017 Catin 7,500 7,500
12 Syaiful H 02/02/2017 Catin 7,500 7,500
13 Muselin 02/02/2017 GDA 12,000 12,000
14 Sutari 02/02/2017 Kolest 9,500 9,500
15 Linda S 03/02/2017 Catin 7,500 7,500
16 Oki Reza A 03/02/2017 Catin 7,500 7,500
17 Suradi 07/02/2017 Catin 7,500 7,500
18 Mugiyati 07/02/2017 Catin 7,500 7,500
19 Bibit Santoso 07/02/2017 Catin 7,500 7,500
20 Hadi K 07/02/2017 GDA 12,000 12,000
21 Binti R 08/02/2017 Catin 7,500 7,500
22 Hadi K 08/02/2017 Catin 7,500 7,500
23 Namiyati 08/02/2017 GDA 12,000 12,000
24 Siti Nur k 09/02/2017 Catin 7,500 7,500
25 M. Khoirul A 09/02/2017 Catin 7,500 7,500
26 Nanang Abdul 09/02/2017 Catin 7,500 7,500
27 Dwi Rahayu 09/02/2017 Catin 7,500 7,500
28 Saminah 10/02/2017 UA 11,000 11,000
29 Rusman Adi 10/02/2017 Catin 7,500 7,500
30 Yuyun Sudarsono 10/02/2017 Catin 7,500 7,500
31 Sipon 11/02/2017 GDA 12,000 12,000
32 Abd. Hadi 11/02/2017 Kolest 9,500 9,500
33 Puji Astutik 11/02/2017 UA 11,000 11,000
34 Misti 13/02/2017 Kolest 9,500 9,500
35 Bunga K 13/02/2017 Catin 7,500 7,500
Pengujian
& rujukan
Pelayanan ANC/KB/
1 2 3 4 5 6 7 8 9 10 11 12 13
36 Ida Farida 14/02/2017 UA 11,000 11,000
37 Nur Laili 14/02/2017 Catin 7,500 7,500
38 Misri 14/02/2017 GDA 12,000 12,000
39 Warsono 16/02/2017 Kolest 9,500 9,500
40 Suratin 16/02/2017 GDA 12,000 12,000
41 Rafidil Anam 18/02/2017 Catin 7,500 7,500
42 Meisi Putri A 18/02/2017 Catin 7,500 7,500
43 Arvin Julistyas 18/02/2017 Catin 7,500 7,500
44 Misri Lestari 18/02/2017 Catin 7,500 7,500
45 Purwanto 18/02/2017 Catin 7,500 7,500
46 Nurul Ilmawati 18/02/2017 Catin 7,500 7,500
47 Ilham 18/02/2017 Catin 7,500 7,500
48 Putri Novita Sari 18/02/2017 Catin 7,500 7,500
49 Abd Rofik 18/02/2017 Catin 7,500 7,500
50 Istianah 18/02/2017 GDA 12,000 12,000
51 Sanayah 18/02/2017 Kolest 9,500 9,500
52 Rasiyah 18/02/2017 GDA 12,000 12,000
53 Lutfi Wulandari 20/02/2017 Catin 7,500 7,500
54 Dedi Tri Handoko 20/02/2017 Catin 7,500 7,500
55 Dwi Lusita S 20/02/2017 Catin 7,500 7,500
56 Moh. Ikbal 20/02/2017 Catin 7,500 7,500
57 Sugimah 20/02/2017 GDA 12,000 12,000
58 Tasrifah 20/02/2017 Kolest 9,500 9,500
59 Wiwin 20/02/2017 Catin 7,500 7,500
60 Fuad Budianto 20/02/2017 Catin 7,500 7,500
61 Rakhijo B 21/02/2017 KIR KES SWASTA 7,500 7,500
62 Supriadi 21/02/2017 Catin 7,500 7,500
63 Puji 21/02/2017 Kolest 9,500 9,500
64 Siti Aisyah 21/02/2017 GDA 12,000 12,000
65 Rasmi 21/02/2017 KIR KES HAJI 25,000 25,000
66 Asnaf 21/02/2017 KIR KES HAJI 25,000 25,000
67 Monera 21/02/2017 KIR KES HAJI 25,000 25,000
68 Karyo Martoyo 21/02/2017 KIR KES HAJI 25,000 25,000
69 Siti Julaikah 21/02/2017 KIR KES HAJI 25,000 25,000
70 Indari 21/02/2017 KIR KES HAJI 25,000 25,000
71 Sumarsih 21/02/2017 KIR KES HAJI 25,000 25,000
72 Suyono 21/02/2017 KIR KES HAJI 25,000 25,000
73 Ivan Wati 21/02/2017 KIR KES HAJI 25,000 25,000
74 Fatimah 21/02/2017 KIR KES HAJI 25,000 25,000
75 Slamet 21/02/2017 KIR KES HAJI 25,000 25,000
76 Patimah 21/02/2017 KIR KES HAJI 25,000 25,000
77 Rumsiyah 21/02/2017 KIR KES HAJI 25,000 25,000
Pengujian
& rujukan
Pelayanan ANC/KB/
1 2 3 4 5 6 7 8 9 10 11 12 13
78 Saladi Baidowi 21/02/2017 KIR KES HAJI 25,000 25,000
79 Mamik Yuliati 21/02/2017 KIR KES HAJI 25,000 25,000
80 Shodip 21/02/2017 KIR KES HAJI 25,000 25,000
81 Sutaji 21/02/2017 KIR KES HAJI 25,000 25,000
82 Surati 21/02/2017 KIR KES HAJI 25,000 25,000
83 Misiati 21/02/2017 KIR KES HAJI 25,000 25,000
84 Husaini 21/02/2017 KIR KES HAJI 25,000 25,000
85 Sumarsih 21/02/2017 KIR KES HAJI 25,000 25,000
86 Salamin 21/02/2017 KIR KES HAJI 25,000 25,000
87 Istiamah 23/02/2017 UA 11,000 11,000
88 Rahmaniah 24/02/2017 UA 11,000 11,000
89 Sainem 24/02/2018 GDA 12,000 12,000
90 Sipon 24/02/2019 Kolest 9,500 9,500
91 Abu Hasan 25/02/2017 Kolest 9,500 9,500
92 Rohati 25/02/2017 GDA 12,000 12,000
93 Evita Aprilia 25/02/2017 Catin 7,500 7,500
94 M. Widiarti 25/02/2017 Catin 7,500 7,500
TOTAL - - 865,000 296,500 1,161,500
Banyuwangi, 28 Februari 2015

