Untitled

JAMINAN SOSIAL KESEHATAN SEMESTA SUMSEL
KOTA PALEMBANG REKAPITULASI KUNJUNGAN PASIEN JAMSOSKES SEMSESTA

RAWAT JALAN TINGKAT PERTAMA / RJTP
NAMA PPK : PUSKESMAS PUNTI KAYU
BULAN : 26 MEI 2017
BIAYA (Rp) SESUAI PERDA

NO TUJUAN NO KK / KTP NO RM NAMA PASIEN UMUR L/P DIAGNOSIS TINDAKAN MEDIS Ket
Retribusi Tindakan Jumlah
1 BP L 1671167524630003 IRWANSYAH 35 TH L GASTRITIS Rp 4,000 Rp 4,000
2 BP L 1671035423030004 79/14 SYAIFUDIN 20TH L DERMATITIS Rp 4,000 Rp 4,000
3 GIGI L 1671074606050006 33/13 ANISA 12 TH P V PERSISTENSI Cbt 1gg susu kiri atas Rp 4,000 Rp 5,000 Rp 9,000
4 MTBS L 1671150206160006 469/16 M AZAM 11 BLN L ISPA Rp 4,000 Rp 4,000
5 GIGI L 1671165453230002 156/16 NAILA 23 TH P ABSES Rp 4,000 Rp 4,000
6 GIGI L 1671076108060003 68/16 RIA 43 TH P V GP Kiri atas cbt 1gg grham ke1 Rp 4,000 Rp 10,000 Rp 14,000
7 BP L 167107100660002 472/15 SUHARTO 51 TH L IMPERTIGO Rp 4,000 Rp 4,000
8 BP L 1671072309660006 33/13 M KADENGAN 52 TH L HYPERTENSI Rp 4,000 Rp 4,000
9 BP L 1671165734220002 YANI 24 TH P GASTRITIS Rp 4,000 Rp 4,000
10 BP L 1671082933220002 LINDA SUSILAWATI 25 TH L DERMATITIS Rp 4,000 Rp 4,000
11 MTBS L 1671150512700001 60/15 M RAFAH 7 TH L CHEPALGIA Rp 4,000 Rp 4,000
12 BP L 1671075010690019 83/16 SRI YUSNANI 47 TH P IMPERTIGO Rp 4,000 Rp 4,000
13 MTBS L 1671151410160003 66/13 A SAUQI 7 BLN L ALERGI Rp 4,000 Rp 4,000
14 BP L 1671076012630008 40/13 MARYAM 50 TH P CONJUNGTIVITIS Rp 4,000 Rp 4,000
15 BP L 1671024252330000 SUCI NIA 2 TH P FEBRIS Rp 4,000 Rp 4,000
16 BP L 1671074011050007 659/17 FITRI 12 TH P CHEPALGIA Rp 4,000 Rp 4,000
17 BP L 1671151005110005 659/17 AHMAD AFI 6 TH L FEBRIS Rp 4,000 Rp 4,000
18
19
20
21
22
23
24
Rp 68,000 Rp 15,000 Rp 83,000
Mengetahui,
Tim Verifikasi Jamsoskes
Dinas Kesehatan Kota Palembang Plt. Kepala Puskesmas Punti Kayu Palembang
Bendahara Penerimaan pembantu s
Makmur Salpator P , SKM , MKM Hermilina, AM. Keb.

