BPJS Kesehatan Cab.

SELONG
FORMULIR PENGAJUAN KLAIM TINGKAT PERTAMA

Nomor FPK : P2209000036701

Provider : SUELA

Bulan Pelayanan : September 2022

Pelayanan : RITP

Total Data : 114

Total Tagihan : Rp. 51.100.000

NO KUNJUNGAN NAMA PESERTA TGL MASUK TGL PULANG TINDAKAN TENAGA MEDIS BIAYA

230309030822P001373 SUKANAH (0002847616356) 29/08/2022 01/09/2022 Rawat Inap di R. Perawatan Biasa dr. ANDRI IRFAN Rp. 540.000

230309030822P001374 NINDI ZAHIRA (0003082074838) 30/08/2022 02/09/2022 Rawat Inap di R. Perawatan Biasa dr. ANDRI IRFAN Rp. 540.000

230309030822P001375 JANNAH (0002817439604) 30/08/2022 01/09/2022 Rawat Inap di R. Perawatan Biasa dr. ANDRI IRFAN Rp. 360.000

230309030922P000060 ERNAWATI (0000840018363) 01/09/2022 02/09/2022 Paket Persalinan per Vaginam normal (oleh Bidan) HAYATI HAPPY, A.Md.Keb Rp. 700.000

230309030922P000086 SASMIATI (0002847617515) 02/09/2022 04/09/2022 Rawat Inap di R. Perawatan Biasa dr. LULUK YUNIAR RIZKA Rp. 360.000

230309030922P000305 NURHASANAH (0002663549212) 02/09/2022 03/09/2022 Rawat Inap di R. Perawatan Biasa dr. LULUK YUNIAR RIZKA Rp. 180.000

230309030922P000306 M. RIDWAN AL (0001301441343) 01/09/2022 02/09/2022 Rawat Inap di R. Perawatan Biasa dr. Mushawwir Umar Rp. 180.000

230309030922P000307 SAMSUATI (0003115781291) 01/09/2022 02/09/2022 Rawat Inap di R. Perawatan Biasa dr. Mushawwir Umar Rp. 180.000

230309030922P000315 RAUDAH (0002957628003) 01/09/2022 02/09/2022 Rawat Inap di R. Perawatan Biasa dr. Mushawwir Umar Rp. 180.000

230309030922P000322 IRMAWATI (0000839130456) 06/09/2022 08/09/2022 Rawat Inap di R. Perawatan Biasa dr. Mushawwir Umar Rp. 360.000

230309030922P000333 MUNRAH (0002817436274) 02/09/2022 03/09/2022 Paket Persalinan per Vaginam normal (oleh Bidan) SAHRAINI, A.Md.Keb Rp. 700.000

230309030922P000334 BAIQ DIAN PUSPA RENI (0000840318377) 03/09/2022 04/09/2022 Paket Persalinan per Vaginam normal (oleh Bidan) SAHRAINI, A.Md.Keb Rp. 700.000

230309030922P000335 TITIK AZURA (0000839609965) 04/09/2022 05/09/2022 Paket Persalinan per Vaginam normal (oleh Bidan) SAHRAINI, A.Md.Keb Rp. 700.000

230309030922P000336 DEWI ANJANI (0002957042474) 07/09/2022 08/09/2022 Paket Persalinan per Vaginam normal (oleh Bidan) SAHRAINI, A.Md.Keb Rp. 700.000

230309030922P000344 M. KHAERUS SA'BANI (0002817408014) 05/09/2022 06/09/2022 Rawat Inap di R. Perawatan Biasa dr. Mushawwir Umar Rp. 180.000

230309030922P000350 SIRIP (0002636036706) 02/09/2022 03/09/2022 Rawat Inap di R. Perawatan Biasa dr. LULUK YUNIAR RIZKA Rp. 180.000

M. LANGGA PRADIFTA SURYA

230309030922P000408 05/09/2022 08/09/2022 Rawat Inap di R. Perawatan Biasa dr. Mushawwir Umar Rp. 540.000
(0002957627531)

