Jampersal Bidan Delima

REKAPITULASI PELAYANAN
PERSALINAN
Nama Klinik/Bidan Jejaring : Klinik Atiqah Medical/PMB. Nurlaila, AM.Keb Nomor : 440/80/SIPB/DPMTRANSNAKER/III/2019 Alamat : Ulee Matang Kec. Seunuddon
Bulan dan Tahun Klaim : Agustus 2020
Dasar Klaim : Surat Edaran Kemenkes HK/MENKES/31/1/2014
Kepada Yth :
Ketua Tim Pengelola BPJS Kesehatan Kab. Aceh Utara
Dengan hormat,
Bersama ini kami ajukan klaim/pertanggung jawaban Dana Pelayanan Kebidanan dan Neonatal Non Kapitasi yang telah kami berikan dengan perincian sebagai berikut :
AQ
NOMOR
ANC INC PNC
IDENTITAS NO.TELPON
No NAMA PASIEN ALAMAT YANG DAPAT G.P.A Tarif
Tarif Total Tarif Tindakan Total Tarif TOTAL
DIHUBUNGI Tanggal Pra Tindakan TARIF
K1 K2 K3 K4 Tarif ANC Jumlah Tanggal INC Persalinan Persalinan Pra Tindakan KF 1 KF 2 KF 3 JUMLAH
NIK/Kartu JKN Rujukan Pra PNC
Normal Normal Rujukan Pra Rujukan
Rujukan
12=(7+8+9+ 24=(20+21+2 25=(12+15+19+2
1 2 3 4 5 6 7 8 9 10 11 13 14 15 16 17 18 19 20 21 22 23
10) 2) 4)
8/3/2020 8/6/2020 8/10/2020
1 Husnawati 0001121293877 Ulee Rubek Timu 0852 9696 8156 II, I, 0 - - - - 50,000 - 8/2/2020 700,000 700,000 - - 125,000 - 25,000 75,000 775,000
Hari Ke 2 Hari Ke 5 Hari Ke 9
8/1/2020 8/6/2020 8/9/2020 8/13/2020
2 Rahmatillah 0000223045727 Ulee Matang 0853 6265 0303 IV, III, 0 - - - 50,000 50,000 8/5/2020 700,000 700,000 - - 125,000 - 25,000 75,000 825,000
Minggu Ke 39 Hari Ke 2 Hari Ke 4 Hari Ke 9
8/4/2020 8/7/2020 8/11/2020 8/15/2020
3 Nurhamni 0000980862546 Teupin kuyuen 0852 6268 9336 VI, V, 0 - - - 50,000 50,000 8/6/2020 700,000 700,000 - - 125,000 - 25,000 75,000 825,000
8/10/2020 8/21/2020
4 Mahdalena 0002305682019 Baktiya 0852 0658 2687 I, 0, 0 - - - 50,000 50,000 - 700,000 - - - 125,000 - - - 25,000 25,000 75,000
Minggu Ke 39 Hari Ke 9
8/6/2020 8/15/2020 8/18/2020 8/22/2020
5 Nurul Masyitah 0002063406273 Lhok Rambideng 0852 1114 9817 II, I, 0 - - - 50,000 50,000 8/14/2020 700,000 700,000 - - 125,000 - 25,000 75,000 825,000
8/15/2020 8/20/2020 8/23/2020 8/27/2020
6 Salmawati 0001844173484 Matang Lada 0852 6020 1549 III, II, 0 - - - 50,000 50,000 8/19/2020 700,000 700,000 - - 125,000 - 25,000 75,000 825,000
8/17/2020 8/21/2020 8/24/2020 8/28/2020
7 Aminah 0002204081662 Idi Rayeuk 0813 6572 0501 I, 0, 0 - - - 50,000 50,000 8/20/2020 700,000 700,000 - - 125,000 - 25,000 75,000 825,000
8/19/2020 8/27/2020
8 Nuraini 0000223982256 Matang Puntong 0852 7282 6392 I, 0, 0 - - - 50,000 50,000 - 700,000 - INF RL 8/20/2020 125,000 125,000 - - 25,000 25,000 200,000
8/19/2020 8/21/2020 8/24/2020 8/28/2020
9 Yusnaini 0001865361396 Teupin kuyuen 0852 6168 0838 II, I, 0 - - - 50,000 50,000 8/20/2020 700,000 700,000 - - 125,000 - 25,000 75,000 825,000
8/18/2020 8/28/2020
10 Nurul Wilda 0000223668628 Teupin kuyuen 0821 6557 7508 I, 0, 0 - - - 50,000 50,000 - 700,000 - INF RL 8/21/2020 125,000 125,000 - - 25,000 25,000 200,000
8/22/2020 8/31/2020
11 Ruhammah 0000223680543 Teupin kuyuen 0853 6194 2356 II, I, 0 - - - 50,000 50,000 - 700,000 - - - 125,000 - - - 25,000 25,000 75,000
8/21/2020 8/31/2020
12 Syamsiah 0000223543719 Lhok Rambideng 0812 6476 3542 II, I, 0 - - - 50,000 50,000 - 700,000 - INF RL 8/24/2020 125,000 125,000 - - 25,000 25,000 200,000
Jumlah Total 550,000 4,900,000 375,000 650,000 6,475,000
Terlampir bersama ini bukti-bukti penunjang yang sah untuk menjadi pertimbangan (copy identitas/partograf/surat ketengangan kelahiran/kohor ibu/bayi/katu ibu/kartu nifas/dll)
Demikian kami sampaikan, untuk realisasinya diucapkan terimakasih.
Mengetahui ; Ulee Matang, 31 Agustus 2020

Pimpinan Atiqah Medical Yang Mengajukan Klaim
( dr. EFENDI YUSUF, M.Kes ) ( NURLAILA, AM.Keb )

NIP. 19760626 200504 2 001
PERSALINAN
Bulan dan Tahun Klaim : September 2020
Kepada Yth :
Dengan hormat,
AQ
NOMOR
ANC INC PNC
IDENTITAS NO.TELPON
Rujukan
12=(7+8+9+ 24=(20+21+2 25=(12+15+19+2
1 2 3 4 5 6 7 8 9 10 11 13 14 15 16 17 18 19 20 21 22 23
10) 2) 4)
01/09/2020 08/09/2020 11/09/2020
1 Nurasiah 0002770586425 Ulee Rubek Timu 082273442586 II, I, 0 - - - 50,000 50,000 700,000 - infus RL 02/09/2020 125,000 125,000 25,000 50,000 225,000
37 minggu hari ke 7 hari ke 10
02/09/2020 13/09/2020 16/09/2020
2 Sumiyah 0002811653447 Ulee Matang 082181716927 II, I, 0 - - - 50,000 50,000 700,000 - Infus RL 07/09/2020 125,000 125,000 25,000 50,000 225,000
08/09/2020 12/09/2020 15/09/2020 19/09/2020
3 Safwati 0002737381094 Peureulak 092367152750 II, I, 0 - - - 50,000 50,000 11/09/2020 700,000 700,000 - - 125,000 - 25,000 75,000 825,000
39 minggu hari ke 2 hari ke 5 hari ke 9
16/09/2020 20/09/2020 23/09/2020 27/09/2020
4 Muridayati 0000980859284 Ulee Rubek Timu 082387715351 II, I, 0 - - - 50,000 50,000 19/09/2020 700,000 700,000 - - 125,000 - 25,000 75,000 825,000
16/09/2020 20/09/2020 23/09/2020 27/09/2020
5 Lisa Karmila 0000222935872 Matang Puntong 085319510405 II, I, 0 - - - 50,000 50,000 19/09/2020 700,000 700,000 - - 125,000 - 25,000 75,000 825,000
18/09/2020 24/09/2020 27/09/2020
6 Yusra 0002610835536 Ulee Rubek Barat 082277731873 I, 0, 0 - - - 50,000 50,000 23/09/2020 700,000 700,000 - - 125,000 - 25,000 50,000 800,000
23/09/2020 25/09/2020 28/09/2020
7 Rosniati 0001121930267 Bantayan 085358401422 III, II, 0 - - - 50,000 50,000 24/09/2020 700,000 700,000 - - 125,000 - 25,000 50,000 800,000
20/09/2020 26/09/2020 29/09/2020
8 Safrina 0002044559182 Teupin Kuyun 082276538275 II, I, 0 - - - 50,000 50,000 25/09/2020 700,000 700,000 125,000 - 25,000 50,000 800,000
Jumlah Total 400,000 4,200,000 250,000 475,000 5,325,000
Mengetahui ; Ulee Matang, 30September 2020


NIP. 19760626 200504 2 001
PERSALINAN
Bulan dan Tahun Klaim : Oktober 2020
Kepada Yth :
Dengan hormat,
AQ
NOMOR
ANC INC PNC
IDENTITAS NO.TELPON
Rujukan
12=(7+8+9+ 24=(20+21+2 25=(12+15+19+2
1 2 3 4 5 6 7 8 9 10 11 13 14 15 16 17 18 19 20 21 22 23
10) 2) 4)
01/10/2020
1 Yusra 0002610835538 Ulee Rubek Barat 082277731873 I, 0, 0 - - - - 50,000 - 23/09/2020 700,000 - - - 125,000 - 25,000 25,000 25,000
Hari ke 9
02/10/2020
2 Rosniati 0001121930267 Bantayan 085358401422 III, II, 0 - - - 50,000 - 24/09/2020 700,000 - - - 125,000 - 25,000 25,000 25,000
Hari ke 9
03/10/2020
3 Safrina 0002044559182 Teupin Kuyun 082276538275 II, I, 0 - - - 50,000 - 25/09/2020 700,000 - - - 125,000 - 25,000 25,000 25,000
Hari ke 9
02/10/2020 05/10/2020 '08/10/2020 12/10/2020
4 AgusLiana 0000980857258 Ulee Matang 081278251009 III, II, 0 - - - 50,000 50,000 04/10/2020 700,000 700,000 - - 125,000 - 25,000 75,000 825,000
37 minggu Hari ke 2 Hari ke 5 Hari Ke 9
05/10/2020 09/10/2020 12/10/2020 16/10/2020
5 Rahmatina 0001880984976 Teupin Kuyun 085361863202 IV,III,0 - - - 50,000 50,000 08/10/2020 700,000 700,000 - - 125,000 - 25,000 75,000 825,000
13/10/2020 17/10/2020 21/10/2020
6 Nazariah 0000981015028 Puuk 082272937098 III, II, 0 - - - 50,000 - 13/10/2020 700,000 700,000 - - 125,000 - 25,000 75,000 775,000
Hari ke 2 Hari ke 5 Hari Ke 9
07/10/2020 15/10/2020 18/10/2020 22/10/2020
7 Safriyana 0002675240471 Ulee Rubek Barat 085213668850 I, 0, 0 - - - 50,000 50,000 14/10/2020 700,000 700,000 - - 125,000 - 25,000 75,000 825,000
21/10/2020 28/10/2020 31/10/2020
8 Aminah 0000980851825 Ulee Rubek Barat 082349570063 I, 0, 0 - - - 50,000 50,000 27/10/2020 700,000 700,000 125,000 - 25,000 50,000 800,000
38 minggu Hari ke 2 Hari ke 5
09/10/2020 23/10/2020 25/10/2020
9 Rahmi widia 0002830598289 Ulee Rubek Timu 082262793694 I, 0, 0 - - - 50,000 50,000 700,000 - - 17/10/2020 125,000 - 25,000 50,000 100,000
32 minggu Hari ke7 Hari Ke 9
Jumlah Total 250,000 3,500,000 - 475,000 4,225,000
Mengetahui ; Ulee Matang, 31 Oktober 2020