NIP NIP : 197710182003121004 NIP : 197211161992022001
JAMINAN SOSIAL KESEHATAN SEMESTA SUMSEL
KOTA PALEMBANG REKAPITULASI KUNJUNGAN PASIEN JAMSOSKES SEMSESTA
RAWAT JALAN TINGKAT PERTAMA / RJTP
BULAN : 27 DESEMBER 2016
NO TUJUAN NO KK / KTP NO RM NAMA PASIEN UMUR L/P DIAGNOSIS TINDAKAN MEDIS BIAYA (Rp) SESUAI PERDA Ket
1 MTBS L 1671151609120004 42/15 ALDO SAPUTRA 4,5 TH L CHEPALGIA Retribusi Tindakan Jumlah
2 MTBS L 1671152907110003 92/15 M.ALGHAZALI 2 TH L FEBRIS Rp 4,000 Rp 4,000
3 MTBS L 1671151002140001 121/13 AISY HAFIY 3.3 TH L FEBRIS Rp 4,000 Rp 4,000
4 BP L 1671070511780005 077/15 SITI DHAROTIN 32 TH P IMPERTIGO Rp 4,000 Rp 4,000
5 KB L 1671152012120003 SHOPIYAH 27 TH P KB PIL Rp 4,000 Rp 4,000
6 MTBS L 1671156707880001 079/13 M. IMAM ANUGRAH 1 TH L ALERGI Rp 4,000 Rp 4,000
7 BP L 1671042106890007 DEKI CITRIADI 28 TH L DERMATITIS Rp 4,000 Rp 4,000
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
JUMLAH Rp 28.000 Rp 28.000
Mengetahui,
Tim Verifikasi Jamsoskes Plt. Kepala Puskesmas Punti Kayu Palembang
Dinas Kesehatan Kota Palembang Bendahara Penerimaan Pembantu

NIP NIP : 197710182003121004 NIP : 197211161992022001
JAMINAN SOSIAL KESEHATAN SEMESTA SUMSEL REKAPITULASI KUNJUNGAN PASIEN JAMSOSKES SEMSESTA
KOTA PALEMBANG RAWAT JALAN TINGKAT PERTAMA / RJTP
KLAIM BULAN
ULAN : 29 MEI 2017
NO BIAYA (Rp) SESUAI PERDA

TUJUAN NO KK / KTP NO RM NAMA PASIEN UMUR L/P DIAGNOSIS TINDAKAN MEDIS Ket
1 BP L 1671152907110003 071/14 MARDALENA 65 TH P HYPERTENSI Rp 4,000 Rp 4,000
2 BP L 1671072905870004 ANGGA KUSUMAH 30 TH L DERMATITIS Rp 4,000 Rp 4,000
3 GIGI L 1671150103140001 051/15 QENAN THUWA 3,3 TH L ABSES Rp 4,000 Rp 4,000
4 BP L 1671072811820007 063/15 DEDI GUNAWAN 35 TH L GASTRITIS Rp 4,000 Rp 4,000
5 TB L 167115610394000 010/13 MELI YULIANTI 23 TH P GASTRITIS Rp 4,000 Rp 4,000
6 MTBS L 1671151010140003 316/15 M. RAKA PRATAMA 2,7 TH L FEBRIS Rp 4,000 Rp 4,000
7 MTBS L 1671156209120005 002/13 SAFIRA WULANDARI 4 TH P COMMONDCOLD Rp 4,000 Rp 4,000
8 BP L 1671044612750010 355/15 ELI ERNA 40 TH P ALERGI Rp 4,000 Rp 4,000
9 BP L 1671074011050007 659/17 FITRI 12 TH P CHEPALGIA Rp 4,000 Rp 4,000
10 BP L 1671151005110005 659/17 AHMAD AFI 6 TH L CHEPALGIA Rp 4,000 Rp 4,000
11 MTBS L 1671154610130002 659/17 KHAIRANI 3 TH P FEBRIS Rp 4,000 Rp 4,000
12 KIA L 1606065910980001 147/15 ASTUTI 22 TH L P HMIL ONC Rp 4,000 Rp 4,000
13 MTBS L 1671152308120002 014/13 SYARIF 5 TH L FEBRIS Rp 4,000 Rp 4,000
14 BP L 1671150705110003 LEO 6 TH L CHEPALGIA Rp 4,000 Rp 4,000
15 MTBS L 1671150609130004 TESAR 4 TH L COMMONDCOLD Rp 4,000 Rp 4,000
16 BP L 1671070312910007 158/17 INDRAJAYA 25 TH L IMPERTIGO Rp 4,000 Rp 4,000
17 BP L 1671152707710001 019/13 DADI 45 TH L IMPERTIGO Rp 4,000 Rp 4,000
18 BP L 1671152106110002 019/13 ANUGRAH 6 TH L FEBRIS Rp 4,000 Rp 4,000
19 MTBS L 1671150804150003 322/15 M. AZRIL 2 TH L FEBRIS Rp 4,000 Rp 4,000
20 BP L 1671070506630019 533/17 MULYADI 54 TH L HYPERTENSI Rp 4,000 Rp 4,000
21 BP L 1671075111940013 004/13 SARTIKA 23 TH P MYALGIA Rp 4,000 Rp 4,000
22
23
24
JUMLAH Rp 84,000 Rp 84,000
Mengetahui,