230309030922P000409 BADRI (0000144930554) 05/09/2022 08/09/2022 Rawat Inap di R. Perawatan Biasa dr. Mushawwir Umar Rp. 540.000
 NO KUNJUNGAN NAMA PESERTA TGL MASUK TGL PULANG TINDAKAN TENAGA MEDIS BIAYA

230309030922P000410 INAQ SALIHIN (0000838845606) 05/09/2022 08/09/2022 Rawat Inap di R. Perawatan Biasa dr. Mushawwir Umar Rp. 540.000

230309030922P000411 maratun rohima (0002320078239) 05/09/2022 07/09/2022 Rawat Inap di R. Perawatan Biasa dr. Mushawwir Umar Rp. 360.000

230309030922P000416 H.M.MUNTAHA ALI (0002663549111) 05/09/2022 07/09/2022 Rawat Inap di R. Perawatan Biasa dr. Mushawwir Umar Rp. 360.000

230309030922P000429 RUMAKSI (0002847613847) 05/09/2022 07/09/2022 Rawat Inap di R. Perawatan Biasa dr. Mushawwir Umar Rp. 360.000

230309030922P000438 PE SANDI (0002817414347) 04/09/2022 05/09/2022 Rawat Inap di R. Perawatan Biasa dr. Mushawwir Umar Rp. 180.000

230309030922P000470 WENDI WATI (0002634200807) 09/09/2022 10/09/2022 Paket Persalinan per Vaginam normal (oleh Bidan) KARTINI, A.Md.Keb Rp. 700.000

230309030922P000487 DELISHA HUMAIRA (0002766115315) 07/09/2022 08/09/2022 Rawat Inap di R. Perawatan Biasa dr. Mushawwir Umar Rp. 180.000

230309030922P000489 M. AQSA AL - FATIH (0002938198656) 08/09/2022 09/09/2022 Rawat Inap di R. Perawatan Biasa dr. Mushawwir Umar Rp. 180.000

NADHIFA SYAFA AZZAHIDA

230309030922P000490 08/09/2022 09/09/2022 Rawat Inap di R. Perawatan Biasa dr. Mushawwir Umar Rp. 180.000
(0003093340577)

230309030922P000491 LINDA ARIANI (0000839458765) 08/09/2022 10/09/2022 Rawat Inap di R. Perawatan Biasa dr. Mushawwir Umar Rp. 360.000

HATIYATUL RIZQI MALIAH

230309030922P000492 08/09/2022 10/09/2022 Rawat Inap di R. Perawatan Biasa dr. Mushawwir Umar Rp. 360.000
(0001978775919)

230309030922P000493 ARFAN SHODIQ (0003087651317) 07/09/2022 08/09/2022 Rawat Inap di R. Perawatan Biasa dr. Mushawwir Umar Rp. 180.000

230309030922P000494 MURTINI (0000839881168) 08/09/2022 09/09/2022 Paket Persalinan per Vaginam normal (oleh Bidan) LILIQ EDIATI, A.Md.Keb Rp. 700.000

230309030922P000499 MARHAEN (0000840754956) 07/09/2022 09/09/2022 Rawat Inap di R. Perawatan Biasa dr. Mushawwir Umar Rp. 360.000

230309030922P000561 WARDIA NINSIH (0001057217005) 12/09/2022 14/09/2022 Rawat Inap di R. Perawatan Biasa dr. ANDRI IRFAN Rp. 360.000

230309030922P000562 SITI RABIATUN (0000840209128) 11/09/2022 14/09/2022 Rawat Inap di R. Perawatan Biasa dr. ANDRI IRFAN Rp. 540.000

230309030922P000571 AMAQ MASRI (0000839988202) 09/09/2022 11/09/2022 Rawat Inap di R. Perawatan Biasa dr. Mushawwir Umar Rp. 360.000

230309030922P000578 HAJAH PATMAWATI (0001316683146) 08/09/2022 11/09/2022 Rawat Inap di R. Perawatan Biasa dr. Mushawwir Umar Rp. 540.000

230309030922P000672 ZAINATIN NISSA (0000839666788) 03/09/2022 05/09/2022 Rawat Inap di R. Perawatan Biasa dr. Mushawwir Umar Rp. 360.000