Mengetahui,
dr. MANGESTI UTAMI

Penata Tingkat I
NIP. 19730110 200604 2 015
BULAN : MARET 2017
Pengujian
Kesehatan
& rujukan
Pelayanan ANC/KB/
1 2 3 4 5 6 7 8 9 10 11 12 13 14
1 Ahmad Qodri 01/03/2017 Catin 7,500 7,500
2 Roni Hadi B 01/03/2017 Catin 7,500 7,500
3 Mila Ambar Wati 01/03/2017 Catin 7,500 7,500
4 Risa Wismaul H 01/03/2017 Catin 7,500 7,500
5 Agus Setyawan 01/03/2017 Catin 7,500 7,500
6 Dewi Ma'rifatul 01/03/2017 Catin 7,500 7,500
7 Rohmad Kh 01/03/2017 Catin 7,500 7,500
8 Suprianingsih 01/03/2017 GDA 12,000 12,000
9 Ponirah 01/03/2017 GDA 12,000 12,000
10 Sukirah 01/03/2017 GDA 12,000 12,000
11 Julita Eka S 02/03/2017 Catin 7,500 7,500
12 Andi Tri W 02/03/2017 Catin 7,500 7,500
13 Ari Setyawan 02/03/2017 Catin 7,500 7,500
14 Siti Nur Holisah 02/03/2017 Catin 7,500 7,500
15 Putri Indiastini 02/03/2017 Catin 7,500 7,500
16 Ardianto 02/03/2017 Catin 7,500 7,500
17 Mansur 02/03/2017 Catin 7,500 7,500
18 Nova Kardela 02/03/2017 Catin 7,500 7,500
19 Siti Rokana 02/03/2017 KOLEST 9,500 9,500
20 Setiasih 02/03/2017 KOLEST 9,500 9,500
21 Wiwit 02/03/2017 GDA 12,000 12,000
22 Yudianto 06/03/2017 Catin 7,500 7,500
23 Siti Asiyah 06/03/2017 Catin 7,500 7,500
24 Agung Dwi H 06/03/2017 KIR KES LAIN 4,500 4,500
25 Fajar Dwi S 10/03/2017 Catin 7,500 7,500
26 Olim Kumalasari 10/03/2017 Catin 7,500 7,500
27 M. Diky Saputra 13/03/2017 Catin 7,500 7,500
28 Nanda Salsabela 13/03/2017 Catin 7,500 7,500
29 Tito Dwi Sulistya 13/03/2017 Catin 7,500 7,500
30 Ardhina Cahya P 13/03/2017 Catin 7,500 7,500
31 Ayu Fitri A 13/03/2017 Catin 7,500 7,500
32 Resa Renata 13/03/2017 Catin 7,500 7,500
33 Nilam Cahya W 13/03/2017 Catin 7,500 7,500
34 Khoirul Anam 13/03/2017 Catin 7,500 7,500
Pengujian
& rujukan
Pelayanan ANC/KB/
1 2 3 4 5 6 7 8 9 10 11 12 13 14
35 Basuni 13/03/2017 KOLEST 10,000 10,000
36 Nur Hasim 13/03/2017 GDA 12,000 12,000
37 Asta 13/03/2017 TMNO KEB 60,000 60,000
38 Suminah 14/03/2017 GDA 12,000 12,000
39 Titin 14/03/2017 UA 12,000 12,000
40 Musadi 14/03/2017 UA 12,000 12,000
41 Haidori 15/03/2017 GDA 12,000 12,000
42 Sugiri 16/03/2017 GDA 12,000 12,000
43 Didit Sugiarto 17/03/2017 Catin 7,500 7,500
44 Siti Khusnul H 17/03/2017 Catin 7,500 7,500
45 Miftahul Syarif 20/03/2017 Catin 7,500 7,500
46 Siti Nurjanah 20/03/2017 Catin 7,500 7,500
47 Kiki Fransiska 20/03/2017 Catin 7,500 7,500
48 Kiki Prasetyo 20/03/2017 Catin 7,500 7,500
49 Mujiatmi 20/03/2017 Catin 7,500 7,500
50 Hariyono 20/03/2017 Catin 7,500 7,500
51 Bonirah 23/03/2017 GDA 12,000 12,000
52 Hairul 24/03/2017 Catin 7,500 7,500
53 Sania St. S 24/03/2017 Catin 7,500 7,500
54 Musalamah 24/03/2017 GDA 12,000 12,000
55 Rusma 24/03/2017 GDA 12,000 12,000
56 Tego 24/03/2017 GDA 12,000 12,000
57 Misnati 24/03/2017 GDA 12,000 12,000
58 Lilik 24/03/2017 GDA 12,000 12,000
59 Astyawati 27/03/2017 Catin 7,500 7,500
60 Panggih Eko Y 27/03/2017 Catin 7,500 7,500
61 Ady Tyastara 27/03/2017 Catin 7,500 7,500
62 Riski Khotimah S 27/03/2017 Catin 7,500 7,500
63 Sipon 27/03/2017 GDA 12,000 12,000
64 Wagirah 29/03/2017 Catin 7,500 7,500
65 Tanwin 29/03/2017 Catin 7,500 7,500
66 Lailatul R 29/03/2017 Catin 7,500 7,500
67 Nur Kolis 29/03/2017 Catin 7,500 7,500
68 Desi Erna F 29/03/2017 Catin 7,500 7,500
69 Sutiah 29/03/2017 KOLEST 9,500 9,500
70 Tito Santana 29/03/2017 Catin 7,500 7,500
71 Suryani 30/03/2017 Catin 7,500 7,500
72 Sudaryono 30/03/2017 Catin 7,500 7,500
73 Mia Ayu P 30/03/2017 Catin 7,500 7,500
74 Yunus Septa B 31/03/2017 Catin 7,500 7,500
75 Suparman 31/03/2017 KOLEST 9,500 9,500
76 Siti Rokanah 31/03/2017 UA 11,000 11,000
Pengujian
& rujukan
Pelayanan ANC/KB/
1 2 3 4 5 6 7 8 9 10 11 12 13 14
77 Siti Khoiriyah 31/03/2017 UA 11,000 11,000
TOTAL - 382,500 338,500 721,000
Banyuwangi, 31 Maret 2017

