RINCIAN KLAIM PASIEN PSA

KODE FASKES : 0265B026

NAMA FKTP : KLINIK DOKTER KELUARGA
TANGGAL
NO NAMA NO.BPJS ALAMAT NO.HP TGL.PELAYANAN REGIO GIGI PSA BIAYA
LAHIR
1 FITRIA PURNAMASARI 0000052078037 3/27/1994 JL.KARNA SOSIAL
NO.29/WONOYOSO 3 08950685183 1/22/2022 11
PSA-Preparasi Rp225,000
2/4/2022 11
PSA-Dressing Rp125,000
2/15/2022 11
PSA-Obturasi Rp225,000
2/23/2022 11
PSA-Tumpatan Permanen Rp275,000

2 TEGUH LUMAKSO 0000050536078 1/14/1966 JL.P.NATAKUSUMA 081258375998/

GG.AIRLANGGA 08256118333 12/15/2021 12
PSA-Preparasi Rp225,000
12/22/2021 12
PSA-Dresssing Rp125,000
12/29/2021 12
PSA-Obturasi Rp225,000
1/14/2022 12
PSA-Tumpatan Permanen Rp275,000
TOTAL Rp1,700,000

Pontianak, 24 Maret 2022

drg.NUZULISA ZULKIFLI
SIP: 503.446/2533/D-kes/Yankesfar/2017
 RINCIAN KLAIM PASIEN PSA
KODE FASKES : 0265G019
NAMA FKTP : drg.Nuzulisa Zulkifli

NO NAMA NO.BPJS TANGGAL LAHIR ALAMAT NO.HP TGL.PELAYANAN REGIO GIGI PSA BIAYA
1 WISE WITNESS NYARONG 0002285257217 10/25/2002
JL.SEKAYAM 9 NO.103 PERUM IV 08125686610 12/22/2021 31
PSA-Preparasi Rp225,000

2 ILHAM YUDIARDI 0001809962739 10/15/2003 JL.TRITURA GG.BUDI LUHUR 081345445538

1/15/2022 11
PSA-Preparasi Rp225,000
2/5/2022 11
PSA-Dresssing Rp125,000
2/14/2022 11
PSA-Obturasi Rp225,000
2/21/2022 11
PSA-Tumpatan Permanen Rp275,000
3 MUHAMMAD DANDI 0001838497037 1/26/2022 PERUMNAS III JL.BENUANG
AMIR FAUZI DALAM NO.152
1/26/2022 22
PSA-Preparasi Rp225,000
2/2/2022 22
PSA-Dresssing Rp125,000
2/9/2022 22
PSA-Obturasi Rp225,000
2/17/2022 22
PSA-Tumpatan Permanen Rp275,000
4 SOVIANI 0000883460169 7/21/2005 JL.YA'M SABRAN GG.KARYA
BAKTI
1/25/2022 22
PSA-Preparasi Rp225,000
2/9/2022 22
PSA-Dresssing Rp125,000
TOTAL Rp2,275,000

Pontianak, 24 Maret 2022

 drg.NUZULISA ZULKIFLI
SIP: 503.446/2533/D-kes/Yankesfar/2017