230309030922P000684 BAIQ TINA ANNISYA (0001965903737) 07/09/2022 08/09/2022 Paket Persalinan per Vaginam normal (oleh Bidan) HAYATI HAPPY, A.Md.Keb Rp. 700.000

230309030922P000814 IPAH (0002596580458) 08/09/2022 10/09/2022 Rawat Inap di R. Perawatan Biasa dr. Mushawwir Umar Rp. 360.000

230309030922P000815 NOVIYTHA (0003072073026) 09/09/2022 10/09/2022 Rawat Inap di R. Perawatan Biasa dr. Mushawwir Umar Rp. 180.000

230309030922P000816 NURHIDAYAH (0002972152528) 07/09/2022 10/09/2022 Rawat Inap di R. Perawatan Biasa dr. Mushawwir Umar Rp. 540.000

230309030922P000845 SULIS (0000841546574) 21/09/2022 22/09/2022 Paket Persalinan per Vaginam normal (oleh Bidan) NIRWANA, A.Md.Keb Rp. 700.000

230309030922P000846 MIASARI (0002591254517) 07/09/2022 08/09/2022 Paket Persalinan per Vaginam normal (oleh Bidan) JULIANTI RIDWAN, A.Md.Keb Rp. 700.000

230309030922P000848 BAIQ ZOHRAH (0002816366725) 19/09/2022 20/09/2022 Paket Persalinan per Vaginam normal (oleh Bidan) SAHRAINI, A.Md.Keb Rp. 700.000

230309030922P000861 RIADHOTUL JINAN (0001978780083) 07/09/2022 09/09/2022 Rawat Inap di R. Perawatan Biasa dr. Mushawwir Umar Rp. 360.000
 NO KUNJUNGAN NAMA PESERTA TGL MASUK TGL PULANG TINDAKAN TENAGA MEDIS BIAYA

M. DAFID GILAL ANOUGRAH

230309030922P000864 15/09/2022 16/09/2022 Rawat Inap di R. Perawatan Biasa dr. ANDRI IRFAN Rp. 180.000
(0000834986698)

230309030922P000876 RIHIN (0000840009227) 15/09/2022 19/09/2022 Rawat Inap di R. Perawatan Biasa dr. ANDRI IRFAN Rp. 720.000

230309030922P000893 ZOYA KHAIFA ZAHRA (0002325832154) 15/09/2022 17/09/2022 Rawat Inap di R. Perawatan Biasa dr. ANDRI IRFAN Rp. 360.000

230309030922P000902 SRI (0000839478914) 14/09/2022 15/09/2022 Paket Persalinan per Vaginam normal (oleh Bidan) ROHIYATUN ZAKIAH, S.Tr.Keb Rp. 700.000

230309030922P000903 NULIATUL AENI (0002608327372) 18/09/2022 19/09/2022 Paket Persalinan per Vaginam normal (oleh Bidan) ROHIYATUN ZAKIAH, S.Tr.Keb Rp. 700.000

230309030922P000904 SAPTINI (0002253699246) 15/09/2022 16/09/2022 Paket Persalinan per Vaginam normal (oleh Bidan) ROHIYATUN ZAKIAH, S.Tr.Keb Rp. 700.000

230309030922P000905 RESIWATI (0002957042553) 20/09/2022 21/09/2022 Paket Persalinan per Vaginam normal (oleh Bidan) SAHRAINI, A.Md.Keb Rp. 700.000

230309030922P000906 REZA APRIANI (0003282516505) 19/09/2022 20/09/2022 Paket Persalinan per Vaginam normal (oleh Bidan) SUSI APRIANI, A.Md.Keb Rp. 700.000

230309030922P000909 m. irsyad awliyan (0003103957495) 14/09/2022 16/09/2022 Rawat Inap di R. Perawatan Biasa dr. ANDRI IRFAN Rp. 360.000

230309030922P000912 M ZAINURR ROSYDI (0000840024843) 11/09/2022 13/09/2022 Rawat Inap di R. Perawatan Biasa dr. Mushawwir Umar Rp. 360.000

230309030922P000913 RENA GIRANI (0000840207688) 14/09/2022 16/09/2022 Rawat Inap di R. Perawatan Biasa dr. ANDRI IRFAN Rp. 360.000

