DATA PROFILE

FKTP PUSKESMAS........................
A. PROFIL FKTP
1. Nama FKTP :............................................
2. Nama Kepala Puskesmas :............................................
(yang bertanda tangan di PKS dengan BPJS Kesehatan)
3. Jabatan :............................................
(Kepala Puskesmas/Plt Kepala Puskesmas)
4. No. Surat Keputusan (SK) Kapus :............................................
5. Jenis Surat Ijin Usaha (sesuai SIOP) :............................................
(Surat Ijin Operasional Puskesmas Rawat Inap/Puskesmas Rawat Jalan)
6. Nomor Surat Ijin Operasional (SIOP) :............................................
7. Alamat FKTP (sesuai SIOP)
a. Jalan/Desa/Dusun :..............................................
b. RT/RW : ...../.....
c. Kelurahan :..............................................
d. Kecamatan :..............................................
e. Kota/Kabupaten :..............................................
f. Kode Pos :..............................................
8. Hari dan Jam Buka Puskesmas : 00.00 s.d 00.00 WIB (Hari……...)
00.00 s.d 00.00 WIB (Hari……...)
9. Nama Person in Charge (PIC) :.............................................
10.Nomor Telepon PIC :.............................................
11.Email Puskesmas :.............................................
12.Nomor Telepon Puskesmas :..............................................

B. DATA REKENING PEMBAYARAN FKTP

(pengisian harus sesuai dengan Buku Rekening/Cek/Bilyet/Giro dan Kartu NPWP)
1. Data Rekening Kapitasi
a. Rekening Atas Nama :........................................................
b. Nama Bank :........................................................
c. Nomor Rekening :........................................................
d. No. NPWP :........................................................
e. Atas Nama NPWP :........................................................
2. Data Rekening Non Kapitasi
a. Rekening Atas Nama :........................................................
b. Nama Bank :........................................................
c. Nomor Rekening :........................................................
d. No. NPWP :........................................................
e. Atas Nama NPWP :........................................................
3. Data Rekening Promotif Preventif
a. Rekening Atas Nama :........................................................
b. Nama Bank :........................................................
c. Nomor Rekening :........................................................
d. No. NPWP :........................................................
e. Atas Nama NPWP :........................................................
 FOTO BUKU TABUNGAN
(HALAMAN DEPAN)

FOTO KARTU NPWP

C. JADWAL PRAKTIK DOKTER (diisi sesuai dengan ketenagaan dan jadwal yang ada pada aplikasi HFIS)
No
Nama Dokter Hari Praktik Jam Praktik
.
1 dr.......................................... ........s.d......... ........s.d.........
2 dr.......................................... ........s.d......... ........s.d.........
3 drg........................................ ........s.d......... ........s.d.........
4 dst.
5 dst.