NIP NIP : 197710182003121004 NIP : 197211161992022001
KLAIM BULAN : 30 MEI 2017
1 KIA KB L 1671155204880004 508/13 ULPA 28 TH P KB PIL Rp 4,000 Rp 4,000
2 BP L 1671150101830005 019/13 JANUARDI 34 TH L DERMATITIS Rp 4,000 Rp 4,000
3 GIGI L 1671072505730006 AZWARI 38 TH L GR 6 Kann bawa KONSUL Rp 4,000 Rp 4,000
4 GIGI L 1671076012670006 004/13 ESY YUNARSIH 49 TH P GP 6 Kann bawa cbt 1 gg grham ke 1 Rp 4,000 Rp 10,000 Rp 14,000
5 MTBS L 1671151702150005 047/15 M. ADITYA 2 TH L ISPA Rp 4,000 Rp 4,000
6 KIA L 1671074301840015 614/17 MIRA LUSDIAH 33 TH P P HMIL ONC Rp 4,000 Rp 4,000
7 BP L 1671074301840015 005/13 ANGGUN 8 TH P COMMONCOLD Rp 4,000 Rp 4,000
8 BP L 1671071512550006 039/14 AMRINA ROSADA 27 TH P GASTRITIS Rp 4,000 Rp 4,000
9 BP L 1671155410900001 039/14 CALRISA CLARA 7 TH P FEBRIS Rp 4,000 Rp 4,000
10 MTBS L 1671151702170001 039/14 ERLANGGA FEBRIAN 3 BLN L ISPA Rp 4,000 Rp 4,000
11 BP L 1671152106110002 236/17 ROBBY ANGGARA 24 TH L DERMATITIS Rp 4,000 Rp 4,000
12 BP L 1671075009630008 443/16 SITI PATIMAH 53TH P REUMATIK Rp 4,000 Rp 4,000
13 BP L 1671075910830008 241/14 TRI LIANI OKTARI 33 TH P IMPERTIGO Rp 4,000 Rp 4,000
14 BP L 1671154504120001 241/14 ZAHRATUSSYIFA SYAKIRA 5 TH P CHEPALGIA Rp 4,000 Rp 4,000
15 BP L 1671155505120005 267/15 MEILIN SHAQIRAH 5 TH P FEBRIS Rp 4,000 Rp 4,000
16 BP L 1671075507550005 080/16 RUSNAINI 52 TH P GP 3 Kann bawa Cbt 1 gg depan Rp 4,000 Rp 7,500 Rp 11,500
17 BP L 1671153006080005 416/16 JOLYAN ANDIKIA 9 TH L COMMONCOLD Rp 4,000 Rp 4,000
18
19
20
21
22
23
24
JUMLAH Rp 68,000 Rp 17,500 Rp 85.500
Mengetahui,

NIP NIP : 197710182003121004 NIP : 197211161992022001
KLAIM BULAN
ULAN : 31 MEI 2017
1 BP L 1671070212520002 249/14 MARSIKIN 65 TH L POST OF Katarak RS Mata masyarakat Rp 4,000 Rp 4,000
2 BP L 1671076307960006 08/13 ERVINA YULITA 20 TH P FEBRIS Rp 4,000 Rp 4,000
3 BP L 1671045905590004 136/15 PERMAISURI 59 TH P HYPERTENSI Rp 4,000 Rp 4,000
4 KIA L 167115680980001 006/13 CHUSNI 28 TH P KB SNTIK Rp 4,000 Rp 4,000
5 MTBS L 1671156707120004 006/13 MISYAH 2 TH P ISPA Rp 4,000 Rp 4,000
6 BP L 1671076210920011 072/15 KHAIRUL 49 TH L DM KONTROL Rp 4,000 Rp 4,000
7 GIGI L 1671077009980014 068/16 RIA 43 TH P Gangreng radix kontrol ulang Rp 4,000 Rp 4,000
8 BP L 1671065609130004 KOMARIA 37 TH P DERMATITIS Rp 4,000 Rp 4,000
9 BP L 1671071001500003 160/13 IMRONI MUSA 42 TH L REUMATIK Rp 4,000 Rp 4,000
10 BP L 1671070219110002 163/14 FAHRUL ROZI 35 TH L IMPERTIGO Rp 4,000 Rp 4,000
11 BP L 1671146802940006 507/17 SUMARNI 24 TH P MYALGIA Rp 4,000 Rp 4,000
12
13
14
15
16
17
18
19
20
21
22
23
24
JUMLAH Rp 44,000 Rp 44,000
Mengetahui,