NIP. 19760626 200504 2 001
PERSALINAN
Bulan dan Tahun Klaim : November 2020
Kepada Yth :
Dengan hormat,
AQ
NOMOR
ANC INC PNC
IDENTITAS NO.TELPON
Rujukan
12=(7+8+9+ 24=(20+21+2 25=(12+15+19+2
1 2 3 4 5 6 7 8 9 10 11 13 14 15 16 17 18 19 20 21 22 23
10) 2) 4)
01/11/2020 02/11/2020 05/11/2020 09/11/2020
1 Khairatul Ula 0001121413634 Tanjong Meunye 082273591772 I, 0, 0 - - - 50,000 50,000 01/11/2020 700,000 700,000 - - 125,000 - 25,000 75,000 825,000
39 minggu Hari ke 2 Hari ke 5 Hari ke 9
01/11/2020 03/11/2020 06/11/2020 10/11/2020
2 Anisawati 0000980861602 Teupin Kuyun 085296666279 III, II, 0 - - - 50,000 50,000 02/11/2020 700,000 700,000 - - 125,000 - 25,000 75,000 825,000
01/11/2020 04/11/2020 07/11/2020 11/11/2020
3 Sri Wahyuni 0001998705497 Matang Lada 085371762567 II, I, 0 - - - 50,000 50,000 03/11/2020 700,000 700,000 - - 125,000 - 25,000 75,000 825,000
02/11/2020 10/11/2020 12/11/2020
4 Muliani 0001832588379 Matang Lada 085270430619 I, 0, 0 - - - 50,000 50,000 700,000 infus RL 04/11/2020 125,000 125,000 25,000 50,000 225,000
40 minggu Hari ke 7 Hari Ke 9
03/11/2020 06/11/2020 09/11/2020 13/11/2020
5 Ainol Mardiah 0002325983139 Ulee Matang 082370533568 V,IV,0 - - - 50,000 50,000 05/11/2020 700,000 700,000 - - 125,000 - 25,000 75,000 825,000
07/11/2020 17/11/2020 19/11/2020
6 Nani Wulandari 0001121305509 Lhoksukon 082210177876 I, 0, 0 - - - 50,000 50,000 700,000 - - 125,000 - 25,000 50,000 100,000
10/11/2020 14/11/2020 17/11/2020 21/11/2020
7 Juraidah 0002419964458 Lhok Rambideng 082361494555 III, II, 0 - - - 50,000 50,000 13/11/2020 700,000 700,000 - - 125,000 - 25,000 75,000 825,000
05/11/2020 17/11/2020 20/11/2020 24/11/2020
8 Uswatul Khaira 0000980838011 Langsa 085276458592 I, 0, 0 - - - 50,000 50,000 16/11/2020 700,000 700,000 125,000 - 25,000 75,000 825,000
13/11/2020 22/11/2020 25/11/2020 29/11/2020
9 Rahmi 0000222845523 Pante Bidari 085371943060 I, 0, 0 - - - 50,000 50,000 21/11/2020 700,000 700,000 - 125,000 - 25,000 50,000 800,000
Jumlah Total 450,000 4,900,000 125,000 600,000 6,075,000
Mengetahui ; Ulee Matang, 30 November 2020


NIP. 19760626 200504 2 001
PERSALINAN
Bulan dan Tahun Klaim : Desember 2020
Kepada Yth :
Dengan hormat,
AQ
NOMOR
ANC INC PNC
IDENTITAS NO.TELPON
Rujukan
12=(7+8+9+ 24=(20+21+2 25=(12+15+19+2
1 2 3 4 5 6 7 8 9 10 11 13 14 15 16 17 18 19 20 21 22 23
10) 2) 4)
01/12/2020 02/12/2020 05/12/2020 09/12/2020
1 Maulidawati 0000223036806 Ulee Matang 085217708480 I, 0, 0 - - - 50,000 50,000 01/12/2020 700,000 700,000 - - 125,000 - 25,000 75,000 825,000
40 minggu Hari Ke 2 Hari Ke 5 Hari Ke 9
04/12/2020 07/12/2020 10/12/2020 14/12/2020
2 Nurzaman 0000222632886 Ulee Matang 085270874468 III, II, 0 - - - 50,000 50,000 06/12/2020 700,000 700,000 - - 125,000 - 25,000 75,000 825,000
05/12/2020 08/12/2020 11/12/2020 15/12/2020
3 Nuryanti 0001443704365 Ulee Matang 082166479901 II, I, 0 - - - 50,000 50,000 07/12/2020 700,000 700,000 - - 125,000 - 25,000 75,000 825,000
01/12/2020 08/12/2020 11/12/2020 15/12/2020
4 Nurul Sakdah 0002499849044 Ulee Matang 081269246226 I, 0, 0 - - - 50,000 50,000 07/12/2020 700,000 700,000 - - 125,000 - 25,000 75,000 825,000
10/12/2020 17/12/2020 20/12/2020
5 Dewi Sri Sartikawati 0002034973157 Ulee Rubek Timu 082260970821 IV,III,0 - - - 50,000 50,000 700,000 INF RL 11/12/2020 125,000 125,000 25,000 50,000 225,000
38 minggu Hari Ke 7 Hari Ke 10
10/12/2020 17/12/2020 20/12/2020
6 Ovi Asrida 0001121442682 Matang Lada 082277808246 I, 0, 0 - - - 50,000 50,000 700,000 - INF RL 11/12/2020 125,000 125,000 25,000 50,000 225,000
12/12/2020 16/12/2020 19/12/2020 23/12/2020
7 Nurhafizah 0002457840532 Paya Dua Ujong 082277688927 I, 0, 0 - - - 50,000 50,000 15/12/2020 700,000 700,000 - - 125,000 - 25,000 75,000 825,000
13/12/2020 17/12/2020 20/12/2020 24/12/2020
8 Rina Zahara 0000223103542 Ulee Rubek Timu 085342406614 I, 0, 0 - - - 50,000 50,000 16/12/2020 700,000 700,000 125,000 - 25,000 75,000 825,000
21/12/2020 24/12/2020 27/12/2020 31/12/2020
9 Dewi Suryani 0002270765777 Teupin kuyuen 082317756974 II, I, 0 - - - 50,000 50,000 23/12/2020 700,000 700,000 - - 125,000 - 25,000 75,000 825,000
15/12/2020 30/12/2020
10 Ismahani 0002450472041 Jambo Masi 081263790230 I, 0, 0 - - - 50,000 50,000 700,000 - INF RL 24/12/2020 125,000 125,000 - 25,000 25,000 200,000
40 minggu Hari Ke 7
23/12/2020 27/12/2020 30/12/2020
11 Husnawati 0000980851386 Ulee Rubek Barat 085260539520 II, I, 0 - - - 50,000 50,000 26/12/2020 700,000 700,000 - - 125,000 - 25,000 50,000 800,000
22/12/2020 31/12/2020
12 Sadriati 0003059242312 Ulee Matang 082317706511 I, 0, 0 - - - 50,000 50,000 30/12/2020 700,000 700,000 125,000 - - 25,000 25,000 775,000
40 minggu Hari Ke 2
Jumlah Total 600,000 6,300,000 375,000 725,000 8,000,000
Mengetahui ; Ulee Matang, 31 Desember 2020


NIP. 19760626 200504 2 001
PERSALINAN
Bulan dan Tahun Klaim : Januari 2021
Kepada Yth :
Dengan hormat,
AQ
NOMOR
ANC INC PNC
IDENTITAS NO.TELPON
Rujukan
12=(7+8+9+ 24=(20+21+2 25=(12+15+19+2
1 2 3 4 5 6 7 8 9 10 11 13 14 15 16 17 18 19 20 21 22 23
10) 2) 4)
02/01/2021
1 Ismahani 0002450472041 Jambo Masi 081263790230 I, 0, 0 - - - 50,000 700,000 - - 125,000 - 25,000 25,000 25,000
Hari Ke 10
03/01/2021
2 Husnawati 0000980851386 Matang Baro 085260539520 II, I, 0 - - - 50,000 700,000 - - 125,000 - 25,000 25,000 25,000
Hari Ke 9
03/01/2021 07/01/2021
3 Sadriati 0003059242312 Ulee Matang 082317706511 I, 0, 0 - - - 50,000 700,000 - - 125,000 - 25,000 50,000 50,000
Hari Ke 5 Hari Ke 9
07/01/2021 10/01/2021
4 Yoan Ernia 0000264840118 Ulee Rubek Barat 085283376998 III,0,2 - - - 50,000 700,000 INF RL 01/01/2021 125,000 125,000 25,000 50,000 175,000
Hari Ke 7 Hari Ke 10
03/01/2021 06/01/2021 09/01/2021 13/01/2021
5 Ratna Yanti 0003055613883 Teupin Kuyuen 082383908822 I, 0, 0 - - - 50,000 50,000 05/01/2021 700,000 700,000 125,000 25,000 75,000 825,000
39 minggu Hari ke 2 Hari Ke 5 Hari Ke 9
18/01/2021 21/01/2021
6 Marhamah 0001121273122 Ulee Matang 082272771093 I, 0, 0 - - - 50,000 700,000 - INF RL 12/01/2021 125,000 125,000 25,000 50,000 175,000
03/01/2021 14/01/2021 17/01/2021 21/02/2021
7 Yusnidar 0002321006286 Teupin Kuyuen 082368226890 II, I, 0 - - - 50,000 50,000 13/01/2021 700,000 700,000 - - 125,000 - 25,000 75,000 825,000
07/01/2021 19/01/2021 22/01/2021
8 Nurmaniah Usman 0000222675254 Ulee Matang 085373607060 VIII,VII,0 - - - 50,000 50,000 700,000 INF RL 13/01/2021 125,000 125,000 25,000 50,000 225,000
15/01/2021 18/01/2021 21/01/2021 25/01/2021
9 Lindawati 0000223700027 Ulee Rubek Timu 082312135821 IV,III,0 - - - 50,000 50,000 17/01/2021 700,000 700,000 - - 125,000 - 25,000 75,000 825,000
17/01/2021 20/02/2021 23/01/2021 27/01/2021
10 Husnidar 0002432230468 Matang Lada 085359306058 I, 0, 0 - - - 50,000 50,000 19/01/2021 700,000 700,000 125,000 25,000 75,000 825,000
19/01/2021 27/01/2021 30/01/2021
11 Nani Suriyani 0001121305059 Ulee Matang 082175732988 II, I, 0 - - - 50,000 50,000 700,000 INF RL 21/01/2021 125,000 125,000 25,000 50,000 225,000
27/01/2021 30/01/2021
12 Maulina 0000223077813 Ulee Matang 085262951890 III,II,0 - - - 50,000 700,000 INF RL 21/01/2021 125,000 125,000 25,000 50,000 175,000
22/01/2021 24/01/2021 27/01/2021 31/01/2021
13 Juliana 0002769631244 Matang Lada 085359142786 II, I, 0 - - - 50,000 50,000 23/01/2021 700,000 700,000 125,000 25,000 75,000 825,000
24/01/2021 26/01/2021 29/01/2021
14 Juairiah 0002317086819 Teupin Kuyuen 082167296845 III,II,0 - - - 50,000 50,000 25/01/2021 700,000 700,000 - - 125,000 - 25,000 50,000 800,000
23/01/2021 31/01/2021
15 Cut Putri Maulina 0000980838821 Lhok Rambideng 081269223579 I, 0, 0 - - - 50,000 50,000 700,000 INF RL 25/01/2021 125,000 125,000 25,000 25,000 200,000
38 minggu Hari Ke 7
25/01/2021 27/01/2021 30/01/2021
16 Isnawati 0003067821009 Cot Girek Kandang 082365700081 I, 0, 0 - - - 50,000 50,000 26/01/2021 700,000 700,000 125,000 25,000 50,000 800,000
20/01/2021
17 Rosmalinda 0002480689372 Lamteh Dayah 081361145497 I, 0, 0 - - - 50,000 50,000 700,000 INF RL 27/01/2021 125,000 125,000 25,000 175,000
40 minggu
Jumlah Total 550,000 4,900,000 875,000 850,000 7,175,000
Mengetahui ; Ulee Matang, 31 Januari 2021

