BPJS Kesehatan Cab.

BOYOLALI
FORMULIR PENGAJUAN KLAIM TINGKAT PERTAMA

Nomor FPK : P2202000022846

Provider : Wonosamodro
Bulan Pelayanan : February 2022

Pelayanan : Promotif

Total Data : 34

Total Tagihan : Rp. 680.000

NoKunjungan NAMA TANGGAL TINDAKAN HASIL TENAGA MEDIS BIAYA

119.00
014900020222P000255 PARSINI 10/02/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Anis Setyati Rp. 20.000
mgr/dl
124.00
014900020222P000256 SOLIKAH 10/02/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Anis Setyati Rp. 20.000
mgr/dl
106.00
014900020222P000257 SUNARTI 10/02/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Anis Setyati Rp. 20.000
mgr/dl

014900020222P000258 KOMSATUN 10/02/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 98.00 mgr/dl dr. Anis Setyati Rp. 20.000

117.00
014900020222P000259 RUSIYEM 10/02/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Anis Setyati Rp. 20.000
mgr/dl
101.00
014900020222P000260 KARTINI 10/02/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Anis Setyati Rp. 20.000
mgr/dl
105.00
014900020222P000261 SITI SAROH 10/02/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Anis Setyati Rp. 20.000
mgr/dl

014900020222P000262 RUMINAH 10/02/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 95.00 mgr/dl dr. Anis Setyati Rp. 20.000

109.00
014900020222P001064 NAPSIYAH 10/02/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Anis Setyati Rp. 20.000
mgr/dl
124.00
014900020222P001516 SITI ROCHATUN 26/02/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Anis Setyati Rp. 20.000
mgr/dl
274.00
014900020222P001517 NURHAYATI 26/02/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Anis Setyati Rp. 20.000
mgr/dl
323.00
014900020222P001518 SUYAT SURADI 26/02/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Anis Setyati Rp. 20.000
mgr/dl

014900020222P001519 SAMINEM 26/02/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 89.00 mgr/dl dr. Anis Setyati Rp. 20.000
 NoKunjungan NAMA TANGGAL TINDAKAN HASIL TENAGA MEDIS BIAYA

126.00
014900020222P001520 MATENI 26/02/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Anis Setyati Rp. 20.000
mgr/dl
322.00
014900020222P001521 HARTI WAHYUNINGSIH 26/02/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Anis Setyati Rp. 20.000
mgr/dl
209.00
014900020222P001522 SUKINAH 26/02/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Anis Setyati Rp. 20.000
mgr/dl
357.00
014900020222P001523 MUSRINI 26/02/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Anis Setyati Rp. 20.000
mgr/dl
343.00
014900020222P001524 SITI AISAH 26/02/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Anis Setyati Rp. 20.000
mgr/dl
108.00
014900020222P001525 SURATINEM 26/02/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Anis Setyati Rp. 20.000
mgr/dl
313.00
014900020222P001526 WARTINI 26/02/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Anis Setyati Rp. 20.000
mgr/dl
238.00
014900020222P001527 PUNIYEM AL PUJIASTUTI 26/02/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Anis Setyati Rp. 20.000
mgr/dl
467.00
014900020222P001528 SRI SULASMIATI 10/02/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Anis Setyati Rp. 20.000
mgr/dl
460.00
014900020222P001529 WAGINEM 10/02/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Anis Setyati Rp. 20.000
mgr/dl
378.00
014900020222P001530 JALMONO 10/02/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Anis Setyati Rp. 20.000
mgr/dl
289.00
014900020222P001531 ZUHRIYAH 10/02/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Anis Setyati Rp. 20.000
mgr/dl
220.00
014900020222P001532 TUKINI 10/02/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Anis Setyati Rp. 20.000
mgr/dl
163.00
014900020222P001533 SUKINAH 10/02/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Anis Setyati Rp. 20.000
mgr/dl
363.00
014900020222P001534 YATINI 10/02/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Anis Setyati Rp. 20.000
mgr/dl
121.00
014900020222P001535 TUMIYEM 10/02/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Anis Setyati Rp. 20.000
mgr/dl
422.00
014900020222P001536 MONAH 10/02/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Anis Setyati Rp. 20.000
mgr/dl
203.00
014900020222P001537 SUGIYANTI 10/02/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Anis Setyati Rp. 20.000
mgr/dl
155.00
014900020222P001538 KUSMIYATI 10/02/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Anis Setyati Rp. 20.000
mgr/dl
149.00
014900020222P001539 ROKANI 10/02/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Anis Setyati Rp. 20.000
mgr/dl
410.00
014900020222P001540 JUWARI 10/02/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Anis Setyati Rp. 20.000
mgr/dl
Tanggal terima FPK, Tanggal, 09/08/2022
Verifikator Pengaju Klaim