NIP NIP : 197710182003121004 NIP : 197211161992022001
KLAIM BULAN : 02 JUNI 2017
TUJUAN NO KK / KTP NO RM NAMA PASIEN UMUR L/P DIAGNOSIS TINDAKAN MEDIS

BIAYA (Rp) SESUAI PERDA Ket
NO Retribusi Tindakan Jumlah
1 MTBS L 1671151905160002 268/16 LUTFI AQEEL TSANI 1 TH L ISPA Rp 4,000 Rp 4,000
2 GIGI L 1671155606890003 187/16 AISYAH AMIN 19 TH P ABSES Rp 4,000 Rp 4,000
3 MTBS L 1671072709060002 030/14 SYAUQI 2 TH L FEBRIS Rp 4,000 Rp 4,000
4 BP L 1671071006840025 030/14 NOPI ARSY 21 TH P GASTRITIS Rp 4,000 Rp 4,000
5 BP L 1671156000930005 139/13 ROMEO APRIYANDA 20 TH L IMPERTIGO Rp 4,000 Rp 4,000
6 BP L 16710-72507060005 555/16 REGATRI SAPUTRA 11 TH P CHEPALGIA Rp 4,000 Rp 4,000
7 BP L 1671071906890009 006/15 JONI ISKANDAR 27 TH L GASTRITIS Rp 4,000 Rp 4,000
8 BP L 1671071702080005 153/16 SATRIA DWI C 9 TH L DERMATITIS Rp 4,000 Rp 4,000
9 KIA L 1671076512960008 086/17 DEASY PERMATASARI 20 TH P DERMATITIS Rp 4,000 Rp 4,000
10 BP L 1671154606660002 283/14 JAMILA 51 TH P HYPERTENSI Rp 4,000 Rp 4,000
11 BP L 1671155307150001 057/16 M. DWI SAPUTRA 10 TH L COMMONDCOLD Rp 4,000 Rp 4,000
12 MTBS L 1671074912000006 006/13 MEYSA 2 TH P FEBRIS Rp 4,000 Rp 4,000
13 BP L 1671154904940001 025/13 LITA 33 TH P IMPERTIGO Rp 4,000 Rp 4,000
14 BP L 1671154309990003 293/15 DIVA 5,5 TH P CHEPALGIA Rp 4,000 Rp 4,000
15
16
17
18
19
20
21
22
23
24
JUMLAH Rp 56,000 Rp 56,000
Mengetahui,

NIP NIP : 197710182003121004 NIP : 197211161992022001
KLAIM BULAN
ULAN : 03 JUNI 2017
TUJUAN NO KK / KTP NO RM NAMA PASIEN UMUR L/P DIAGNOSIS TINDAKAN MEDIS

1 MTBS L 1671155902150007 012/13 CICI FEBRI YANI 2,3 TH P FEBRIS Rp 4,000 Rp 4,000
2 BP L 1671076106720005 ROSMALA DEWI 45 TH P HYPERTENSI Rp 4,000 Rp 4,000
3 GIGI L 1671075005010012 006/13 DWI RAHMAWATI 16 TH P GASTRITIS Rp 4,000 Rp 4,000
4 BP L 16710704077400012 054/13 MUSLIMIN 42 TH L IMPERTIGO Rp 4,000 Rp 4,000
5 BP L 1671075212600031 053/15 NURHASANAH 53 TH P HYPERTENSI Rp 4,000 Rp 4,000
6 BP L 1671070709980006 316/15 ARI KUSUMA 18 TH L GASTRITIS Rp 4,000 Rp 4,000
7 BP L 1671155666890003 639/17 AYU WANDIRA 21 TH P MYALGIA Rp 4,000 Rp 4,000
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
JUMLAH Rp 28,000 Rp 28,000
Mengetahui,