Mengetahui,
dr. MANGESTI UTAMI

Penata Tingkat I
NIP. 19730110 200604 2 015
BULAN : APRIL 2017
Pengujian
Kesehatan
& rujukan
Pelayanan ANC/KB/
1 2 3 4 5 6 7 8 9 10 11 12 13
1 Wiwik 01/04/2017 GDA 12,000 12,000
2 Sumiati 01/04/2017 GDA 12,000 12,000
3 Tri Sundari 01/04/2017 KOLEST + UA 20,500 20,500
4 Khusnul K 03/04/2017 Catin 7,500 7,500
5 Fatimah 03/04/2017 KOLEST + UA 20,500 20,500
6 Nonik Istiyah 04/04/2017 Catin 7,500 7,500
7 Winarno 04/04/2017 Catin 7,500 7,500
8 Irma Puji A 05/04/2017 Catin 7,500 7,500
9 Lukman N 05/04/2017 Catin 7,500 7,500
10 H. Siti Aisah 06/04/2017 GDA 12,000 12,000
11 Ida Rahayu 06/04/2017 Catin 7,500 7,500
12 Ketut Susanto 06/04/2017 Catin 7,500 7,500
13 Rano 07/04/2017 GDA 12,000 12,000
14 Lilik 07/04/2017 kOLEST 9,500 9,500
15 Fandy Putra 07/04/2017 Catin 7,500 7,500
16 Siti Khoirun Nisa 07/04/2017 Catin 7,500 7,500
17 Eka Emilia Pratiwi 07/04/2017 Catin 7,500 7,500
18 Febi Firmansyah 07/04/2017 Catin 7,500 7,500
19 Novia Dwi L 07/04/2017 Catin 7,500 7,500
20 Sapta Dwi R 07/04/2017 Catin 7,500 7,500
21 Fitrianingsih 08/04/2017 Catin 7,500 7,500
22 Sariyanto 08/04/2017 Catin 7,500 7,500
23 Mutmainah 08/04/2017 Catin 7,500 7,500
24 Febriana S 08/04/2017 Catin 7,500 7,500
25 Hariyono 08/04/2017 Catin 7,500 7,500
26 Sipon 11/04/2017 KOLEST 9,500 9,500
27 Mar'ati 11/04/2017 GDA 12,000 12,000
28 Bonirah 12/04/2017 GDA 12,000 12,000
29 Hapipi 12/04/2017 KOLEST + UA 20,500 20,500
30 Fajar Siswoyo 13/04/2017 Catin 7,500 7,500
31 Fitriatus S 13/04/2017 Catin 7,500 7,500
32 Siti Muawanah 15/04/2017 Catin 7,500 7,500
33 Sugiono 15/04/2017 Catin 7,500 7,500
34 Sahrul 17/04/2017 GDA 12,000 12,000
Pengujian
& rujukan
Pelayanan ANC/KB/
1 2 3 4 5 6 7 8 9 10 11 12 13
35 Sunarlin 17/04/2017 GDA 12,000 12,000
36 Aminah 17/04/2017 Catin 7,500 7,500
37 M. Dahim 17/04/2017 Catin 7,500 7,500
38 M. Agung M 17/04/2017 Catin 7,500 7,500
39 Tri Ernawati 17/04/2017 Catin 7,500 7,500
40 M. Alfan S 17/04/2017 Catin 7,500 7,500
41 Annisa Advani 17/04/2017 Catin 7,500 7,500
42 Ah. Husaini 18/04/2017 Catin 7,500 7,500
43 Nia Anisa 18/04/2017 Catin 7,500 7,500
44 Sahrul 18/04/2017 UA 11,000 11,000
45 Kasiyem 18/04/2017 KOLEST + UA 20,500 20,500
46 Mawardi 18/04/2017 KOLEST 9,500 9,500
47 Sunyoto 18/04/2017 GDA 12,000 12,000
48 Arifin 19/04/2017 Catin 7,500 7,500
49 Maulidia J 19/04/2017 Catin 7,500 7,500
50 Nurul Sri L 19/04/2017 Catin 7,500 7,500
51 Imam Fadillah 19/04/2017 Catin 7,500 7,500
52 Sukati 19/04/2017 GDA 12,000 12,000
53 Nur Kholis 20/04/2017 Catin 7,500 7,500
54 Suci Wiji Tri L 20/04/2017 Catin 7,500 7,500
55 Hatriya 20/04/2017 Catin 7,500 7,500
56 Jemirin 20/04/2017 Catin 7,500 7,500
57 Kasiyati 20/04/2017 Catin 7,500 7,500
58 Suherman 20/04/2017 Catin 7,500 7,500
59 Ratna Dwi L 21/04/2017 KIR KES LAIN 5,000 5,000
60 Lilis Suryani 22/04/2017 KIR KES LAIN 5,000 5,000
61 Sipon 25/04/2017 KOLEST 9,500 9,500
62 Rofik Hidayat 25/04/2017 Catin 7,500 7,500
63 Binti Rofiatul H 25/04/2017 Catin 7,500 7,500
64 Nur Khalimah 25/04/2017 Catin 7,500 7,500
65 Oni Osman C 25/04/2017 Catin 7,500 7,500
66 Syaiful Rizal 25/04/2017 Catin 7,500 7,500
67 Mujiati 25/04/2017 Catin 7,500 7,500
68 Desi Eka P 25/04/2017 Catin 7,500 7,500
69 Ghofi Rullah 25/04/2017 Catin 7,500 7,500
70 Fera Ema A 25/04/2017 Catin 7,500 7,500
71 Cahyo Purnomo 26/04/2017 Catin 7,500 7,500
72 Lutfi Muta'a K 26/04/2017 Catin 7,500 7,500
73 Endar Wadi 26/04/2017 Catin 7,500 7,500
74 Eka Finta R 26/04/2017 Catin 7,500 7,500
75 Tego 26/04/2017 Catin 7,500 7,500
76 Supartimah 26/04/2017 Catin 7,500 7,500
Pengujian
& rujukan
Pelayanan ANC/KB/
1 2 3 4 5 6 7 8 9 10 11 12 13
77 Tosan 26/04/2017 Catin 7,500 7,500
78 Hariyati 26/04/2017 KIR KES LAIN 5,000 5,000
79 Widiarko Yoga P 26/04/2017 KIR KES SWASTA 7,500 7,500
80 Siti Aisah 26/04/2017 GDA 12,000 12,000
81 Rami 26/04/2017 KOLEST + UA 20,500 20,500
82 Asminah 26/04/2017 GDA 12,000 12,000
83 Sujianto 27/04/2017 GDA 12,000 12,000
84 Unik Ayu 27/04/2017 GDA 12,000 12,000
TOTAL - - 442,500 319,500 762,000
Banyuwangi, 29 April 2017

Mengetahui,
dr. MANGESTI UTAMI

Penata Tingkat I
NIP. 19730110 200604 2 015
BULAN : Juni 2018
Pengujian
Kesehatan
& rujukan
Pelayanan ANC/KB/
1 2 3 4 5 6 7 8 9 10 11 12 13
1 Moh jaelani 2/06/2018 Kir Kesehatan 10,000 10,000
2 Saminah 2/06/2018 Kir Kesehatan 10,000 10,000
3 Timah 2/06/2018 GDA 15,000 15,000
4 Heni dwi masitah 4/06/2018 Catin 10,000 10,000
5 Sulton dwi F 4/06/2018 Catin 10,000 10,000
6 Desi pramita 4/06/2018 Catin 10,000 10,000
7 Riska 4/06/2018 Gigi 40,000 40,000
8 Andy susanto 4/06/2018 Catin 10,000 10,000
9 Bahtiar 5/06/2018 Kir Kesehatan 10,000 10,000
10 Ferikal F 8/06/2018 Catin 10,000 10,000
11 Niki fatmawati 8/06/2018 Catin 10,000 10,000
12 Jehan insiyah 8/06/2018 Catin 10,000 10,000
13 Legiman 8/06/2018 Catin 10,000 10,000
14 Siamah 8/06/2018 Catin 10,000 10,000
15 Tio 8/06/2018 Gigi 80,000 80,000
16 Wiwik 8/06/2018 Gigi 40,000 40,000
17 Sunarto 9/06/2018 Kir Kesehatan 10,000 10,000
18 Mestiyah 9/06/2018 GDA 15,000 15,000
19 Siamat 21/06/2018 Kulest 25,000 25,000
20 Subari 22/06/2018 Kir Kesehatan 10,000 10,000
21 Elma rohana 22/06/2018 Catin 10,000 10,000
22 Dwi Indra setiawan 22/06/2018 Catin 10,000 10,000
23 Sukirah 22/06/2018 GDA.Kulet.Asu 60,000 60,000
24 Sunartik 23/06/2018 Kulest 25,000 25,000
25 Ponisri 23/06/2018 GDA 15,000 15,000
26 Riziek 25/06/2018 Jahit luka 100,000 100,000
27 Khusnul khotimah 25/06/2018 Kir Kesehatan 10,000 10,000
28 Viki fermansah 26/06/2018 Catin 10,000 10,000
29 Disa budi H 26/06/2018 Catin 10,000 10,000
30 Siti Nurhayati 26/06/2018 GDA 15,000 15,000
31 Supik 26/06/2018 Kulest 25,000 25,000
32 Moh saiful 28/06/2018 Catin 10,000 10,000
33 Tria Fitriani 28/06/2018 Catin 10,000 10,000
34 Nur maulana 28/06/2018 Catin 10,000 10,000
Pengujian
& rujukan
Pelayanan ANC/KB/
1 2 3 4 5 6 7 8 9 10 11 12 13
35 Iswanto 28/06/2018 Catin 10,000 10,000
36 Umi hasanah 28/06/2018 Catin 10,000 10,000
37 Pathor 28/06/2018 Catin 10,000 10,000
38 Siti Asiyah 28/06/2018 Catin 10,000 10,000
39 Agus salim 28/06/2018 Kulest 25,000 25,000
40 Slamet 28/06/2018 Kulest,GDA 40,000 40,000
137 Marsela Catin 10,000 10,000
TOTAL 100,000 160,000 - 270,000 260,000 790,000