230309030922P000915 ELI ERMAWATI (0001501768181) 12/09/2022 14/09/2022 Rawat Inap di R. Perawatan Biasa dr. ANDRI IRFAN Rp. 360.000

230309030922P000917 JARWAN HERWANI (0000834099333) 12/09/2022 13/09/2022 Rawat Inap di R. Perawatan Biasa dr. Mushawwir Umar Rp. 180.000

230309030922P000919 KUHAENI (0002847624985) 21/09/2022 22/09/2022 Paket Persalinan per Vaginam normal (oleh Bidan) ROHIYATUN ZAKIAH, S.Tr.Keb Rp. 700.000

230309030922P000941 HULDIATUN (0000841076436) 21/09/2022 24/09/2022 Rawat Inap di R. Perawatan Biasa dr. Mushawwir Umar Rp. 540.000

230309030922P001010 NIA LESTARI (0000839740162) 23/09/2022 24/09/2022 Paket Persalinan per Vaginam normal (oleh Bidan) SAHRAINI, A.Md.Keb Rp. 700.000

230309030922P001012 HASRUL HARAHAP (0002817409241) 13/09/2022 15/09/2022 Rawat Inap di R. Perawatan Biasa dr. ANDRI IRFAN Rp. 360.000

230309030922P001013 MAHIRUN (0000840523331) 12/09/2022 14/09/2022 Rawat Inap di R. Perawatan Biasa dr. ANDRI IRFAN Rp. 360.000

230309030922P001014 AMRULLAH (0002847611182) 12/09/2022 14/09/2022 Rawat Inap di R. Perawatan Biasa dr. Mushawwir Umar Rp. 360.000

230309030922P001019 cinta amelia (0000839664472) 12/09/2022 14/09/2022 Rawat Inap di R. Perawatan Biasa dr. ANDRI IRFAN Rp. 360.000

230309030922P001024 ayra mysha naira (0003097907695) 12/09/2022 14/09/2022 Rawat Inap di R. Perawatan Biasa dr. ANDRI IRFAN Rp. 360.000

230309030922P001026 SABARUDIN (0002663228305) 10/09/2022 13/09/2022 Rawat Inap di R. Perawatan Biasa dr. ANDRI IRFAN Rp. 540.000

230309030922P001027 ALISA KURNIA (0002408155659) 11/09/2022 12/09/2022 Rawat Inap di R. Perawatan Biasa dr. ANDRI IRFAN Rp. 180.000

230309030922P001038 AMAQ FAESAL (0003144865983) 21/09/2022 22/09/2022 Rawat Inap di R. Perawatan Biasa dr. LULUK YUNIAR RIZKA Rp. 180.000

230309030922P001045 al-maira nurhidayah (0003259834479) 21/09/2022 22/09/2022 Rawat Inap di R. Perawatan Biasa dr. LULUK YUNIAR RIZKA Rp. 180.000

230309030922P001062 HAJI NURRAHMAN (0000839528392) 11/09/2022 12/09/2022 Rawat Inap di R. Perawatan Biasa dr. ANDRI IRFAN Rp. 180.000

230309030922P001070 HAPIPAH (0002113307245) 11/09/2022 13/09/2022 Rawat Inap di R. Perawatan Biasa dr. ANDRI IRFAN Rp. 360.000

230309030922P001078 salsiah (0002596237931) 15/09/2022 18/09/2022 Rawat Inap di R. Perawatan Biasa dr. ANDRI IRFAN Rp. 540.000
 NO KUNJUNGAN NAMA PESERTA TGL MASUK TGL PULANG TINDAKAN TENAGA MEDIS BIAYA

230309030922P001080 DINA LAILATIN HUSNA (0003173982748) 25/09/2022 27/09/2022 Rawat Inap di R. Perawatan Biasa dr. Mushawwir Umar Rp. 360.000

230309030922P001102 HOYA SAFITRI (0000840020297) 26/09/2022 27/09/2022 Paket Persalinan per Vaginam normal (oleh Bidan) ESI PAHITA, S.Tr.Keb Rp. 700.000

230309030922P001103 NURUL AINI (0000838121837) 13/09/2022 14/09/2022 Paket Persalinan per Vaginam normal (oleh Bidan) BQ. ANGGI ERMIWATI, A.Md.Keb Rp. 700.000

