BPJS Kesehatan Cab.

BOJONEGORO
FORMULIR PENGAJUAN KLAIM TINGKAT PERTAMA

Nomor FPK : P2208000023945

Provider : KLINIK KELUARGA ERA SEHAT

Bulan Pelayanan : August 2022

Pelayanan : Promotif

Total Data : 104

Total Tagihan : Rp. 1.040.000

NoKunjungan NAMA TANGGAL TINDAKAN HASIL TENAGA MEDIS BIAYA

124.00
1305U0160822P001041 SARTINI 02/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl

1305U0160822P001042 YANN SSIDHARTA 02/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 99.00 mgr/dl dr. Erwin Era Prasetya Rp. 10.000

109.00
1305U0160822P001044 ASWATI 02/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl
128.00
1305U0160822P001045 CATURIANI KRISNAWATI 02/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl
105.00
1305U0160822P001047 SUMIJI 02/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl

1305U0160822P001049 GUNAWAN ADRIANTO 02/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 94.00 mgr/dl dr. Erwin Era Prasetya Rp. 10.000

101.00
1305U0160822P001054 TATIT DIRGANTARA 02/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl
106.00
1305U0160822P001788 SAPUAN 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl

1305U0160822P001789 WANTINI 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 96.00 mgr/dl dr. Erwin Era Prasetya Rp. 10.000

100.00
1305U0160822P001791 DIDIK EKO PRAYITNO 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl

1305U0160822P001792 DEDY WINARKO 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 91.00 mgr/dl dr. Erwin Era Prasetya Rp. 10.000

1305U0160822P001794 MUNTIASIH 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 90.00 mgr/dl dr. Erwin Era Prasetya Rp. 10.000

121.00
1305U0160822P001795 MOCHAMAD SOKRAN 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl
117.00
1305U0160822P001796 SRI MULYONO 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl
 NoKunjungan NAMA TANGGAL TINDAKAN HASIL TENAGA MEDIS BIAYA

124.00
1305U0160822P002041 SHOFIYATUN 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl
110.00
1305U0160822P002042 SUDARSIH 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl

1305U0160822P002044 YUDHI PRASETYONO 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 96.00 mgr/dl dr. Erwin Era Prasetya Rp. 10.000

114.00
1305U0160822P002046 SUDARTIK 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl
129.00
1305U0160822P002050 SUHARTI 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl

1305U0160822P002052 SUTIKNO 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 88.00 mgr/dl dr. Erwin Era Prasetya Rp. 10.000

1305U0160822P002054 KHOMSATUN 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 99.00 mgr/dl dr. Erwin Era Prasetya Rp. 10.000

120.00
1305U0160822P002055 MUNDI HARTONO 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl
117.00
1305U0160822P002056 NUR PAKIH 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl

1305U0160822P002064 JANOE ISMANTO 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 81.00 mgr/dl dr. Erwin Era Prasetya Rp. 10.000

131.00
1305U0160822P002065 IMANULLAH FARHAN 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl
102.00
1305U0160822P002066 ENDRO CAHYONO 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl
102.00
1305U0160822P002067 KARTINI 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl
123.00
1305U0160822P002070 SITI NGAISAH 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl
111.00
1305U0160822P002072 HJ. KAMSRI, SM 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl
106.00
1305U0160822P002073 SITI SUHARTIK 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl
114.00
1305U0160822P002074 JAENURI 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl

1305U0160822P002075 SUTOMO 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 81.00 mgr/dl dr. Erwin Era Prasetya Rp. 10.000

114.00
1305U0160822P002079 DARNO 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl
100.00
1305U0160822P002081 ADJI PURWANTO 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl
117.00
1305U0160822P002085 LIESDIANA 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl

1305U0160822P002086 WIWIK PUDJI HARIYANI 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 92.00 mgr/dl dr. Erwin Era Prasetya Rp. 10.000

127.00
1305U0160822P002087 MUSTA'IN 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl
 NoKunjungan NAMA TANGGAL TINDAKAN HASIL TENAGA MEDIS BIAYA

154.00
1305U0160822P002088 DJOKO HERTOTOK 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl
106.00
1305U0160822P002090 EKA KARYAWATI 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl
125.00
1305U0160822P002091 SYUKRAN 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl

1305U0160822P002092 MINDARTIK 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 84.00 mgr/dl dr. Erwin Era Prasetya Rp. 10.000

101.00
1305U0160822P002093 ANIK SRIWIJAYANTI 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl
145.00
1305U0160822P002094 SISYONIAS 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl
126.00
1305U0160822P002095 SULAWISNO 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl
107.00
1305U0160822P002096 ALI FAUZI 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl
131.00
1305U0160822P002099 HENDRY WALUYO WATI 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl
103.00
1305U0160822P002100 NYARI 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl
116.00
1305U0160822P002101 YONI HESTI WARDANI 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl
111.00
1305U0160822P002103 ENDANG PUJI ASTUTI 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl
118.00
1305U0160822P002108 KUSMIATI 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl

1305U0160822P002109 SUPRIHADI 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 91.00 mgr/dl dr. Erwin Era Prasetya Rp. 10.000

1305U0160822P002110 PARMAN 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 80.00 mgr/dl dr. Erwin Era Prasetya Rp. 10.000

101.00
1305U0160822P002111 WILUJENG PRIHATINI 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl
102.00
1305U0160822P002112 NANI SUMINAH 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl
107.00
1305U0160822P002114 KHOLISOH 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl
130.00
1305U0160822P002115 TOTOK PUDJI WALUYO 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl
100.00
1305U0160822P002116 DIAN EKSI SUKMAWARNI 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl
125.00
1305U0160822P002117 SUPIJATUN 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl
111.00
1305U0160822P002119 SARBINI 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl
 NoKunjungan NAMA TANGGAL TINDAKAN HASIL TENAGA MEDIS BIAYA

182.00
1305U0160822P002120 LASRUN 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl

1305U0160822P002122 ASMUNARNI 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 89.00 mgr/dl dr. Erwin Era Prasetya Rp. 10.000

112.00
1305U0160822P002123 SUNARYADI 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl

1305U0160822P002126 RUMIYATI 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 94.00 mgr/dl dr. Erwin Era Prasetya Rp. 10.000

104.00
1305U0160822P002127 SOPJAN EFFENDI 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl
100.00
1305U0160822P002129 SUHARIYANTO 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl
114.00
1305U0160822P002130 ABDUL ROZI 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl
102.00
1305U0160822P002132 LILIK SULISTYOWATI 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl

1305U0160822P002134 SETIYANTO, S.Pd 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 96.00 mgr/dl dr. Erwin Era Prasetya Rp. 10.000

115.00
1305U0160822P002135 ARI YUNIYANTO 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl
111.00
1305U0160822P002136 BISMO SETYO ADJI 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl
101.00
1305U0160822P002138 B SITI AISYAH EWR 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl
110.00
1305U0160822P002140 SITI CHUSNAH 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl
120.00
1305U0160822P002145 SRI MURWATI ENDANG MASTUTI 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl
167.00
1305U0160822P002148 SETYANTO 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl
127.00
1305U0160822P002149 KUSMIHARTO 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl
109.00
1305U0160822P002150 TAMUNTIK 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl
115.00
1305U0160822P002151 AKIM 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl
192.00
1305U0160822P002153 RUSTIJATININGSIH 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl
109.00
1305U0160822P002154 SRI SURYATI 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl

1305U0160822P002155 MISTO 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 85.00 mgr/dl dr. Erwin Era Prasetya Rp. 10.000

100.00
1305U0160822P002158 IRNAWATI 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl
 NoKunjungan NAMA TANGGAL TINDAKAN HASIL TENAGA MEDIS BIAYA

1305U0160822P002160 SUPRAPTI 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 88.00 mgr/dl dr. Erwin Era Prasetya Rp. 10.000

1305U0160822P002162 SUMITO 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 80.00 mgr/dl dr. Erwin Era Prasetya Rp. 10.000

102.00
1305U0160822P002163 HERUTRIYATMIKA 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl
175.00
1305U0160822P002164 SRI HARTINI 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl
123.00
1305U0160822P002165 WIWIK ANDARIJATI 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl
128.00
1305U0160822P002166 WAKIAH 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl
107.00
1305U0160822P002170 SITI MUSTAKILAH 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl

1305U0160822P002171 ISCA NOERMAWATI 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 91.00 mgr/dl dr. Erwin Era Prasetya Rp. 10.000

105.00
1305U0160822P002172 SRI RENANING TYAS 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl
175.00
1305U0160822P002176 SRI HANDAYANI 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl

1305U0160822P002178 SITI KUMARYATI 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 95.00 mgr/dl dr. Erwin Era Prasetya Rp. 10.000

146.00
1305U0160822P002179 ALIPA 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl
119.00
1305U0160822P002180 NURUL FARIDA 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl
100.00
1305U0160822P002182 DJASMADI 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl
101.00
1305U0160822P002183 SOETIKNO 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl
105.00
1305U0160822P002184 MOH. HUDAN 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl
121.00
1305U0160822P002185 KASTURIP 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl
102.00
1305U0160822P002186 DJUARI 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl
114.00
1305U0160822P002187 KAMARI 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl
119.00
1305U0160822P002188 LASMANTO 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl

1305U0160822P002189 RINI MUSTIKOWATI 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 92.00 mgr/dl dr. Erwin Era Prasetya Rp. 10.000

1305U0160822P002191 SAMAD 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis 82.00 mgr/dl dr. Erwin Era Prasetya Rp. 10.000

103.00
1305U0160822P002194 DEDE NURAIDA 01/08/2022 Gula Darah Puasa (GDP) - PRB/Prolanis dr. Erwin Era Prasetya Rp. 10.000
mgr/dl
Tanggal terima FPK, Tanggal, 09/09/2022
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