NIP. 19760626 200504 2 001
PERSALINAN
Bulan dan Tahun Klaim : Februari 2021
Kepada Yth :
Dengan hormat,
AQ
NOMOR
ANC INC PNC
IDENTITAS NO.TELPON
Rujukan
12=(7+8+9+ 24=(20+21+2 25=(12+15+19+2
1 2 3 4 5 6 7 8 9 10 11 13 14 15 16 17 18 19 20 21 22 23
10) 2) 4)
01/02/2021 03/02/2021 06/02/2021 10/02/2021
1 Salihati 0002269100575 Ulee Rubek Timu 085359969472 III,II,0 - - - 50,000 50,000 02/02/2021 700,000 700,000 125,000 25,000 75,000 825,000
40 minggu hari ke 2 Hari ke 5 Hari ke 9
04/02/2021 18/02/2021 21/02/2021
2 Aminah 0000223621389 Krueng Lingka Barat 085322011990 II, I, 0 - - - 50,000 50,000 700,000 - Infus RL 12/02/2021 125,000 125,000 25,000 50,000 225,000
21/02/2021 24/02/2021
3 Rosmawar 0002199010757 Krueng Lingka Barat 085369910471 X,IX,0 - - - 50,000 700,000 Infus RL 15/02/2021 125,000 125,000 25,000 50,000 175,000
Hari ke 7 Hari ke 10
10/02/2021 17/02/2021 20/02/2021 24/02/2021
4 Safrianti 0000980534147 Ulee Matang 082304617581 III,II,0 - - - 50,000 50,000 16/02/2021 700,000 700,000 - - 125,000 - 25,000 75,000 825,000
18/02/2021 21/02/2021 24/02/2021 28/02/2021
5 Nurjannah 0002312296301 Ulee Rubek Barat 082299364640 II, I, 0 - - - 50,000 50,000 20/02/2021 700,000 700,000 - - 125,000 - 25,000 75,000 825,000
20/02/2021 22/02/2021 25/02/2021 28/02/2021
6 Maulizayani 0001793148333 Matang Lada 082311920135 I, 0, 0 - - - 50,000 50,000 21/02/2021 700,000 700,000 - - 125,000 - 25,000 75,000 825,000
39 minggu hari ke 2 hari ke 5 Hari ke 8
Jumlah Total 250,000 2,800,000 250,000 400,000 3,700,000
Mengetahui ; Ulee Matang, 28 Februari 2021


NIP. 19760626 200504 2 001
PERSALINAN
Bulan dan Tahun Klaim : April 2021
Kepada Yth :
Dengan hormat,
AQ
NOMOR
ANC INC PNC
IDENTITAS NO.TELPON
Rujukan
12=(7+8+9+ 24=(20+21+2 25=(12+15+19+2
1 2 3 4 5 6 7 8 9 10 11 13 14 15 16 17 18 19 20 21 22 23
10) 2) 4)
01/04/2021 02/04/2021 05/04/2021 09/04/2021
1 Ikhwana 0000223063119 Ulee Matang 082360984561 I, 0, 0 - - - 50,000 50,000 01/04/2021 700,000 700,000 - - 125,000 - 25,000 75,000 825,000
01/04/2021 02/04/2021 05/04/2021 09/04/2021
2 Risma Yani 0000980836885 Meunasah Drang 082273174793 II, I, 0 - - - 50,000 50,000 01/04/2021 700,000 700,000 - - 125,000 - 25,000 75,000 825,000
01/04/2021 03/04/2021 06/04/2021 10/04/2021
3 Khairuniah 0000222978273 Ulee Matang IV,III,0 - - - 50,000 50,000 02/04/2021 700,000 700,000 - - 125,000 - 25,000 75,000 825,000
02/04/2021 04/04/2021 07/04/2021 11/04/2021
4 Nazariah 0000980856292 Suka Mulya II, I, 0 - - - 50,000 50,000 02/04/2021 700,000 700,000 125,000 25,000 75,000 825,000
02/04/2021 04/04/2021 07/04/2021 11/04/2021
5 Putri Nurul Islammi 0002049071692 Ulee Matang 082249224181 I, 0, 0 - - - 50,000 50,000 03/04/2021 700,000 700,000 125,000 25,000 75,000 825,000
03/04/2021 05/04/2021 08/04/2021 12/04/2021
6 Rita Yani 0001121346448 Matang Karieng 082370152199 II, I, 0 - - - 50,000 50,000 04/04/2021 700,000 70,000 125,000 25,000 75,000 825,000
04/04/2021 12/04/2021 15/04/2021
7 Wirdawati 0002258727388 Matang Lada 081224010016 I, 0, 0 - - - 50,000 50,000 700,000 INF RL 06/04/2021 125,000 25,000 50,000 100,000
15/04/2021 18/04/2021 21/04/2021 25/04/2021
8 Peni Yanti 0001121299931 Ulee Matang 082383717265 II, I, 0 - - - 50,000 50,000 17/04/2021 700,000 700,000 125,000 25,000 75,000 825,000
17/04/2021 24/04/2021 27/04/2021
9 Nurmawati 0000223048023 Ulee Matang III,II,0 - - - 50,000 50,000 700,000 INF RL 18/04/2021 125,000 25,000 50,000 100,000
16/04/2021 19/04/2021 22/04/2021 26/04/2021
10 Nuraini 0002320993563 Seuneubok Doe 0853 6284 9224 II, I, 0 - - - 50,000 50,000 18/04/2021 700,000 700,000 125,000 25,000 75,000 825,000
19/04/2021 27/04/2021 30/04/2021
11 Nurhayati 0000229201266 Ulee Rubek Barat II, I, 0 - - - 50,000 50,000 700,000 INF RL 21/04/2021 125,000 25,000 50,000 100,000
20/04/2021 28/04/2021
12 Nurbaiti 0000003212559 Teupin Kuyuen IV,III,0 - - - 50,000 50,000 700,000 INF RL 22/04/2021 125,000 25,000 25,000 75,000
40 minggu Hari Ke 7
23/04/2021 26/04/2021 29/04/2021
13 Safnita 0001121293912 Ulee Rubek Timu II, I, 0 - - - 50,000 50,000 25/04/2021 700,000 700,000 125,000 25,000 50,000 800,000
Jumlah Total 650,000 5,670,000 - 825,000 7,775,000
Mengetahui ; Ulee Matang, 30 April 2021


NIP. 19760626 200504 2 001
PERSALINAN
Bulan dan Tahun Klaim : Mei 2021
Kepada Yth :
Dengan hormat,
AQ
NOMOR
ANC INC PNC
IDENTITAS NO.TELPON
Rujukan
12=(7+8+9+ 24=(20+21+2 25=(12+15+19+2
1 2 3 4 5 6 7 8 9 10 11 13 14 15 16 17 18 19 20 21 22 23
10) 2) 4)
02/05/2021 10/05/2021 13/05/2021
1 Zaituni 0001117174353 Teupin Kuyun 082261844809 I, 0, 0 - - - 50,000 50,000 700,000 - infus RL 04/05/2021 125,000 125,000 25,000 50,000 225,000
04/05/2021 06/05/2021 09/05/2021 13/05/2021
2 Asmiati 0000980852444 Ulee Rubek Barat 082311273882 VI,V,0 - - - 50,000 50,000 05/05/2021 700,000 700,000 125,000 25,000 75,000 825,000
03/05/2021 06/05/2021 09/05/2021 13/05/2021
3 Nuriza 000111779939 Ulee Rubek Timu 085277643939 III, II, 0 - - - 50,000 50,000 05/05/2021 700,000 700,000 - - 125,000 - 25,000 75,000 825,000
08/05/2021 10/05/2021 13/05/2021 17/05/2021
4 Aminah 0000980861894 Teupin Kuyun 082368919414 V,IV,I - - - 50,000 50,000 09/05/2021 700,000 700,000 - - 125,000 - 25,000 75,000 825,000
10/05/2021 13/05/2021 16/05/2021 20/05/2021
5 Putri Yani 0000222832866 Simpang keuramat III, II, 0 - - - 50,000 50,000 12/05/2021 700,000 700,000 - - 125,000 - 25,000 75,000 825,000
12/05/2021 14/05/2021 17/05/2021 21/05/2021
6 Maimunah 0002215459326 Ulee Rubek Barat 085275549286 III, II, 0 - - - 50,000 50,000 13/05/2021 700,000 700,000 - - 125,000 - 25,000 75,000 825,000
18/05/2021 21/05/2021 24/05/2021 28/05/2021
7 Ira Yenita 0001121375553 Lhok Rambideng III, II, 0 - - - 50,000 50,000 20/05/2021 700,000 700,000 - - 125,000 - 25,000 75,000 825,000
21/05/2021 29/05/2021
8 Putri Ariani 0000196592523 Ulee Matang 082217725165 I, 0, 0 - - - 50,000 50,000 700,000 infus RL 23/05/2021 125,000 125,000 25,000 25,000 200,000
40 minggu hari ke 7
Jumlah Total 400,000 4,200,000 250,000 525,000 5,375,000
Mengetahui ; Ulee
Ulee
Mata
Matang, 31 Mei 2021