230309030922P001105 AKHIRUDIN (0000839919868) 25/09/2022 26/09/2022 Rawat Inap di R. Perawatan Biasa dr. Mushawwir Umar Rp. 180.000

230309030922P001126 AMAQ MAQRIPAT (0002847617504) 18/09/2022 20/09/2022 Rawat Inap di R. Perawatan Biasa dr. LULUK YUNIAR RIZKA Rp. 360.000

230309030922P001127 NAUSHAD ALFANDY (0003279240821) 18/09/2022 19/09/2022 Rawat Inap di R. Perawatan Biasa dr. ANDRI IRFAN Rp. 180.000

230309030922P001128 SUMAWILIH (0000840799664) 18/09/2022 20/09/2022 Rawat Inap di R. Perawatan Biasa dr. LULUK YUNIAR RIZKA Rp. 360.000

230309030922P001129 M. RADIT HIDAYATULLOH (0002817415618) 16/09/2022 18/09/2022 Rawat Inap di R. Perawatan Biasa dr. ANDRI IRFAN Rp. 360.000

230309030922P001130 LALU SUPARNI (0002739729802) 16/09/2022 20/09/2022 Rawat Inap di R. Perawatan Biasa dr. LULUK YUNIAR RIZKA Rp. 720.000

230309030922P001131 IKA INDRIA RINI (0000840135115) 17/09/2022 19/09/2022 Rawat Inap di R. Perawatan Biasa dr. LULUK YUNIAR RIZKA Rp. 360.000

230309030922P001132 HAERUL ANWAR (0000841805864) 17/09/2022 19/09/2022 Rawat Inap di R. Perawatan Biasa dr. ANDRI IRFAN Rp. 360.000

230309030922P001138 fajriah (0001788887711) 28/09/2022 29/09/2022 Paket Persalinan per Vaginam normal (oleh Bidan) NURUL HIDAYATI Rp. 700.000

230309030922P001140 BQ. ISNAINI RAHMAWATI (0002420630109) 28/09/2022 29/09/2022 Paket Persalinan per Vaginam normal (oleh Bidan) ROHIYATUN ZAKIAH, S.Tr.Keb Rp. 700.000

230309030922P001175 HUDIANI (0002214385953) 21/09/2022 22/09/2022 Paket Persalinan per Vaginam normal (oleh Bidan) HAYATI HAPPY, A.Md.Keb Rp. 700.000

230309030922P001181 SUSANTI (0002847613184) 28/09/2022 29/09/2022 Paket Persalinan per Vaginam normal (oleh Bidan) HAYATI HAPPY, A.Md.Keb Rp. 700.000

230309030922P001228 susi susanti (0002588003098) 04/09/2022 05/09/2022 Paket Persalinan per Vaginam normal (oleh Bidan) BQ. ANGGI ERMIWATI, A.Md.Keb Rp. 700.000

230309030922P001229 RINY APRIANI (0002595766162) 23/09/2022 24/09/2022 Paket Persalinan per Vaginam normal (oleh Bidan) BQ. ANGGI ERMIWATI, A.Md.Keb Rp. 700.000

230309030922P001230 NEPRIDAYANTI (0000840151631) 28/09/2022 29/09/2022 Paket Persalinan per Vaginam normal (oleh Bidan) SAHRAINI, A.Md.Keb Rp. 700.000

230309030922P001231 SISKA MAHDAYANTI (0000839781753) 23/09/2022 26/09/2022 Rawat Inap di R. Perawatan Biasa dr. Mushawwir Umar Rp. 540.000

230309030922P001256 QURRATUL AINI (0000840997449) 29/09/2022 30/09/2022 Paket Persalinan per Vaginam normal (oleh Bidan) FARIDA RISMAYANI, A.Md.Keb Rp. 700.000

230309030922P001257 SELINA NASABILA (0000839807144) 27/09/2022 30/09/2022 Rawat Inap di R. Perawatan Biasa dr. Mushawwir Umar Rp. 540.000

230309030922P001258 MUSTAPA (0001057215767) 28/09/2022 30/09/2022 Rawat Inap di R. Perawatan Biasa dr. Mushawwir Umar Rp. 360.000