Mengetahui,
dr. FERDAUS
Penata Tingkat I
NIP. 197000530 200701 1 008
BULAN : JUNI 2017
Pengujian
Kesehatan
& rujukan
Pelayanan ANC/KB/
1 2 3 4 5 6 7 8 9 10 11 12 13 14
1 Budi Riyanto 02/06/2017 Catin 7,500 7,500
2 Dwi Agustinawati 02/06/2017 Catin 7,500 7,500
3 Saeful Bahri 02/06/2017 Catin 7,500 7,500
4 Ayu Rahmawati 02/06/2017 Catin 7,500 7,500
5 Tutus Damayanti 02/06/2017 Catin 7,500 7,500
6 Agus Supriyono 02/06/2017 Catin 7,500 7,500
7 Tulus Susanto 02/06/2017 GDA 12,000 12,000
8 Sri Astutik 03/06/2017 KOLEST+UA 20,500 20,500
9 Hadi Purnomo 05/06/2017 Catin 7,500 7,500
10 Gusyani 05/06/2017 Catin 7,500 7,500
11 Supriyono 05/06/2017 KIR KES SWASTA 7,500 7,500
12 Bambang A 05/06/2017 KIR KES SWASTA 7,500 7,500
13 M. Abdul Malik S 07/06/2017 Catin 7,500 7,500
14 Anis Nikmatur R 07/06/2017 Catin 7,500 7,500
15 Dita Dwi K 07/06/2017 Catin 7,500 7,500
16 Moh Efendi 07/06/2017 Catin 7,500 7,500
17 Jumilah 07/06/2017 GDA 12,000 12,000
18 Devi Eka Ayu 08/06/2017 Catin 7,500 7,500
19 Maskur 08/06/2017 Catin 7,500 7,500
20 Salamin 08/06/2017 GDA+KOLEST+UA 32,500 32,500
21 Rosidi 08/06/2017 GDA+KOLEST 21,500 21,500
22 Sulami 10/06/2017 KIR KES SWASTA 7,500 7,500
23 Siti Mutmainah 10/06/2017 Catin 7,500 7,500
24 M. Ali Makrus 10/06/2017 Catin 7,500 7,500
25 Ah. Suyono 13/06/2017 KIR KES SWASTA 7,500 7,500
26 Warini 13/06/2017 GDA 12,000 12,000
27 Ristiyan Surya P 13/06/2017 Catin 7,500 7,500
28 Regita Anuraga 13/06/2017 Catin 7,500 7,500
29 Yayuk Setiyarini 13/06/2017 Catin 7,500 7,500
30 Saiful Anam 13/06/2017 Catin 7,500 7,500
31 Katinem 14/06/2017 KIR KES SWASTA 7,500 7,500
32 Katinum 14/06/2017 KIR KES SWASTA 7,500 7,500
33 Endah Wahyuni 15/06/2017 Catin 7,500 7,500
34 M. Indra 15/06/2017 Catin 7,500 7,500
Pengujian
& rujukan
Pelayanan ANC/KB/
1 2 3 4 5 6 7 8 9 10 11 12 13 14
35 Edi Waluyo 15/06/2017 KIR KES SWASTA 7,500 7,500
36 Bonirah 15/06/2017 GDA 12,000 12,000
37 Junaidi 16/06/2017 Catin 7,500 7,500
38 Gusti Candra L 16/06/2017 Catin 7,500 7,500
39 Erlin Nova M 16/06/2017 Catin 7,500 7,500
40 Teguh Pribadi 16/06/2017 Catin 7,500 7,500
41 Andrika Tunia L 16/06/2017 Catin 7,500 7,500
42 Nurul W 16/06/2017 Catin 7,500 7,500
43 M.Soim P 16/06/2017 Catin 7,500 7,500
44 Warsini 16/06/2017 GDA 12,000 12,000
45 Sukirman 19/06/2017 KIR KES SWASTA 7,500 7,500
46 Eva Holidi 19/06/2017 Catin 7,500 7,500
47 Taufan Fauzi 19/06/2017 Catin 7,500 7,500
48 Nurul Hotimah 19/06/2017 KOLEST+UA 20,500 20,500
49 Puput Indah L 20/06/2017 Catin 7,500 7,500
50 Sartini 20/06/2017 GDA 12,000 12,000
51 Wasito 20/06/2017 KOLEST+UA 20,500 20,500
52 Ali Mansur 20/06/2017 GDA 12,000 12,000
53 Ah. Dairobi 21/06/2017 Catin 7,500 7,500
54 Ponisri 21/06/2017 Catin 7,500 7,500
55 Siti Huzaimah 21/06/2017 Catin 7,500 7,500
56 Lukman Hakim 21/06/2017 Catin 7,500 7,500
57 Endrik Lilik A 21/06/2017 Catin 7,500 7,500
58 Bahno 21/06/2017 Catin 7,500 7,500
59 Rindiyatin 21/06/2017 Catin 7,500 7,500
60 Eko Prasetyo 21/06/2017 Catin 7,500 7,500
61 Fahra Rosna U 21/06/2017 Catin 7,500 7,500
62 Dimas Prakoso 21/06/2017 Catin 7,500 7,500
63 Ilham Nur 21/06/2017 KIR KES SWASTA 7,500 7,500
64 Wakyu Triatmoko 22/06/2017 Catin 7,500 7,500
65 Sukati 22/06/2017 GDA 12,000 12,000
66 Samini 22/06/2017 GDA 12,000 12,000
67 Mundiyah 22/06/2017 GDA 12,000 12,000
68 Rumsiyah 22/06/2017 UA 11,000 11,000
Pengujian
& rujukan
Pelayanan ANC/KB/
1 2 3 4 5 6 7 8 9 10 11 12 13 14
69 Husaini 22/06/2017 KOLEST 9,500 9,500
70 Sutaji 22/06/2017 KOLEST 9,500 9,500
TOTAL - 390,000 265,500 655,500