NIP. 19760626 200504 2 001
PERSALINAN
Bulan dan Tahun Klaim : Juni 2021
Kepada Yth :
Dengan hormat,
AQ
NOMOR
ANC INC PNC
IDENTITAS NO.TELPON
Rujukan
12=(7+8+9+ 24=(20+21+2 25=(12+15+19+2
1 2 3 4 5 6 7 8 9 10 11 13 14 15 16 17 18 19 20 21 22 23
10) 2) 4)
01/06/2021 02/06/2021 06/06/2021 10/06/2021
1 Yusmawar 0000223612266 Teupin Kuyuen 082211223487 V,IV,0 - - - 50,000 50,000 01/06/2021 700,000 700,000 - - 125,000 - 25,000 75,000 825,000
38 minggu Hari ke 2Hari Ke 5 Hari Ke 9
01/06/2021 02/06/2021 06/06/2021 10/06/2021
2 Nurul Hayati 0000223714113 Teupin Kuyuen 081212251175 II, I, 0 - - - 50,000 50,000 01/06/2021 700,000 700,000 - - 125,000 - 25,000 75,000 825,000
02/06/2021 04/06/2021 07/06/2021 11/06/2021
3 Isma Khaira 0002242201138 Matang Lada 082273899259 II, I, 0 - - - 50,000 50,000 03/06/2021 700,000 700,000 - - 125,000 - 25,000 75,000 825,000
02/06/2021 06/06/2021 09/06/2021 13/06/2021
4 Marlina 0002238653935 Matang Lada 085362010365 IV,III,0 - - - 50,000 50,000 05/06/2021 700,000 700,000 125,000 25,000 75,000 825,000
05/06/2021 07/06/2021 10/06/2021 14/06/2021
5 Wina Astuti 0001817483938 Ulee Rubek Barat 082330668938 I, 0, 0 - - - 50,000 50,000 06/06/2021 700,000 700,000 125,000 25,000 75,000 825,000
05/06/2021 08/06/2021 11/06/2021 15/06/2021
6 Yusnidar 0000223992641 Ulee titi 085277238100 II, I, 0 - - - 50,000 50,000 07/06/2021 700,000 700,000 125,000 25,000 75,000 825,000
09/06/2021 16/06/2021 19/06/2021
7 Dufrina 0001877369646 Ulee Matang 085216101367 II, I, 0 - - - 50,000 50,000 700,000 INF RL 10/06/2021 125,000 125,000 25,000 50,000 225,000
07/06/2021 15/06/2021 18/06/2021
8 Aminah 0001830805852 Ulee Rubek Barat 082364453516 I, 0, 0 - - - 50,000 50,000 700,000 09/06/2021 125,000 25,000 50,000 100,000
16/06/2021 22/06/2021 25/06/2021
9 Irna Dewi 0001310313655 Peukan Bada 082360005161 I, 0, 0 - - - 50,000 50,000 700,000 INF RL 16/06/2021 125,000 125,000 25,000 50,000 225,000
19/06/2021 21/06/2021 24/06/2021 28/06/2021
10 Safriana 0000222954017 Ulee Rubek Barat 082247325399 I, 0, 0 - - - 50,000 50,000 20/06/2021 700,000 700,000 125,000 25,000 75,000 825,000
19/06/2021 22/06/2021 25/06/2021 29/06/2021
11 Eli 0002419884033 Matang Rawa 082272937137 II, I, 0 - - - 50,000 50,000 21/06/2021 700,000 700,000 125,000 25,000 75,000 825,000
25/06/2021
12 Nurafnidar 0000222524504 Matang Lada 085260271199 IV,III,0 - - - 50,000 50,000 700,000 INF RL 26/06/2021 125,000 125,000 25,000 175,000
38 minggu
24/06/2021
13 Nurmawati 0000223995486 Matang Lada 082361039477 IV,III,0 - - - 50,000 50,000 700,000 INF RL 26/06/2021 125,000 125,000 25,000 175,000
39 minggu
Jumlah Total 650,000 5,600,000 500,000 750,000 7,500,000
Mengetahui ; Ulee
Ulee
Mata
Matang, 30 Juni 2021

NIP. 19760626 200504 2 001
PERSALINAN
Bulan dan Tahun Klaim : Juli 2021
Kepada Yth :
Dengan hormat,
AQ
NOMOR
ANC INC PNC
IDENTITAS NO.TELPON
Rujukan
12=(7+8+9+ 24=(20+21+2 25=(12+15+19+2
1 2 3 4 5 6 7 8 9 10 11 13 14 15 16 17 18 19 20 21 22 23
10) 2) 4)
02/07/2021 05/07/2021
1 Nurafnidar 0000222524504 Matang Lada 085260271199 IV,III,0 - - - 50,000 700,000 - - 125,000 - 25,000 50,000 50,000
02/07/2021 05/07/2021
2 Nurmawati 0000223995486 Matang Lada 082361039477 IV,III,0 - - - 50,000 700,000 - - 125,000 - 25,000 50,000 50,000
01/07/221 03/07/2021 06/07/2021 10/07/2021
3 Safrina Devi 0002675241134 Ulee Matang 082331611429 III,II,0 - - - 50,000 50,000 02/07/2021 700,000 700,000 - - 125,000 - 25,000 75,000 825,000
01/07/2021 04/07/2021 07/07/2021 11/07/2021
4 Desy Handayani 0000224134209 085361718665 III,II,0 - - - 50,000 50,000 03/07/2021 700,000 700,000 125,000 25,000 75,000 825,000
02/07/2021 09/07/2021 12/07/2021
5 Salmiati 0001960469752 Teupin Kuyuen 082277343581 IV,III,0 - - - 50,000 50,000 700,000 INF RL 03/07/2021 125,000 125,000 25,000 50,000 225,000
01/07/2021 09/07/2021 12/07/2021
6 Rosleni 0002300301742 Matang Lada 081269109954 I, 0, 0 - - - 50,000 50,000 700,000 - INF RL 03/07/2021 125,000 125,000 25,000 50,000 225,000
04/07/2021 06/07/2021 09/07/2021 13/07/2021
7 Nurlaili 0002584538605 Matang Karieng 082370813010 I, 0, 0 - - - 50,000 50,000 05/07/2021 700,000 700,000 - - 125,000 - 25,000 75,000 825,000
09/07/2021 11/07/2021 14/07/2021 18/07/2021
8 Murzakiah 0001908762052 Teupin Kuyuen 081269158580 I, 0, 0 - - - 50,000 50,000 10/07/2021 700,000 700,000 125,000 25,000 75,000 825,000
02/07/2021 12/07/2021 15/07/2021 19/07/2021
9 Yusnidar 0000222832642 Ulee Matang 085277532330 I, 0, 0 - - - 50,000 50,000 11/07/2021 700,000 700,000 - - 125,000 - 25,000 75,000 825,000
08/07/2021 12/07/2021 15/07/2021 19/07/2021
10 Mutiawati 0000223228811 Krueng Lingka Barat 085261093735 III,II,0 - - - 50,000 50,000 11/07/2021 700,000 700,000 125,000 25,000 75,000 825,000
12/07/2021 19/07/2021 22/07/2021
11 Rosyita Dewi 0002116088076 Simpang Kramat 085234670159 I, 0, 0 - - - 50,000 50,000 700,000 INF RL 13/07/2021 125,000 125,000 25,000 50,000 225,000
07/07/2021 15/07/2021 18/07/2021 22/07/2021
12 Marlina 0001872222366 Matang Lada 085296663856 II, I, 0 - - - 50,000 50,000 14/07/2021 700,000 700,000 125,000 25,000 75,000 825,000
13/07/2021 20/07/2021 23/07/2021 27/07/2021
13 Mahyuni 0000980859486 082370634218 IV,III,0 - - - 50,000 50,000 19/07/2021 700,000 700,000 125,000 25,000 75,000 825,000
15/07/2021 23/07/2021 26/07/2021 30/07/2021
14 Zulfaizah 0000223087149 Ulee Matang 082386651493 I, 0, 0 - - - 50,000 50,000 22/07/2021 700,000 700,000 125,000 25,000 75,000 825,000
23/07/2021 30/07/2021
15 Wardah 0002769631503 Cot Rheu 082368213836 I, 0, 0 - - - 50,000 50,000 700,000 INF RL 24/07/2021 125,000 125,000 25,000 25,000 200,000
40 minggu Hari Ke 7
21/07/2021 28/07/2021 31/07/2021
16 Rahmayani 0001117208057 Ulee Titi 085277661816 III,II,0 - - - 50,000 50,000 27/07/2021 700,000 700,000 125,000 25,000 50,000 800,000
27/07/2021 30/07/2021
17 Ainsyah 0001117174814 Teupin Kuyuen V,IV,0 - - - 50,000 50,000 29/07/2021 700,000 700,000 125,000 25,000 25,000 775,000
39 minggu Hari ke 2
Jumlah Total 750,000 7,700,000 500,000 1,025,000 9,975,000
Mengetahui ; Ulee Matang, 31 Juli 2021