230309030922P001259 INTAN FEBRIANTI (0000840698594) 28/09/2022 30/09/2022 Rawat Inap di R. Perawatan Biasa dr. Mushawwir Umar Rp. 360.000

230309030922P001260 MUHAMMAD NAZRI (0000144930249) 26/09/2022 28/09/2022 Rawat Inap di R. Perawatan Biasa dr. Mushawwir Umar Rp. 360.000

SOPIANA ASTUTI WIDIAWATI

230309030922P001261 26/09/2022 29/09/2022 Rawat Inap di R. Perawatan Biasa dr. Mushawwir Umar Rp. 540.000
(0000840291377)

230309030922P001262 JUMAWAN (0002052070852) 28/09/2022 30/09/2022 Rawat Inap di R. Perawatan Biasa dr. Mushawwir Umar Rp. 360.000

230309030922P001263 SAZA AKILA (0000840091307) 20/09/2022 22/09/2022 Rawat Inap di R. Perawatan Biasa dr. LULUK YUNIAR RIZKA Rp. 360.000
 NO KUNJUNGAN NAMA PESERTA TGL MASUK TGL PULANG TINDAKAN TENAGA MEDIS BIAYA

230309030922P001264 ITA YULIANA DEWI (0002847619179) 25/09/2022 27/09/2022 Rawat Inap di R. Perawatan Biasa dr. Mushawwir Umar Rp. 360.000

BAIQ FAIDA ANNAILA RAHMA

230309030922P001265 26/09/2022 30/09/2022 Rawat Inap di R. Perawatan Biasa dr. Mushawwir Umar Rp. 720.000
(0002114960591)

230309030922P001266 SASRIANA (0001057254186) 26/09/2022 28/09/2022 Rawat Inap di R. Perawatan Biasa dr. Mushawwir Umar Rp. 360.000

230309030922P001278 AMAQ HUS (0000840215215) 25/09/2022 27/09/2022 Rawat Inap di R. Perawatan Biasa dr. Mushawwir Umar Rp. 360.000

230309030922P001282 DETI RATNASARI (0000839614217) 26/09/2022 28/09/2022 Rawat Inap di R. Perawatan Biasa dr. Mushawwir Umar Rp. 360.000

230309030922P001292 muhamad saleh (0002071136114) 25/09/2022 28/09/2022 Rawat Inap di R. Perawatan Biasa dr. Mushawwir Umar Rp. 540.000

230309030922P001293 NAPIZATUS SAYIDAH (0002419342841) 25/09/2022 28/09/2022 Rawat Inap di R. Perawatan Biasa dr. Mushawwir Umar Rp. 540.000

MUHAMMAD ALFIN SAPUTRA

230309030922P001294 21/09/2022 23/09/2022 Rawat Inap di R. Perawatan Biasa dr. LULUK YUNIAR RIZKA Rp. 360.000
(0001548788679)

230309030922P001295 MARHAENI (0000839689299) 23/09/2022 25/09/2022 Rawat Inap di R. Perawatan Biasa dr. Mushawwir Umar Rp. 360.000

230309030922P001296 HAENIAH (0001978779609) 24/09/2022 25/09/2022 Rawat Inap di R. Perawatan Biasa dr. Mushawwir Umar Rp. 180.000

230309030922P001297 PE SANDI (0002817414347) 19/09/2022 23/09/2022 Rawat Inap di R. Perawatan Biasa dr. LULUK YUNIAR RIZKA Rp. 720.000

230309030922P001298 AMRUN (0003290685851) 22/09/2022 24/09/2022 Rawat Inap di R. Perawatan Biasa dr. ANDRI IRFAN Rp. 360.000

230309030922P001299 ZUROHMI ROSYDIANA (0000840454964) 22/09/2022 24/09/2022 Rawat Inap di R. Perawatan Biasa dr. ANDRI IRFAN Rp. 360.000

230309030922P001300 NITA AGUSTANIA (0001057255018) 22/09/2022 24/09/2022 Rawat Inap di R. Perawatan Biasa dr. ANDRI IRFAN Rp. 360.000

Tanggal terima FPK, Tanggal, 05/01/2023

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