Mengetahui,
dr. MANGESTI UTAMI

Penata Tingkat I
NIP. 19730110 200604 2 015
BULAN : JULI 2017
Pengujian
Kesehatan
& rujukan
Pelayanan ANC/KB/
1 2 3 4 5 6 7 8 9 10 11 12 13 14
1 Wahyu T 01/07/2017 Catin 7,500 7,500
2 Moh. Rofii 01/07/2017 Catin 7,500 7,500
3 Septya Ernawati 01/07/2017 Catin 7,500 7,500
4 Nur Imamah 01/07/2017 Catin 7,500 7,500
5 Welly Nelly K 01/07/2017 Catin 7,500 7,500
6 Sandi 03/07/2017 KIR KES SWASTA 7,500 7,500
7 Moh. Arif Janata S 03/07/2017 Catin 7,500 7,500
8 Bella Proboretno 03/07/2017 Catin 7,500 7,500
9 Riko Mergo P 03/07/2017 Catin 7,500 7,500
10 Bibin Ismiasih 03/07/2017 Catin 7,500 7,500
11 Sandy Perdana 03/07/2017 Catin 7,500 7,500
12 Alisa Agustin 03/07/2017 Catin 7,500 7,500
13 Sukirah 03/07/2017 GDA 12,000 12,000
14 Rohani 03/07/2017 KOLEST 9,500 9,500
15 Poniyem 03/07/2017 UA 11,000 11,000
16 Sunarlin 03/07/2017 GDA 12,000 12,000
17 Mundiyah 03/07/2017 GDA 12,000 12,000
18 Supiyatun 03/07/2017 GDA 12,000 12,000
19 Subairi 03/07/2017 UA 11,000 11,000
20 Supiyani 04/07/2017 GDA 12,000 12,000
21 Kiptiyah 04/07/2017 Catin 7,500 7,500
22 Nanang wahyu 04/07/2017 Catin 7,500 7,500
23 Ridi Astutik 04/07/2017 Catin 7,500 7,500
24 Iwan Sugiyanto 04/07/2017 Catin 7,500 7,500
25 Murniyati 04/07/2017 Catin 7,500 7,500
26 Nurhasan 04/07/2017 Catin 7,500 7,500
27 Nuri Riiskian 05/07/2017 KIR KES SWASTA 7,500 7,500
28 Agung Setiawan 05/07/2017 KIR KES SWASTA 7,500 7,500
29 Hani Supani 05/07/2017 KIR KES SWASTA 7,500 7,500
30 Suhartono 05/07/2017 Catin 7,500 7,500
31 Mia Amrillah 05/07/2017 Catin 7,500 7,500
32 Tugiyem 05/07/2017 GDA 12,000 12,000
33 Siti Aisyah 05/07/2017 GDA 12,000 12,000
34 Nurudin 05/07/2017 KOLEST 9,500 9,500
Pengujian
& rujukan
Pelayanan ANC/KB/
1 2 3 4 5 6 7 8 9 10 11 12 13 14
35 Dista Nurcahyani 06/07/2017 Catin 7,500 7,500
36 Tegak Wahyu 06/07/2017 Catin 7,500 7,500
37 Rumiyati 06/07/2017 Catin 7,500 7,500
38 M. Huri 06/07/2017 Catin 7,500 7,500
39 Hakim Wijaya 06/07/2017 Catin 7,500 7,500
40 Novitasari 06/07/2017 Catin 7,500 7,500
41 Ingga arlinda 06/07/2017 Catin 7,500 7,500
42 Heri andrianto 06/07/2017 Catin 7,500 7,500
43 Hotijah 06/07/2017 KOLEST 9,500 9,500
44 Widodo santoso 06/07/2017 KIR KES SWASTA 7,500 7,500
45 Slamet sono 07/07/2017 GDA 12,000 12,000
46 Sumiati 07/07/2017 KOLEST 9,500 9,500
47 Sangkrah 08/07/2017 KOLEST+UA 20,500 20,500
48 Suwaris 08/07/2017 Catin 7,500 7,500
49 Sulastri 08/07/2017 Catin 7,500 7,500
50 Sri Wahyuni 08/07/2017 KIR KES SWASTA 7,500 7,500
51 Febi Lindawati 10/07/2017 Catin 7,500 7,500
52 Eko 10/07/2017 Catin 7,500 7,500
53 Sri Masruroh 13/07/2017 Catin 7,500 7,500
54 Miswatho 13/07/2017 Catin 7,500 7,500
55 Susi andayani 13/07/2017 Catin 7,500 7,500
56 Rudi subandriyo 13/07/2017 Catin 7,500 7,500
57 Suja'i 13/07/2017 KIR KES SWASTA 7,500 7,500
58 Dewi 13/07/2017 JAHIT LUKA 40,000 40,000
59 Rosiful Aqli 14/07/2017 Catin 7,500 7,500
60 Reni Apriliani 14/07/2017 Catin 7,500 7,500
61 Rusdi 14/07/2017 KIR KES SWASTA 7,500 7,500
62 St Maimunah 15/07/2017 Catin 7,500 7,500
63 Icuk Sunardianto 15/07/2017 Catin 7,500 7,500
64 M.Faishal Perdiansyah 15/07/2017 Catin 7,500 7,500
65 Ayu Anastasya 15/07/2017 Catin 7,500 7,500
66 Ika L 15/07/2017 Catin 7,500 7,500
67 Suhari 15/07/2017 Catin 7,500 7,500
68 Nadia 15/07/2017 Catin 7,500 7,500
69 Tugiyem 15/07/2017 GDA 12,000 12,000
70 Suwarni 17/07/2017 GDA 12,000 12,000
71 Maria T 17/07/2017 KOLEST+UA 20,500 20,500
72 Salamah 17/07/2017 Catin 7,500 7,500
73 Toad 17/07/2017 Catin 7,500 7,500
74 M. Khoiri 18/07/2017 Catin 7,500 7,500
75 Susi Rrimbia 18/07/2017 Catin 7,500 7,500
76 Wagimin 18/07/2017 UA 11,000 11,000
Pengujian
& rujukan
Pelayanan ANC/KB/
1 2 3 4 5 6 7 8 9 10 11 12 13 14
77 Amilia Hidiana 19/07/2017 Catin 7,500 7,500
78 Ady Ferdianto 19/07/2017 Catin 7,500 7,500
79 Rindi Wulandari 19/07/2017 Catin 7,500 7,500
80 Sofi anan 19/07/2017 Catin 7,500 7,500
81 Dian arta 19/07/2017 Catin 7,500 7,500
82 Imam Tukamun 19/07/2017 Catin 7,500 7,500
83 Suyono 20/07/2017 KIR KES SWASTA 7,500 7,500
84 Ida Trisnawati 20/07/2017 Catin 7,500 7,500
85 Budiyanto 20/07/2017 Catin 7,500 7,500
86 Sri Wahyuni 20/07/2017 Catin 7,500 7,500
87 Andri Setyawan 20/07/2017 Catin 7,500 7,500
88 Sumiati 20/07/2017 GDA 12,000 12,000
89 Munijah 24/07/2017 GDA 12,000 12,000
90 Sukesi 24/07/2017 UA 11,000 11,000
91 Andik Widiyanto 24/07/2017 Catin 7,500 7,500
92 Nur Aini 24/07/2017 Catin 7,500 7,500
93 Iiswanto 25/07/2017 KIR KES SWASTA 7,500 7,500
94 Gimin 25/07/2017 UA 11,000 11,000
95 Asmaun 25/07/2017 GDA 12,000 12,000
96 Ahmadi 25/07/2017 KOLEST 9,500 9,500
97 Alfia Puspita N 26/07/2017 Catin 7,500 7,500
98 Ahmad Jailani 26/07/2017 Catin 7,500 7,500
99 Indri Dwi Purwanti 27/07/2017 Catin 7,500 7,500
100 Dapit Waluyo 27/07/2017 Catin 7,500 7,500
101 Sipon 28/07/2017 UA 11,000 11,000
102 Linda Ernawati 29/07/2017 Catin 7,500 7,500
103 St. Saudah 29/07/2017 Catin 7,500 7,500
104 Tri Jefriyanto 29/07/2017 Catin 7,500 7,500
105 Sri Hariyani 29/07/2017 Catin 7,500 7,500
106 Wantoro 29/07/2017 Catin 7,500 7,500
107 Agus Supriyadi 31/07/2017 KIR KES SWASTA 7,500 7,500
108 Dian Amalia 31/07/2017 KIR KES SWASTA 7,500 7,500
109 Tri Sunarsih 31/07/2017 Catin 7,500 7,500
110 Anggar G 31/07/2017 Catin 7,500 7,500
111 Singgih P 31/07/2017 Catin 7,500 7,500
112 Zhilhanun F 31/07/2017 Catin 7,500 7,500
113 Kikim W 31/07/2017 Catin 7,500 7,500
114 Mahrus S 31/07/2017 Catin 7,500 7,500
115 Seneng 31/07/2017 KOLEST 9,500 9,500
116 Lasmani 31/07/2017 UA 11,000 11,000
117 Puji Astutik 31/07/2017 Catin 7,500 7,500
118 M. Ainur Rofik 31/07/2017 Catin 7,500 7,500
Pengujian
& rujukan
Pelayanan ANC/KB/
1 2 3 4 5 6 7 8 9 10 11 12 13 14
119 Devi Rosita 31/07/2017 Catin 7,500 7,500
120 M. Fatoni ashar 31/07/2017 Catin 7,500 7,500
121 Imam Munjiat 31/07/2017 KIR KES SWASTA 7,500 7,500
122 Kusnanto 31/07/2017 KIR KES SWASTA 7,500 7,500
123 Ismadi 31/07/2017 KIR KES SWASTA 7,500 7,500
124 Mulyo basuki 31/07/2017 KIR KES SWASTA 7,500 7,500
- - 712,500 371,000 1,083,500
Banyuwangi, 31 Juli 2017