NIP. 19760626 200504 2 001
PERSALINAN
Bulan dan Tahun Klaim : Agustus 2021
Kepada Yth :
Dengan hormat,
AQ
NOMOR
ANC INC PNC
IDENTITAS NO.TELPON
Rujukan
12=(7+8+9+ 24=(20+21+2 25=(12+15+19+2
1 2 3 4 5 6 7 8 9 10 11 13 14 15 16 17 18 19 20 21 22 23
10) 2) 4)
02/08/2021 06/08/2021
1 Ainsyah 0001117174814 Teupin Kuyuen V,IV,0 - - - 50,000 700,000 - - 125,000 - 25,000 50,000 50,000
Hari Ke 5 Hari Ke 9
01/08/2021 03/08/2021 06/08/2021 10/08/2021
2 Hasdiana 0000223122396 Ulee Rubek Timur 085342475688 XIV,XI,III - - - 50,000 50,000 02/08/2021 700,000 700,000 - - 125,000 - 25,000 75,000 825,000
03/08/2021 10/08/2021 13/08/2021
3 Jumina 0000222946143 Matang Lada 085295064632 III,II,0 - - - 50,000 50,000 700,000 INF RL 04/08/2021 125,000 125,000 25,000 50,000 225,000
03/08/2021 07/08/2021 10/08/2021 14/08/2021
4 Zalikha 0000223661856 Lhok Rambideng 082277273713 II, I, 0 - - - 50,000 50,000 06/08/2021 700,000 700,000 125,000 25,000 75,000 825,000
05/08/2021 13/08/2021 16/08/2021
5 Irmawati 0000223677797 Teupin Kuyuen 085212590526 I, 0, 0 - - - 50,000 50,000 700,000 INF RL 07/08/2021 125,000 125,000 25,000 50,000 225,000
03/08/2021 13/08/2021 16/08/2021
6 Suryanti 0002226040042 Ulee Matang 082266895736 II, I, 0 - - - 50,000 50,000 700,000 INF RL 07/08/2021 125,000 125,000 25,000 50,000 225,000
05/08/2021 08/08/2021 11/08/2021 15/08/2021
7 Maulita 0000222962231 Ulee Rubek Barat 081284290819 III,II,0 - - - 50,000 50,000 07/08/2021 700,000 700,000 125,000 25,000 75,000 825,000
07/08/2021 09/08/2021 12/08/2021 16/08/2021
8 Intan Zuhra 0000223580114 Lhok Rambideng 085270466878 I, 0, 0 - - - 50,000 50,000 08/08/2021 700,000 700,000 125,000 25,000 75,000 825,000
11/08/2021 18/08/2021 21/08/2021
9 Maisura 0002455312397 Banda Masen 082368034174 I, 0, 0 - - - 50,000 50,000 700,000 12/08/2021 125,000 125,000 25,000 50,000 225,000
12/08/2021 19/08/2021 22/08/2021
10 Masyitah 0000216161144 Teupin Kuyuen 085361955814 V,III,II - - - 50,000 50,000 700,000 INF RL 13'08/2021 125,000 125,000 25,000 50,000 225,000
10/08/2021 19/08/2021 22/08/2021 26/08/2021
11 Erawati 0000222687887 Teupin Kuyuen 081271329560 II, I, 0 - - - 50,000 50,000 18/08/2021 700,000 700,000 125,000 25,000 75,000 825,000
26/08/2021 29/08/2021
12 Fauzabiljannah 0001121394069 Ulee Rubek Timur 082276194562 II, I, 0 - - - 50,000 50,000 28/08/2021 700,000 700,000 125,000 25,000 25,000 775,000
39 minggu Hari ke 2
26/08/2021
13 Safliana 0001121456531 Matang Lada 085276224795 I, 0, 0 - - - 50,000 50,000 700,000 INF RL 28/08/2021 125,000 125,000 25,000 175,000
40 minggu
Jumlah Total 600,000 4,200,000 750,000 700,000 6,250,000
Mengetahui ; Ulee
UleeMata
Matang, 31 Agustus 2021

NIP. 19760626 200504 2 001
PERSALINAN
Bulan dan Tahun Klaim : September 2021
Kepada Yth :
Dengan hormat,
AQ
NOMOR
ANC INC PNC
IDENTITAS NO.TELPON
Rujukan
12=(7+8+9+ 24=(20+21+2 25=(12+15+19+2
1 2 3 4 5 6 7 8 9 10 11 13 14 15 16 17 18 19 20 21 22 23
10) 2) 4)
06/09/2021 08/09/2021 11/09/2021 15/09/2021
1 Wardani 0000980836964 Matang Anoe 085217708480 V,IV,0 - - - 50,000 50,000 07/09/2021 700,000 700,000 - - 125,000 - 25,000 75,000 825,000
06/09/2021 08/09/2021 11/09/2021 15/09/2021
2 Agustina 0002745446613 Matang Lada 085270874468 II, I, 0 - - - 50,000 50,000 07/09/2021 700,000 700,000 - - 125,000 - 25,000 75,000 825,000
07/09/2021 10/09/2021 13/09/2021 17/09/2021
3 Marhamah 0002229999118 Mns. Geudong II, I, 0 - - - 50,000 50,000 09/09/2021 700,000 700,000 - - 125,000 - 25,000 75,000 825,000
10/09/2021 13/09/2021 16/09/2021 20/09/2021
4 Suryani Awahab 0002296698647 Lhok Rambideng IV,III,0 - - - 50,000 50,000 12/09/2021 700,000 700,000 - - 125,000 - 25,000 75,000 825,000
15/09/2021 23/09/2021 26/09/2021
5 Masliani 0001884387778 Matang Lada 082365648914 III,II,0 - - - 50,000 50,000 17/09/2021 700,000 700,000 125,000 25,000 50,000 800,000
18/09/2021 25/09/2021 28/09/2021
6 Marhami 0000222673882 Ulee Matang 085272927013 IV,III,0 - - - 50,000 50,000 700,000 - INF RL 11/12/2020 125,000 125,000 25,000 50,000 225,000
24/09/2021 26/09/2021 28/09/2021
7 Murniati 0000223614628 Lhok Rambideng 082239125541 VIII,VII,0 - - - 50,000 50,000 25/09/2021 700,000 700,000 - - 125,000 - 25,000 50,000 800,000
26/09/2021 28/09/2021
8 Cut Intan Eka Putri 0001122658705 Alue Ie Puteh 085314390947 I, 0, 0 - - - 50,000 50,000 27/09/2021 700,000 700,000 125,000 - 25,000 25,000 775,000
39 minggu Hari Ke 2
26/09/2021
9 Marhamah Nurdin 0000222931675 Ulee Rubek Barat 082286296937 IV,III,0 - - - 50,000 50,000 700,000 INF RL 28/09/2021 125,000 125,000 25,000 175,000
39 minggu
28/09/2021 30/09/2021
10 Aslamiyah 0001121338697 Ulee Rubek Barat 085271761460 VII,VI,0 - - - 50,000 50,000 29/09/2021 700,000 700,000 125,000 25,000 25,000 775,000
40 minggu Hari Ke 2
27/09/2021 30/09/2021
11 Nurul Mualla 0000980862737 Teupin Kuyuen 085260539520 I, 0, 0 - - - 50,000 50,000 29/09/2021 700,000 700,000 - - 125,000 - 25,000 25,000 775,000
39 minggu Hari Ke 2
Jumlah Total 550,000 6,300,000 250,000 525,000 7,625,000
Mengetahui ; Ulee Matang, 30 September 2021


NIP. 19760626 200504 2 001
PERSALINAN
Bulan dan Tahun Klaim : Oktober 2021
Kepada Yth :
Dengan hormat,
AQ
NOMOR
ANC INC PNC
IDENTITAS NO.TELPON
Rujukan
12=(7+8+9+ 24=(20+21+2 25=(12+15+19+2
1 2 3 4 5 6 7 8 9 10 11 13 14 15 16 17 18 19 20 21 22 23
10) 2) 4)
02/10/2021
1 Murniati 0000223614628 Lhok Rambideng 082239125541 VIII,VII,0 - - - 50,000 700,000 - - 125,000 - 25,000 25,000 25,000
Hari Ke 8
02/10/2021 06/10/2021
2 Cut Intan Eka Putri 0001122658705 Alue Ie Puteh 085314390947 I, 0, 0 - - - 50,000 700,000 - - 125,000 - 25,000 50,000 50,000
Hari Ke 5 Hari Ke 9
04/10/2021 07/10/2021
3 Marhamah Nurdin 0000222931675 Ulee Rubek Barat 082286296937 IV,III,0 - - - 50,000 700,000 - - 125,000 - 25,000 50,000 50,000
03/10/2021 07/10/2021
4 Aslamiyah 0001121338697 Ulee Rubek Barat 085371761460 VII,VI,0 - - - 50,000 700,000 125,000 25,000 50,000 50,000
03/10/2021 07/10/2021
5 Nurul Mualla 0000980862737 Teupin Kuyuen I, 0, 0 - - - 50,000 700,000 125,000 25,000 50,000 50,000
Hari Ke 5 Hari Ke 9
08/10/2021 11/10/2021 14/10/2021 18/10/2021
6 Aura Nazila 0000223969893 Matang Lada 085215920140 I, 0, 0 - - - 50,000 50,000 10/10/2021 700,000 700,000 125,000 25,000 75,000 825,000
11/10/2021 15/10/2021 18/10/2021 22/10/2021
7 Rahmah 0002283958967 Cot Merbo 085212902141 V,VI,0 - - - 50,000 50,000 14/10/2021 700,000 700,000 - - 125,000 - 25,000 75,000 825,000
10/10/10/2021 21/10/2021 24/10/2021
8 Ekanusanti 0000223662137 Lhok Rambideng 082320002401 II, I, 0 - - - 50,000 50,000 700,000 INF RL 15/10/2021 125,000 125,000 25,000 50,000 225,000
13/10/2021 17/10/2021 20/10/2021 24/10/2021
9 Dahliana 0000980859418 Ulee Rubek Timu 081263250770 II, I, 0 - - - 50,000 50,000 16/10/2021 700,000 700,000 - - 125,000 - 25,000 75,000 825,000
15/10/2021 19/10/2021 22/10/2021 26/10/2021
10 Safridar 0002446323805 Ulee Rubek Barat 082161052070 IV,III,0 - - - 50,000 50,000 18/10/2021 700,000 700,000 125,000 25,000 75,000 825,000
18/10/2021 21/10/2021 24/10/2021 28/10/2021
11 Irawati 0000223687956 Lhok Rambideng 082252827514 IV,III,0 - - - 50,000 50,000 20/10/2021 700,000 700,000 125,000 25,000 75,000 825,000
20/10/2021 27/10/2021 30/10/2021
12 Eli Yana 0001121376903 Panton Labu 001397342467 II, I, 0 - - - 50,000 50,000 700,000 INF RL 21/10/2021 125,000 125,000 25,000 50,000 225,000
11/10/2021 24/10/2021 27/10/2021 31/10/2021
13 Mutia Amanda 0001121370759 Teupin Keubeu 085269342085 II, I, 0 - - - 50,000 50,000 23/10/2021 700,000 700,000 125,000 25,000 75,000 825,000
23/10/2021 26/10/2021 29/10/2021
14 Mirnawati 0001802031502 Teupin Kuyuen III,II,0 - - - 50,000 50,000 25/10/2021 700,000 700,000 - - 125,000 - 25,000 50,000 800,000
21/10/2021
15 Fitriani 0000223114296 Seuneubok do 085373585312 II, I, 0 - - - 50,000 50,000 700,000 INF RL 26/10/2021 125,000 125,000 25,000 175,000
39 minggu
26/10/2021 28/10/2021
16 Yusnidar 0000220778021 Teupin Kuyuen 082361090970 II, I, 0 - - - 50,000 50,000 27/10/2021 700,000 700,000 125,000 25,000 25,000 775,000
39 minggu Hari ke 2
25/10/2021 28/10/2021
17 Muslimah 0000222969881 Ulee Rubek Barat 085362914490 V,VI,0 - - - 50,000 50,000 27/10/2021 700,000 700,000 125,000 25,000 25,000 775,000
40 minggu Hari ke 2
29/10/2021 31/10/2021
18 Mawar yani 0002046366393 Teupin Kuyun 085276381351 I, 0, 0 50,000 50,000 30/10/2021 700,000 700,000 25,000 25,000 775,000
39 minggu Hari ke 2
Jumlah Total 650,000 7,000,000 375,000 900,000 8,925,000
Mengetahui ; Ulee Matang, 31 Oktober 2021

NIP. 19760626 200504 2 001
PERSALINAN
Bulan dan Tahun Klaim : November 2021
Kepada Yth :
Dengan hormat,
AQ
NOMOR
ANC INC PNC
IDENTITAS NO.TELPON
Rujukan
12=(7+8+9+ 24=(20+21+2 25=(12+15+19+2
1 2 3 4 5 6 7 8 9 10 11 13 14 15 16 17 18 19 20 21 22 23
10) 2) 4)
02/11/2021
1 Mirna Wati 0001802031502 Teupin Kuyuen III,II,0 - - - 50,000 700,000 - - 125,000 - 25,000 25,000 25,000
Hari Ke 9
01/11/2021 04/11/2021
2 Fitriani 0000223114296 Seuneubok Doe 085373585312 II,I,0 - - - 50,000 700,000 - - 125,000 - 25,000 50,000 50,000
01/11/2021 04/11/2021
3 Yusnidar 0000220778021 Teupin Kuyuen 082361090970 II,I,0 - - - 50,000 700,000 - - 125,000 - 25,000 50,000 50,000
Hari Ke 6 Hari Ke 9
01/11/2021 04/11/2021
4 Muslimah 0000222969881 Ulee Rubek Barat 085362914490 V,VI,0 - - - 50,000 700,000 125,000 25,000 50,000 50,000
Hari Ke 6 Hari Ke 9
03/11/2021 07/11/2021
5 Mawar Yani 0002046366393 Teupin Kuyuen 085276381351 I, 0, 0 - - - 50,000 700,000 125,000 25,000 50,000 50,000
Hari Ke 5 Hari Ke 9
01/11/2021 03/11/2021 06/11/2021 10/11/2021
6 Riska Mayanda 0002675241112 Ulee Matang 085270214055 I, 0, 0 - - - 50,000 50,000 02/11/2021 700,000 700,000 125,000 25,000 75,000 825,000
01/11/2021 03/11/2021 06/11/2021 10/11/2021
7 Mismarni 0000980851252 Ulee Rubek Barat 085358720599 III,II,0 - - - 50,000 50,000 02/11/2021 700,000 700,000 - - 125,000 - 25,000 75,000 825,000
03/11/2021 05/11/2021 08/11/2021 12/11/2021
8 Erna Yati 0000223962603 Kuta Meuligo 081388711323 II, I, 0 - - - 50,000 50,000 04/11/2021 700,000 700,000 125,000 25,000 75,000 825,000
06/11/2021 13/11/2021 16/11/2021
9 Badriah Husna 0001117120239 Ulee Rubek Timu 082252758554 I, 0, 0 - - - 50,000 50,000 700,000 INF RL 07/11/2021 125,000 125,000 25,000 50,000 225,000
05/11/2021 09/11/2021 12/11/2021 16/11/2021
10 Nurfadillah 0000223314759 Ulee Rubek Barat 085210097055 III,II,0 - - - 50,000 50,000 08/11/2021 700,000 700,000 125,000 25,000 75,000 825,000
07/11/2021 15/11/2021 18/11/2021
11 Yusnita 0000980856235 Ulee Matang I, 0, 0 - - - 50,000 50,000 700,000 INF RL 09/11/2021 125,000 125,000 25,000 50,000 225,000
10/11/2021 12/11/2021 15/11/2021 19/11/2021
12 Dewianti 0000980856742 Ulee Matang 082273238723 VI,V,0 - - - 50,000 50,000 11/11/2021 700,000 700,000 125,000 25,000 75,000 825,000
11/11/2021 18/11/2021 21/11/2021
13 Ainsyah 0000223648209 Teupin Kuyuen 085358412976 V,VI,0 - - - 50,000 50,000 700,000 INF RL 12/11/2021 125,000 125,000 25,000 50,000 225,000
10/11/2021 13/11/2021 16/11/2021 20/11/2021
14 Aminah 0000224195275 Ulee Rubek Timu IV,III,0 - - - 50,000 50,000 12/11/2021 700,000 700,000 - - 125,000 - 25,000 75,000 825,000
13/11/2021 16/11/2021 19/11/2021 23/11/2021
15 Nurmalinda Yani 0002261176086 Simpang Tiga 082276196596 II, I, 0 - - - 50,000 50,000 15/11/2021 700,000 700,000 125,000 25,000 75,000 825,000
13/11/2021 21/11/2021 24/11/2021 28/11/2021
16 Nur Azmi 0002254939378 Ulee Rubek Timu 082275620981 II, I, 0 - - - 50,000 50,000 20/11/2021 700,000 700,000 125,000 25,000 75,000 825,000
23/11/2021
17 Rauzatul Jannah 0001301990758 Ulee Matang 085289485977 II,0,I - - - 50,000 50,000 700,000 INF RL 25/11/2021 125,000 125,000 25,000 175,000
41 minggu
19/11/2021 29/11/2021
18 Baitun Nadia 0000003354197 Matang Lada 085320808502 II, I, 0 50,000 50,000 28/11/2021 700,000 700,000 125,000 25,000 25,000 775,000
39 minggu Hari ke 2
27/11/2021 30/11/2021
19 Iklima 0001120786301 Ulee Rubek Barat IV,III,0 50,000 50,000 29/11/2021 700,000 700,000 125,000 25,000 25,000 775,000
39 minggu Hari ke 2
Jumlah Total 700,000 7,000,000 500,000 1,025,000 9,225,000
Mengetahui ; Ulee Matang, 30 November 2021


NIP. 19760626 200504 2 001
PERSALINAN
Bulan dan Tahun Klaim : Desember 2021
Kepada Yth :
Dengan hormat,
AQ
NOMOR
ANC INC PNC
IDENTITAS NO.TELPON
Rujukan
12=(7+8+9+ 24=(20+21+2 25=(12+15+19+2
1 2 3 4 5 6 7 8 9 10 11 13 14 15 16 17 18 19 20 21 22 23
10) 2) 4)
01/12/2021 04/12/2021
1 Rauzatul Jannah 0001301990758 Ulee Matang I, 0, 0 - - - 50,000 700,000 - - 125,000 - 25,000 50,000 50,000
02/12/2021 06/12/2021
2 Baitun Nadia 0000003354197 Matang Lada 085320808502 II, I, 0 - - - 50,000 700,000 - - 125,000 - 25,000 50,000 50,000
Hari Ke 5 Hari Ke 9
03/12/2021 07/12/2021
3 Iklima 0001120786301 Ulee Rubek Barat IV,III,0 - - - 50,000 700,000 - - 125,000 - 25,000 50,000 50,000
Hari Ke 5 Hari Ke 9
05/12/2021 14/12/2021 17/12/2021
4 Rosnidar 0000980854672 Matang Lada 085277397068 V,IV,0 - - - 50,000 50,000 700,000 INF RL 08/12/2021 125,000 125,000 25,000 50,000 225,000
07/12/2021 11/12/2021 14/12/2021 18/12/2021
5 Maulidawati 0001832588324 Alue Rambee III,II,0 - - - 50,000 50,000 10/12/2021 700,000 700,000 125,000 25,000 75,000 825,000
09/12/2021 12/12/2021 15/12/2021 19/12/2021
6 Suryana 0000980839113 Lhok Rambideng 082259877082 I, 0, 0 - - - 50,000 50,000 11/12/2021 700,000 700,000 125,000 25,000 75,000 825,000
10/12/2021 18/12/2021 21/12/2021
7 Ambar Wati 0000980859352 Lueng peut II, I, 0 - - - 50,000 50,000 700,000 INF RL 12/12/2021 125,000 125,000 25,000 50,000 225,000
09/12/2021 26/12/2021 29/12/2021
8 Lena Fazila 0002312777068 Matang Lada I, 0, 0 - - - 50,000 50,000 700,000 INF RL 20/12/2021 125,000 125,000 25,000 50,000 225,000
26/10/2021 29/12/2021
9 Nanda Rizkia 0000003239774 Pulo Kiton 082286296937 I, 0, 0 - - - 50,000 700,000 INF RL 20/12/2021 125,000 125,000 25,000 50,000 175,000
25/12/2021 28/12/2021 31/12/2021
10 Salamah 0002290999645 Ulee Titi 085295039482 VI,V,0 - - - 50,000 50,000 27/12/2021 700,000 700,000 125,000 25,000 50,000 800,000
Jumlah Total 300,000 2,100,000 500,000 550,000 3,450,000
Mengetahui ; Ulee
Ulee Matang,
Mat 30 September 2021

NIP. 19760626 200504 2 001
PERSALINAN
Bulan dan Tahun Klaim : Januari 2022
Kepada Yth :
Dengan hormat,
AQ
NOMOR
ANC INC PNC
IDENTITAS NO.TELPON
Rujukan
12=(7+8+9+ 24=(20+21+2 25=(12+15+19+2
1 2 3 4 5 6 7 8 9 10 11 13 14 15 16 17 18 19 20 21 22 23
10) 2) 4)
01/01/2022 08/01/2022
1 Mursyidah 0000980861872 Teupin Kuyuen 085322620211 I, 0, 0 - - - 50,000 50,000 700,000 INF RL 02/01/2022 125,000 125,000 25,000 25,000 200,000
40 minggu Hari Ke 7
01/01/2022 04/01/2022 07/01/2022
2 Nurbadri 0000223684209 Teupin Kuyuen 085260639516 IV,III,0 - - - 50,000 50,000 03/01/2022 700,000 700,000 - - 125,000 - 25,000 50,000 800,000
03/01/2022 07/01/2022 10/01/2022
3 Muliana 0000222887801 Paya Dua Uram 082294818887 I, 0, 0 - - - 50,000 50,000 06/01/2022 700,000 700,000 125,000 25,000 50,000 800,000
05/01/2022 16/01/2022
4 Sri Marwani 0002779776505 Teupin Kuyuen 082317714930 IV,III,0 - - - 50,000 50,000 700,000 INF RL 10/01/2022 125,000 125,000 25,000 25,000 200,000
40 minggu Hari Ke 7
14/01/2022 17/01/2022 20/01/2022
5 Yusmayani 0000222627712 Ulee Matang I, 0, 0 - - - 50,000 50,000 16/01/2022 700,000 700,000 125,000 25,000 50,000 800,000
18/01/2022 20/01/2022 23/01/2022
6 Mursyidah 0001825021056 Geulumpang Payong 085358789380 II, I, 0 - - - 50,000 50,000 19/01/2022 700,000 700,000 125,000 25,000 50,000 225,000
20/01/2022 24/01/2022 27/01/2022
7 Rahmatillah 0000980848181 Krung Lingka Timu 081263319940 II, I, 0 - - - 50,000 50,000 23/01/2022 700,000 700,000 125,000 25,000 50,000 800,000
23/01/2022 26/01/2022 29/01/2022
8 Safwati 0001121346224 Ulee Rubek Barat 082362260056 III,II,0 - - - 50,000 50,000 25/01/2022 700,000 700,000 125,000 25,000 50,000 800,000
26/01/2022 29/01/2022
9 Khatijah 0000980861409 Teupin Kuyuen 085260759155 IV,III,0 - - - 50,000 50,000 28/01/2022 700,000 700,000 125,000 25,000 25,000 775,000
39 minggu Hari ke 2
25/01/2022 29/01/2022
10 Malahayati 0001858551614 Ulee Matang III,II,0 - - - 50,000 50,000 28/01/2022 700,000 700,000 125,000 25,000 25,000 775,000
39 minggu Hari ke 2
26/01/2022 30/01/2022
11 Irdawati 0002064059483 Lhok Rambideng III,II,0 - - - 50,000 50,000 29/01/2022 700,000 700,000 125,000 25,000 25,000 775,000
39 minggu Hari ke 2
29/01/2022
12 Marlina 0002265437812 Ulee Rubek Timur 082388193957 IV,III,0 - - - 50,000 50,000 700,000 INF RL 30/01/2022 125,000 125,000 25,000 175,000
39 minggu
Jumlah Total 600,000 6,300,000 375,000 425,000 7,125,000
Mengetahui ; Ulee
UleeMata
Matang, 31 Januari 2022