Mengetahui,
dr. MANGESTI UTAMI

Penata Tingkat I
NIP. 19730110 200604 2 015
BULAN : AGUSTUS 2017
Pengujian
Kesehatan
& rujukan
Pelayanan ANC/KB/
1 2 3 4 5 6 7 8 9 10 11 12 13 14
1 Abd Malik 01/08/2017 GDA 12,000 12,000
2 Nurudin 01/08/2017 UA 11,000 11,000
3 St. Aisah 01/08/2017 GDA 12,000 12,000
4 Ach. Budianto 01/08/2017 GDA 12,000 12,000
5 Supianingsih 02/08/2017 GDA 12,000 12,000
6 Asri 03/08/2017 KOLEST 9,500 9,500
7 Setianingsih 03/08/2017 GDA 12,000 12,000
8 Paimin 03/08/2017 KIR KES SWASTA 7,500 7,500
9 Suryono 03/08/2017 KIR KES SWASTA 7,500 7,500
10 M. Nurhuda 03/08/2017 KIR KES SWASTA 7,500 7,500
11 Sarwono 03/08/2017 KIR KES SWASTA 7,500 7,500
12 Suroso 03/08/2017 KIR KES SWASTA 7,500 7,500
13 Romlah 04/08/2017 UA 11,000 11,000
14 Sahriyanto 04/08/2017 KOLEST 9,500 9,500
15 Kudus Rasminto 05/08/2017 KIR KES SWASTA 7,500 7,500
16 Asih 05/08/2017 KOLEST 9,500 9,500
17 Moh. Luthful H 05/08/2017 Catin 7,500 7,500
18 Saroh Ernawari 05/08/2017 Catin 7,500 7,500
19 Moh. Suhaili 05/08/2017 Catin 7,500 7,500
20 Vina Febriyanti 05/08/2017 Catin 7,500 7,500
21 Eko Hiro 05/08/2017 Catin 7,500 7,500
22 Rini H 05/08/2017 Catin 7,500 7,500
23 Afadah 07/08/2017 KIR KES SWASTA 7,500 7,500
24 Susilo 07/08/2017 KIR KES SWASTA 7,500 7,500
25 Tulon 07/08/2017 Catin 7,500 7,500
26 Rumsiah 07/08/2017 Catin 7,500 7,500
27 Silatul Rochma 07/08/2017 Catin 7,500 7,500
28 Heri Wahyuni 07/08/2017 Catin 7,500 7,500
29 Ifa Lestari 07/08/2017 Catin 7,500 7,500
30 Sutrisno 07/08/2017 Catin 7,500 7,500
31 Siyani 07/08/2017 KOLEST 9,500 9,500
32 Sunarlin 07/08/2017 GDA 12,000 12,000
33 Supriyadi 07/08/2017 KOLEST 9,500 9,500
34 Suminah 07/08/2017 GDA 12,000 12,000
Pengujian
& rujukan
Pelayanan ANC/KB/
1 2 3 4 5 6 7 8 9 10 11 12 13 14
35 Rahmani 08/08/2017 UA 11,000 11,000
36 Rupiah 09/08/2017 UA 11,000 11,000
37 Novi Ardianto 09/08/2017 Catin 7,500 7,500
38 Fais Rahmawati 09/08/2017 Catin 7,500 7,500
39 Aini Murti 09/08/2017 Catin 7,500 7,500
40 Moh. Samsul Abdillah 09/08/2017 Catin 7,500 7,500
41 Ivy Ayuningtyas 09/08/2017 Catin 7,500 7,500
42 Anugerah Widhi A 09/08/2017 Catin 7,500 7,500
43 Raveena Sapna 09/08/2017 Catin 7,500 7,500
44 Ahmad Rofik 09/08/2017 Catin 7,500 7,500
45 Sayu Sentikawati 10/08/2017 Catin 7,500 7,500
46 Slamet Habib 10/08/2017 Catin 7,500 7,500
47 Istiqomah 10/08/2017 KIR KES SWASTA 7,500 7,500
48 Arisman 10/08/2017 KIR KES SWASTA 7,500 7,500
49 Suryani 10/08/2017 Catin 7,500 7,500
50 Tohari 10/08/2017 Catin 7,500 7,500
51 Wisha Aditya 10/08/2017 Catin 7,500 7,500
52 Ezty Utami 10/08/2017 Catin 7,500 7,500
53 Murtini 12/08/2017 Catin TMNO GIGI 20,000 20,000
54 Suryono 12/08/2017 Catin TMNO GIGI 40,000 40,000
55 Umar 14/08/2017 Catin 7,500 7,500
56 St. Hamidah 14/08/2017 Catin 7,500 7,500
57 Eka Nur Safitri 14/08/2017 Catin 7,500 7,500
58 Wahyu Kriswantoro 14/08/2017 Catin 7,500 7,500
59 Tasripin 14/08/2017 Catin 7,500 7,500
60 Sri Maikowati 14/08/2017 Catin 7,500 7,500
61 Winda Mayasari 14/08/2017 Catin 7,500 7,500
62 Riski Setyawan 14/08/2017 Catin 7,500 7,500
63 Suryono 14/08/2017 TMNO GIGI 40,000 40,000
64 Bayu Fernata S 14/08/2017 Catin 7,500 7,500
65 U'ul Mulyana 14/08/2017 Catin 7,500 7,500
66 Sipon 14/08/2017 KOLEST 9,500 9,500
67 Sutini 14/08/2017 GDA 12,000 12,000
68 Khotimatun 15/08/2017 Catin 7,500 7,500
69 Widi Zatmiko 15/08/2017 Catin 7,500 7,500
70 Sumini 15/08/2017 Catin 7,500 7,500
71 Nur Kholis 15/08/2017 Catin 7,500 7,500
72 Rizal Maulana 15/08/2017 Catin 7,500 7,500
73 Nuri Widyawati 15/08/2017 Catin 7,500 7,500
74 Karlina Indah A 15/08/2017 Catin 7,500 7,500
75 Subairiyah 15/08/2017 Catin 7,500 7,500
76 Nur Iksan 15/08/2017 Catin 7,500 7,500
Pengujian
& rujukan
Pelayanan ANC/KB/
1 2 3 4 5 6 7 8 9 10 11 12 13 14
77 Eni Widayani 16/08/2017 Catin 7,500 7,500
78 Yulius Pasudi 16/08/2017 Catin 7,500 7,500
79 Lailatul N 16/08/2017 Catin 7,500 7,500
80 Eko Prasetyo 16/08/2017 Catin 7,500 7,500
81 Muzayanah 18/08/2017 Catin 7,500 7,500
82 Sapari 18/08/2017 Catin 7,500 7,500
83 Turi 19/08/2017 KOLEST 9,500 9,500
84 Poniyem 19/08/2017 GDA 12,000 12,000
85 Warsito 19/08/2017 GDA 12,000 12,000
86 Sumiyati 21/08/2017 Catin 7,500 7,500
87 Sabar Abdiansyah 21/08/2017 Catin 7,500 7,500
88 Endro Susanto 21/08/2017 Catin 7,500 7,500
89 Oktaviana Sari 21/08/2017 Catin 7,500 7,500
90 Tugiyem 21/08/2017 GDA 12,000 12,000
91 Moh. Diki Usa 22/08/2017 KIR KES SWASTA 7,500 7,500
92 Kusayati 22/08/2017 Catin 7,500 7,500
93 Herminto 22/08/2017 Catin 7,500 7,500
94 Yayuk Hariyani 22/08/2017 Catin 7,500 7,500
95 Heri Juniarto 22/08/2017 Catin 7,500 7,500
96 Endang H 22/08/2017 Catin 7,500 7,500
97 Yudi Subianto 22/08/2017 Catin 7,500 7,500
98 Wasiatun 22/08/2017 Catin 7,500 7,500
99 Hj. Soinem 22/08/2017 Catin 7,500 7,500
100 Fatrie Wici 22/08/2017 Catin 7,500 7,500
101 Ella Dwi 23/08/2017 Catin 7,500 7,500
102 Ermandi 23/08/2017 Catin 7,500 7,500
103 Sri Supeni 23/08/2017 KIR KES SWASTA 7,500 7,500
104 Ali Wafa 23/08/2017 GDA 12,000 12,000
105 Hariyani 23/08/2017 KOLEST 9,500 9,500
106 Mukmin 24/08/2017 GDA 12,000 12,000
107 Miftakhul Jannah 24/08/2017 Catin 7,500 7,500
108 Khoirul anam 24/08/2017 Catin 7,500 7,500
109 Mulyono 24/08/2017 Catin 7,500 7,500
110 Siti Nailah 24/08/2017 Catin 7,500 7,500
111 Endri handayani 24/08/2017 Catin 7,500 7,500
112 Ustad Hawoji 24/08/2017 Catin 7,500 7,500
113 Isbatut Daryani 24/08/2017 KIR KES SWASTA 5,000 5,000
114 Vina Bandanita 24/08/2017 Catin 7,500 7,500
115 Novita Ratna Dewi 24/08/2017 Catin 7,500 7,500
116 Sofyan 24/08/2017 Catin 7,500 7,500
117 Suminah 26/08/2017 GDA 12,000 12,000
118 Dwi Hariyanto 26/08/2017 Catin 7,500 7,500
Pengujian
& rujukan
Pelayanan ANC/KB/
1 2 3 4 5 6 7 8 9 10 11 12 13 14
119 St. Nur Mujariyah 26/08/2017 Catin 7,500 7,500
120 Melina Dewa Rahma 26/08/2017 Catin 7,500 7,500
121 M. Hasanudin 26/08/2017 Catin 7,500 7,500
122 Reka Wulandari 26/08/2017 Catin 7,500 7,500
123 Ricky s 26/08/2017 Catin 7,500 7,500
124 Dani Rukmana 28/08/2017 Catin 7,500 7,500
125 Sahriye 28/08/2017 KOLEST 9,500 9,500
126 St. Rokanah 29/08/2017 UA 11,000 11,000
127 Suharso 29/08/2017 UA 11,000 11,000
128 Homsah 29/08/2017 KOLEST 9,500 9,500
129 Aan Putri 29/08/2017 Catin 7,500 7,500
130 Zainul Arifin 29/08/2017 Catin 7,500 7,500
131 Rispin Riyanto 29/08/2017 Catin 7,500 7,500
132 Riski Julia Sari 29/08/2017 Catin 7,500 7,500
133 Riski Firmalianto 29/08/2017 Catin 7,500 7,500
134 Sindi Agustin 29/08/2017 Catin 7,500 7,500
135 Suprapto 29/08/2017 KIR KES SWASTA 7,500 7,500
136 Nur Aisyah 30/08/2017 GDA 12,000 12,000
137 Muslim 30/08/2017 Catin 7,500 7,500
138 Izzah Ifkarina 30/08/2017 Catin 7,500 7,500
139 Syamsu Putra 30/08/2017 Catin 7,500 7,500
140 Sriana Ningtyas 30/08/2017 Catin 7,500 7,500
141 Rina Fitria 30/08/2017 Catin 7,500 7,500
142 Alif Muh Rosi 30/08/2017 Catin 7,500 7,500
143 R. Partiwal 30/08/2017 KIR KES SWASTA 7,500 7,500
144 Kusuma Wardani 30/08/2017 Catin 7,500 7,500
145 Ponidi 31/08/2017 Catin 7,500 7,500
146 Buani 31/08/2017 Catin 7,500 7,500
147 Syaiful Anwar 31/08/2017 Catin 7,500 7,500
148 Asnida Munawaroh 31/08/2017 Catin 7,500 7,500
TOTAL - - 852,500 441,000 1,293,500
Banyuwangi, 31 Agustus 2017

Mengetahui,
dr. MANGESTI UTAMI

Penata Tingkat I
NIP. 19730110 200604 2 015
BULAN : APRIL 2018
Pengujian
Kesehatan
& rujukan
Pelayanan ANC/KB/
1 2 3 4 5 6 7 8 9 10 11 12 13
1 Eka Farah Dewi 25-01-2019 Catin 7,500 7,500
2 Ahmad suyadi 25-01-2018 Catin 7,500 7,500
3 Buryamin 25-01-2018 Catin 7,500 7,500
4 St. Nurtalia 25-01-2018 Catin 7,500 7,500
5 Bambang Budi S 25-01-2018 Kir Kesehatan 7,500 7,500
6 Hariyanto 25-01-2018 Catin 7,500 7,500
7 Nofi Asreani 25-01-2018 Catin 7,500 7,500
8 Rohmatin 25-01-2018 20,500 20,500
9 Tami 25-01-2018 20,500 20,500
10 -
11 -
12 -
13 -
14 -
15 -
16 -
17 -
18 -
19 -
20 -
21 -
22 -
23 -
24 -
25 -
26 -
27 -
28 -
29 -
30 -
31 -
32 -
33 -
34 02/09/2017 -
Pengujian
& rujukan
Pelayanan ANC/KB/
1 2 3 4 5 6 7 8 9 10 11 12 13
35 02/09/2017 -
36 02/09/2017 -
37 02/09/2017 -
38 02/09/2017 -
39 02/09/2017 -
40 02/09/2017 -
41 02/09/2017 -
42 02/09/2017 -
43 02/09/2017
44 02/09/2017 -
45 02/09/2017 -
46 02/09/2017 -
47 02/09/2017 -
48 02/09/2017 -
49 02/09/2017 -
50 02/09/2017 -
51 02/09/2017 -
52 02/09/2017 -
53 02/09/2017 -
54 02/09/2017 -
55 02/09/2017 -
56 02/09/2017 -
57 02/09/2017 -
58 02/09/2017 -
59 02/09/2017 -
60 02/09/2017 -
61 02/09/2017 -
62 02/09/2017 -
63 02/09/2017 -
64 02/09/2017 -
65 02/09/2017 -
66 02/09/2017 -
67 02/09/2017 -
68 02/09/2017 -
69 02/09/2017 -
70 02/09/2017 -
TOTAL - 52,500 41,000 93,500