NIP. 19760626 200504 2 001
PERSALINAN
Bulan dan Tahun Klaim : Februari 2022
Kepada Yth :
Dengan hormat,
AQ
NOMOR
ANC INC PNC
IDENTITAS NO.TELPON
Rujukan
12=(7+8+9+ 24=(20+21+2 25=(12+15+19+2
1 2 3 4 5 6 7 8 9 10 11 13 14 15 16 17 18 19 20 21 22 23
10) 2) 4)
03/02/2022 07/02/2022 10/02/2022
1 Aminah 0002317416671 Teupin Kuyun 085270487741 IV,V,0 - - - 50,000 50,000 06/02/2022 700,000 700,000 125,000 25,000 50,000 800,000
07/02/2022 14/02/2022
2 Marwati 0000223124376 Rawang Itek I, 0, 0 - - - 50,000 50,000 700,000 infus RL 08/02/2022 125,000 25,000 25,000 75,000
38 minggu hari ke 7
17/02/2022 20/02/2022 24/02/2022
3 Nurasiah 0001121338934 Ulee Rubek Barat III, II, 0 - - - 50,000 16/02/2022 700,000 700,000 - - 125,000 - 25,000 75,000 775,000
hari ke 2 hari ke 5 hari ke 9
15/02/2022 23/02/2022
4 Mauliza Karimah 0000979167082 Kanot 082295741355 I, 0, 0 - - - 50,000 50,000 700,000 infus RL 17/02/2022 125,000 - 25,000 25,000 75,000
36 minggu hari ke 7
20/02/2022 23/02/2022 26/02/2022
5 Irmayanti 0000223651203 Matang Kumbang 085251884441 II,I,0 - - - 50,000 50,000 22/02/2022 700,000 700,000 - - 125,000 - 25,000 50,000 800,000
22/02/2022 26/02/2022
6 Nurajmi 0000222951216 Matang Lada I, 0, 0 - - - 50,000 50,000 25/02/2022 700,000 700,000 - - 125,000 - 25,000 25,000 775,000
38 minggu hari ke 2
24/02/2022 27/02/2022
7 Mulidar 0000223707824 Ulee Rubek Timu 082275620981 III, II, 0 - - - 50,000 50,000 26/02/2022 700,000 700,000 - - 125,000 - 25,000 25,000 775,000
39 minggu hari ke 2
24/02/2022 27/02/2022
8 Maulida 0000223644688 Ulee Rubek Barat III, II, 0 - - - 50,000 50,000 2/26/2022 700,000 700,000 125,000 25,000 25,000 775,000
40 minggu hari ke 2
Jumlah Total 350,000 4,200,000 - 300,000 4,850,000
Mengetahui ; Ulee
UleeMata
Matang, 28 Februari 2022

NIP. 19760626 200504 2 001
PERSALINAN
Bulan dan Tahun Klaim : Maret 2022
Kepada Yth :
Dengan hormat,
AQ
NOMOR
ANC INC PNC
IDENTITAS NO.TELPON
Rujukan
12=(7+8+9+ 24=(20+21+2 25=(12+15+19+2
1 2 3 4 5 6 7 8 9 10 11 13 14 15 16 17 18 19 20 21 22 23
10) 2) 4)
09/03/2022 13/03/2022 16/03/2022
1 Murriza 0001433010644 Ulee Rubek Barat 081269105553 IV,III,0 - - - 50,000 50,000 12/03/2022 700,000 700,000 - - 125,000 - 25,000 50,000 800,000
10/03/2022 19/03/2022
2 Fatimah Anum 0002321000864 Teupin Kuyuen 085282579042 I, 0, 0 - - - 50,000 50,000 700,000 INF RL 13/03/2022 125,000 - 25,000 25,000 75,000
40 minggu Hari Ke 7
12/03/2022 15/03/2022 18/03/2022
3 Nazariana 0002254915809 Simpang Ulim 081256337189 II, I, 0 - - - 50,000 50,000 14/03/2022 700,000 700,000 - - 125,000 - 25,000 50,000 800,000
13/03/2022 21/03/2022
4 Khumaira 0002229480855 Ulee Matang 082235018419 III,II,0 - - - 50,000 50,000 700,000 INF RL 15/03/2022 125,000 25,000 25,000 75,000
38 minggu Hari Ke 7
14/03/2022 17/03/2022 20/03/2022
5 Dewi 000313300351 Teupin Kuyuen 081273285446 IV,III,0 - - - 50,000 50,000 16/03/2022 700,000 700,000 125,000 25,000 50,000 800,000
15/03/2022 22/03/2022
6 Nurulhafni 0000223737085 Teupin Kuyuen III,II,0 - - - 50,000 50,000 700,000 INF RL 16/03/2022 125,000 25,000 25,000 75,000
39 minggu Hari Ke 7
17/03/2022 24/03/2022
7 Mirawati 0002262476621 Matang Anoe 081376383536 I, 0, 0 - - - 50,000 50,000 700,000 INF RL 18/03/2022 125,000 - 25,000 25,000 75,000
40 minggu Hari Ke 7
18/03/2022 21/03/2022 24/03/2022
8 Ti Rasyidah 0000223517193 Ulee Matang 085270540023 II, I, 0 - - - 50,000 50,000 20/03/2022 700,000 700,000 125,000 25,000 50,000 800,000
20/03/2022 23/03/2022 26/03/2022
9 Nila Wati 0000003738723 Matang Lada 085260085941 II, I, 0 - - - 50,000 50,000 22/03/2022 700,000 700,000 - - 125,000 - 25,000 50,000 800,000
21/03/2022 24/03/2022 27/03/2022 31/03/2022
10 Nurul Aliah 0001121373033 Bukit Seulamat 082274010221 II, I, 0 - - - 50,000 50,000 23/03/2022 700,000 700,000 125,000 25,000 75,000 825,000
20/03/2022 26/03/2022 29/03/2022
11 Faridah 0000223568605 Ulee Titi 0853 5796 3755 IV,III,0 - - - 50,000 50,000 25/03/2022 700,000 700,000 125,000 25,000 50,000 800,000
20/03/2022 31/03/2022
12 Maryani 0000980857664 Ulee Matang VI,V,0 - - - 50,000 50,000 700,000 INF RL 25/03/2022 125,000 25,000 25,000 75,000
37 minggu Hari Ke 7
23/03/2022
13 Emayati 0001270239838 Ulee Rubek Timu III,II,0 - - - 50,000 50,000 700,000 INF RL 26/03/2022 125,000 25,000 50,000
40 minggu
26/03/2022
14 Tahtinur 0001609465318 Teupin Kuyuen I, 0, 0 - - - 50,000 50,000 700,000 INF RL 27/03/2022 125,000 - 25,000 50,000
39 minggu
30/03/2022
15 Nurakmal 0000980855829 Matang Karieng I, 0, 0 - - - 50,000 29/03/2022 700,000 700,000 125,000 25,000 25,000 725,000
Hari ke 2
02/03/2022
16 Nurajmi 0000223651203 Matang Lada I, 0, 0 - - - 50,000 700,000 125,000 25,000 25,000 25,000
Hari ke 9
02/03/2022 06/03/2022
17 Mulidar 0000223707824 Ulee Rubek Timu 082275620981 III,II,0 - - - 50,000 700,000 125,000 25,000 50,000 50,000
Hari ke 5 Hari ke 9
Jumlah Total 700,000 5,600,000 - 600,000 6,900,000
Mengetahui ; Ulee Matang, 31 Maret 2022

NIP. 19760626 200504 2 001
PERSALINAN
Bulan dan Tahun Klaim : April 2022
Kepada Yth :
Dengan hormat,
AQ
NOMOR
ANC INC PNC
IDENTITAS NO.TELPON
No NAMA PASIEN ALAMAT YANG DAPAT G.P.A Tarif Total Tarif
Tarif Total Tarif Tindaka Tanggal TOTAL
DIHUBUNGI Tarif Tanggal Tindaka Tindakan TARIF
K1 K2 K3 K4 Jumlah Persalinan Persalinan n Pra Pra KF 1 KF 2 KF 3 JUMLAH
NIK/Kartu JKN ANC INC n Pra Pra PNC
Normal Normal Rujukan Rujukan
Rujukan Rujukan
12=(7+8+ 24=(20+21 25=(12+15+1
1 2 3 4 5 6 7 8 9 10 11 13 14 15 16 17 18 19 20 21 22 23
9+10) +22) 9+24)
02/04/2022 04/04/2022 07/04/2022
1 Mariana 0001859215555 Lhok Rambideng 082383766170 II, I, 0 - - - 50,000 50,000 03/04/2022 700,000 700,000 25,000 50,000 800,000
09/04/2022 17/04/2022
2 Tairahtul Jannah 0001121293124 Ulee Matang 081264390689 I, 0, 0 - - - 50,000 50,000 700,000 INF RL 11/04/2022 25,000 25,000 75,000
37 minggu Hari Ke 7
15/04/2022 18/04/2022 21/04/2022
3 Nurlina 000021772463 Ujong Mesjid Lp 085373103493 II, I, 0 - - - 50,000 50,000 17/04/2022 700,000 700,000 25,000 50,000 800,000
16/04/2022 20/04/2022 23/04/2022
4 Ti Hajar 0002321000201 G U Unoe 082311731352 III,II,0 - - - 50,000 50,000 19/04/2022 700,000 700,000 25,000 50,000 800,000
24/04/2022 27/04/2022 30/04/2022
5 Bismi Zahara 0000222941349 Matang Raya Timu 082274077674 I, 0, 0 - - - 50,000 50,000 26/04/2022 700,000 700,000 25,000 50,000 800,000
26/04/2022
6 Nurfadillah 0002941151758 Rima Keuneurom 085277503111 I, 0, 0 - - - 50,000 50,000 700,000 INF RL 27/04/2022 25,000 50,000
40 minggu
23/04/2022 29/04/2022
7 Dita Faradila 0002327036128 Matang Serdang 082363580644 I, 0, 0 - - - 50,000 50,000 28/04/2022 700,000 700,000 25,000 25,000 775,000
40 minggu hari ke 2
01/04/2022
8 Ti Rasyidah 0000223517193 Ulee Matang 085270540023 II, I, 0 - - - 50,000 700,000 25,000 25,000 25,000
Hari ke 12
02/04/2022
9 Nila Wati 0000003738723 Matang Lada 085360085941 II, I, 0 - - - 50,000 700,000 25,000 25,000 25,000
Hari ke 11
Jumlah Total 350,000 3,500,000 - 300,000 4,150,000
Mengetahui ; Ulee
Ulee Mat
Matang , 30 April 2022

NIP. 19760626 200504 2 001
CEKLIS KLAIM PERSALINAN
BIDAN JEJARING NURLAILA, AM.Keb
BULAN PELAYANAN ………………. TAHUN 2022
NOMOR : ……………..…………….
Yang bertanda tangan dibawah ini :
1. Nama : NURLAILA, AM.Keb

2. Jabatan : Penanggung Jawab PMB NURLAILA, AM.Keb
Menyatakan telah melakukan pengecekan dan menghitung terhadap jumlah pengajuan klaim persalinan bulan pelayanan
………………. Tahun 2022.
Dengan kelengkapan sebagai berikut :
Kelengkapan dan Kesesuaian Berkas

No. Jenis Bidan Jejaring Puskesmas/Klinik/DPP Verifikator Keterangan
Jumlah Sesuai Lengkap Jumlah Sesuai Lengkap Jumlah Sesuai Lengkap
Berkas Administrasi Klaim
a. KTP
b. Kartu Keluarga
1
c. Kartu JKN
d. Formulir Pernyataan Peserta
e. Bukti Pernyataan Pelayanan
Pelayanan ANC
2 a. Lembaran Identitas Peserta
b. Catatan Kesehatan Ibu Hamil
Pelayanan INC
3 a. Patograf
b. Surat Kelahiran
Pelayanan PNC
4 a. Catatan Kesehatan Ibu Nifas
b. Catatan Kesehatan Bayi Baru Lahir
Pelayanan Pra Rujukan
5
a. Resume Tindakan Pra Rujukan
Pelayanan KB
a. Salinan Kartu Peserta KB
6
b. Lembaran Persetujuan Tindakan Medik
c. Kartu Status Peserta KB
Demikian cheklis ini dibuat untuk dapat dipergunakan sebagaimana mestinya.
Ulee Matang, …………………….. 20..

Pimpinan FKTP Bidan Jejaring
…………………………….. NURLAILA, AM.Keb

NIP. 19760626 200504 2 001
PRAKTIK MANDIRI BIDAN (PMB)
NURLAILA, AM.Keb
Jl. Panteu Breuh-Ulee Rubek Desa Ulee Matang Kec. Seunuddon Kab. Aceh
Utara
Nomor : 440/80/SIPB/DPMTRANSNAKER/III/2019
SURAT PERNYATAAN TANGGUNG JAWAB MUTLAK

PENGAJUAN KLAIM BIAYA PELAYANAN KESEHATAN
TERHADAP PESERTA JAMINAN KESEHATAN NASIONAL
NOMOR : ………………………………
Yang bertanda tangan dibawah ini :
Nama : NURLAILA, AM.Keb

NIP/NRP/Nomor Pegawai : 19760626 200504 2 001
Jabatan : Penanggung Jawab PMB NURLAILA, AM.Keb
Nomor HP : 0821 9849 0898
Alamat : Desa Ulee Matang Kec. Seunuddon
Kabupaten Aceh Utara
Dengan ini menyatakan dan bertanggung jawab secara penuh atas hal - hal sebagai
berikut :
1. Dokumen-dokumen yang dipersyaratkan dalam rangka pengajuan klaim pelayanan

kesehatan peserta JKN dengan lengkap dan benar, dan siap diaudit sewaktu-waktu.
2. Apabila di kemudian hari terbukti pernyataan ini tidak benar dan menimbulkan kerugian
Negara, kami bersedia mengembalikan kerugian tersebut dan dilakukan proses sesuai
ketentuan hukum yang berlaku
Demikian surat pernyataan ini dibuat dengan sebenarnya.
Ulee Matang, ………..……….. 20..

Yang bertanda tangan
NURLAILA, AM.Keb
NIP. 19760626 200504 2 001
PRAKTIK MANDIRI BIDAN (PMB)
NURLAILA, AM.Keb
Jl. Panteu Breuh-Ulee Rubek Desa Ulee Matang Kec. Seunuddon Kab. Aceh Utara
Nomor : 440/12/SIPB/DPMTRANSNAKER/III/2022
Kilinik Atiqah Medical Keude Alue Ie Puteh

No. 39/KAM/03/2022
SURAT PENGANTAR
Nomor : / / 20
Ulee Matang,
Kepada Yth :
Di -
Tempat
Dengan Hormat,
Kami merujuk Penderita :
Nama :
Umur :
Pekerjaan :
Alamat :
Diagnosa sementara :
Tindakan Pra rujukan :
Jam berangkat :
Jam tiba :
Tanda tangan pasien / keluarga Bidan pengirim
…………………………… NURLAILA, AM.Keb

NIP. 19760626 200504 2 001
Petugas penerima
…………………………….

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REKAPITULASI PELAYANAN

Jumlah Total 550,000 4,900,000 375,000 650,000 6,475,000

Mengetahui ; Ulee Matang, 31 Agustus 2020

( dr. EFENDI YUSUF, M.Kes ) ( NURLAILA, AM.Keb )

Jumlah Total 400,000 4,200,000 250,000 475,000 5,325,000

Mengetahui ; Ulee Matang, 30September 2020

( dr. EFENDI YUSUF, M.Kes ) ( NURLAILA, AM.Keb )

Jumlah Total 250,000 3,500,000 - 475,000 4,225,000

Mengetahui ; Ulee Matang, 31 Oktober 2020

( dr. EFENDI YUSUF, M.Kes ) ( NURLAILA, AM.Keb )

Jumlah Total 450,000 4,900,000 125,000 600,000 6,075,000

Mengetahui ; Ulee Matang, 30 November 2020

( dr. EFENDI YUSUF, M.Kes ) ( NURLAILA, AM.Keb )

Jumlah Total 600,000 6,300,000 375,000 725,000 8,000,000

Mengetahui ; Ulee Matang, 31 Desember 2020

( dr. EFENDI YUSUF, M.Kes ) ( NURLAILA, AM.Keb )

Jumlah Total 550,000 4,900,000 875,000 850,000 7,175,000

Mengetahui ; Ulee Matang, 31 Januari 2021

Jumlah Total 250,000 2,800,000 250,000 400,000 3,700,000

Mengetahui ; Ulee Matang, 28 Februari 2021

( dr. EFENDI YUSUF, M.Kes ) ( NURLAILA, AM.Keb )

Jumlah Total 650,000 5,670,000 - 825,000 7,775,000

Mengetahui ; Ulee Matang, 30 April 2021

( dr. EFENDI YUSUF, M.Kes ) ( NURLAILA, AM.Keb )

Jumlah Total 400,000 4,200,000 250,000 525,000 5,375,000

( dr. EFENDI YUSUF, M.Kes ) ( NURLAILA, AM.Keb )

Jumlah Total 650,000 5,600,000 500,000 750,000 7,500,000

( dr. EFENDI YUSUF, M.Kes ) ( NURLAILA, AM.Keb )

Jumlah Total 750,000 7,700,000 500,000 1,025,000 9,975,000

Mengetahui ; Ulee Matang, 31 Juli 2021

Jumlah Total 600,000 4,200,000 750,000 700,000 6,250,000

( dr. EFENDI YUSUF, M.Kes ) ( NURLAILA, AM.Keb )

Jumlah Total 550,000 6,300,000 250,000 525,000 7,625,000

Mengetahui ; Ulee Matang, 30 September 2021

( dr. EFENDI YUSUF, M.Kes ) ( NURLAILA, AM.Keb )

Jumlah Total 650,000 7,000,000 375,000 900,000 8,925,000

Mengetahui ; Ulee Matang, 31 Oktober 2021

Jumlah Total 700,000 7,000,000 500,000 1,025,000 9,225,000

Mengetahui ; Ulee Matang, 30 November 2021

( dr. EFENDI YUSUF, M.Kes ) ( NURLAILA, AM.Keb )

Jumlah Total 300,000 2,100,000 500,000 550,000 3,450,000

( dr. EFENDI YUSUF, M.Kes ) ( NURLAILA, AM.Keb )

Jumlah Total 600,000 6,300,000 375,000 425,000 7,125,000

( dr. EFENDI YUSUF, M.Kes ) ( NURLAILA, AM.Keb )

Jumlah Total 350,000 4,200,000 - 300,000 4,850,000

( dr. EFENDI YUSUF, M.Kes ) ( NURLAILA, AM.Keb )

Jumlah Total 700,000 5,600,000 - 600,000 6,900,000

Mengetahui ; Ulee Matang, 31 Maret 2022

Jumlah Total 350,000 3,500,000 - 300,000 4,150,000

( dr. EFENDI YUSUF, M.Kes ) ( NURLAILA, AM.Keb )

Yang bertanda tangan dibawah ini :

1. Nama : NURLAILA, AM.Keb

Dengan kelengkapan sebagai berikut :

Kelengkapan dan Kesesuaian Berkas

Demikian cheklis ini dibuat untuk dapat dipergunakan sebagaimana mestinya.

Ulee Matang, …………………….. 20..

…………………………….. NURLAILA, AM.Keb

SURAT PERNYATAAN TANGGUNG JAWAB MUTLAK

Yang bertanda tangan dibawah ini :

Nama : NURLAILA, AM.Keb

1. Dokumen-dokumen yang dipersyaratkan dalam rangka pengajuan klaim pelayanan

Demikian surat pernyataan ini dibuat dengan sebenarnya.