Mengetahui,
Pengujian
& rujukan
Pelayanan ANC/KB/
1 2 3 4 5 6 7 8 9 10 11 12 13
dr. MANGESTI UTAMI

Penata Tingkat I
NIP. 19730110 200604 2 015
BULAN : OKTOBER 2017
Pengujian
Kesehatan
& rujukan
Pelayanan ANC/KB/
1 2 3 4 5 6 7 8 9 10 11 12 13
1 02/10/2017 -
2 02/10/2017 -
3 02/10/2017 -
4 02/10/2017 -
5 02/10/2017 -
6 02/10/2017 -
7 02/10/2017 -
8 02/10/2017 -
9 02/10/2017 -
10 02/10/2017 -
11 02/10/2017 -
12 02/10/2017 -
13 02/10/2017 -
14 02/10/2017 -
15 02/10/2017 -
16 02/10/2017 -
17 02/10/2017 -
18 02/10/2017 -
19 02/10/2017 -
20 02/10/2017 -
21 02/10/2017 -
22 02/10/2017 -
23 02/10/2017 -
24 02/10/2017 -
25 02/10/2017 -
26 02/10/2017 -
27 02/10/2017 -
28 02/10/2017 -
29 02/10/2017 -
30 02/10/2017 -
31 02/10/2017 -
32 02/10/2017 -
33 02/10/2017 -
34 02/10/2017 -
Pengujian
& rujukan
Pelayanan ANC/KB/
1 2 3 4 5 6 7 8 9 10 11 12 13
35 02/10/2017 -
36 02/10/2017 -
37 02/10/2017 -
38 02/10/2017 -
39 02/10/2017 -
40 02/10/2017 -
41 02/10/2017 -
42 02/10/2017 -
43 02/10/2017
44 02/10/2017 -
45 02/10/2017 -
46 02/10/2017 -
47 02/10/2017 -
48 02/10/2017 -
49 02/10/2017 -
50 02/10/2017 -
51 02/10/2017 -
52 02/10/2017 -
53 02/10/2017 -
54 02/10/2017 -
55 02/10/2017 -
56 02/10/2017 -
57 02/10/2017 -
58 02/10/2017 -
59 02/10/2017 -
60 02/10/2017 -
61 02/10/2017 -
62 02/10/2017 -
63 02/10/2017 -
64 02/10/2017 -
65 02/10/2017 -
66 02/10/2017 -
67 02/10/2017 -
68 02/10/2017 -
69 02/10/2017 -
70 02/10/2017 -
TOTAL - - - -

Mengetahui,
Pengujian
& rujukan
Pelayanan ANC/KB/
1 2 3 4 5 6 7 8 9 10 11 12 13
dr. MANGESTI UTAMI

Penata Tingkat I
NIP. 19730110 200604 2 015

Jasa Pelayanan 1999 OKE JAN - AGST

Diunggah oleh

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Jasa Pelayanan 1999 OKE JAN - AGST

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REKAPITULASI HASIL PELAYANAN PASIEN RAWAT JALAN (NON PENJAMINAN)

KABUPATEN BANYUWANGI TAHUN 2021

TOTAL 135,000 - - - - 1,765,000 65,000 1,965,000

Pejabat Pelaksana teknis Kegiatan

TOTAL 70,000 - 30,000 - - 2,220,000 590,000 2,910,000

Pejabat Pelaksana teknis Kegiatan

TELAH TERIMA DARI : Pengguna Anggaran Dinas Kesehatan Kabupaten Banyuwangi

Dengan rincian pengeluaran sebagai berikut:

JUMLAH PPh Pasal 21 JUMLAH JASA

1 dr. ERI DWI SUSANTO III B Dokter 267,240 40,086 227,154 1.

Banyuwangi, 17 Juni 2021

Menyetujui : Disetujui Lunas Dibayar :

dr. H WIDJI LESTARIONO M.MKes MUJITO,SKM,M.MKes DIAN PUSPITA, SE

TELAH TERIMA DARI : Pengguna Anggaran Dinas Kesehatan Kabupaten Banyuwangi

Kode Kegiatan : 01.02.01.18.01

Dengan rincian pengeluaran sebagai berikut:

JUMLAH PPh Pasal 21 JUMLAH JASA

1 dr. Mangesti Utami III d Dokter 268,940 13,447 255,493 1.

6 Sunarlin Tenaga Apotek 63,280 0 63,280 6.

JUMLAH 791,000 28,872 762,129

Menyetujui: Disetujui : Lunas Dibayar:

dr. WIDJI LESTARIONO MUJITO, SKM DIAN PUSPITASARI, SE

TELAH TERIMA DARI : Pengguna Anggaran Dinas Kesehatan Kabupaten Banyuwangi

Kode Kegiatan : 01.02.01.18.01

Dengan rincian pengeluaran sebagai berikut:

JUMLAH PPh Pasal 21 JUMLAH JASA

1 dr. Mangesti Utami III d Dokter 362,304 18,115 344,189 1.

6 Sunarlin Tenaga Apotek 85,248 0 85,248 6.

JUMLAH 1,065,600 38,894 1,026,706

Menyetujui: Disetujui : Lunas Dibayar:

dr. WIDJI LESTARIONO MUJITO, SKM DIAN PUSPITASARI, SE

TELAH TERIMA DARI : Pengguna Anggaran Dinas Kesehatan Kabupaten Banyuwangi

Kode Kegiatan : 01.02.01.18.01

Dengan rincian pengeluaran sebagai berikut:

JUMLAH PPh Pasal 21 JUMLAH JASA

1 dr. Mangesti Utami III d Dokter 412,420 20,621 391,799 1.

6 Sunarlin Tenaga Apotek 97,040 0 97,040 6.

JUMLAH 1,213,000 44,275 1,168,726

Menyetujui: Disetujui : Lunas Dibayar:

dr. WIDJI LESTARIONO MUJITO, SKM DIAN PUSPITASARI, SE

Banyuwangi, 31 Januari 2017

dr. MANGESTI UTAMI

Banyuwangi, 28 Februari 2015

dr. MANGESTI UTAMI

Banyuwangi, 31 Maret 2017

dr. MANGESTI UTAMI

Banyuwangi, 29 April 2017

dr. MANGESTI UTAMI

Banyuwangi, 30 Juni 2018

Banyuwangi, 30 Juni 2017

dr. MANGESTI UTAMI

Banyuwangi, 31 Juli 2017

dr. MANGESTI UTAMI

Banyuwangi, 31 Agustus 2017

dr. MANGESTI UTAMI

Banyuwangi, 30 Juni 2017

dr. MANGESTI UTAMI

Banyuwangi, 30 Juni 2017

dr. MANGESTI UTAMI

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