NIP NIP : 197710182003121004 NIP : 197211161992022001
TUJUAN NO KK / KTP NO RM NAMA PASIEN UMUR L/P DIAGNOSIS TINDAKAN MEDIS BIAYA (Rp) SESUAI PERDA 2 Ket
1 MTBS L 1671155506130001 94/14 AKIRA LARASATI 4 TH P FEBRIS Rp 4,000 Rp 4,000
2 MTBS L 1671150310160002 03/13 DAFFA FAIZ 8 BLN L ISPA Rp 4,000 Rp 4,000
3 GIGI L 1671075005010012 64/15 M.NAYARUDIN 7,5 TH L I PERSISTENSI Cbt gg susu kiri atas Rp 4,000 Rp 5,000 Rp 9,000
4 BP L 1671155904090003 369/14 AZAHRA AURORA 8 TH P CHEPALGIA Rp 4,000 Rp 4,000
5 BP L 1671156512660001 456/16 ZAINAB 51 TH P HYPERTENSI Rp 4,000 Rp 4,000
6 KIA L 1671074111900007 587/13 SINARIA 27 TH P KB PIL Rp 4,000 Rp 4,000
7 GIGI L 167115060410005 587/13 LUCY 7 TH L I I PERSISTENSI Cbt gg susu kann atas Rp 4,000 Rp 5,000 Rp 9,000
8 MTBS L 1671155409120003 227/14 TRI SUHARTI 4,7 TH P FEBRIS Rp 4,000 Rp 4,000
9 GIGI L 1671074301640015 614/17 MIRA LUSDIAH 33 TH P ABSES Rp 4,000 Rp 4,000
10 GIGI L 160602301210000 614/17 ANISA 15 TH P ABSES Rp 4,000 Rp 4,000
11 KB PIL L 167109450170005 35/14 MENIYATI 35 TH P KB PIL Rp 4,000 Rp 4,000
12 BP L 167107471720011 08/15 SYAMSIDA 45 TH P MYALGIA Rp 4,000 Rp 4,000
13 BP L 167115520110006 08/15 ANGGRAINI 7 TH P CHEPALGIA Rp 4,000 Rp 4,000
14 BP L 1671055302080002 ALIF 15 TH L DERMATITIS Rp 4,000 Rp 4,000
15 KB PIL L 1671154210670001 214/14 OENGKT.W 29 TH P KB PIL Rp 4,000 Rp 4,000
16 BP L 1671154210670001 25/13 ALI HASAN 38 TH L DERMATITIS Rp 4,000 Rp 4,000
17 BP L 1671070808580020 428/16 EVI 29 TH P GASTRITIS Rp 4,000 Rp 4,000
18 BP L 1671072906820008 428/16 OKAN 6 TH L COMMONDCOLD Rp 4,000 Rp 4,000
19 MTBS L 1671085601830004 428/16 ERIK 6 BLN L ALERGI Rp 4,000 Rp 4,000
20 BP L 1671075009630008 443/16 SITI PATIMAH 54 TH P REUMATIK Rp 4,000 Rp 4,000
21 MTBS L 1671151406130001 05/14 ROBANI 1 TH L ALERGI Rp 4,000 Rp 4,000
22 BP L 1671154111040001 405/15 WULANDARI 13 TH P FEBRIS Rp 4,000 Rp 4,000
23 MTBS L 1671155411110002 405/15 NINO 1,8 TH L ISPA Rp 4,000 Rp 4,000
24 BP L 1671152105540002 128/16 ASMANI 63 TH L HYPERTENSI KONTROL ULANG Rp 4,000 Rp 4,000
JUMLAH Rp 96,000 Rp 10,000 Rp 106,000
Mengetahui,

NIP NIP : 197710182003121004 NIP : 197211161992022001
KLAIM BULAN
ULAN : 06 JUNI 2017

1 GIGI L 1671076611940005 270 AMAR ZACKY 6 TH L I PERSISTNSI Cbt 1 gg susu kiri bawa Rp 4,000 Rp 5,000 Rp 9,000
2 BP L 1671154604930001 006/13 APRISA NURHAYATI 24 TH P GASTRITIS Rp 4,000 Rp 4,000
3 GIGI L 1671070312910007 064/15 PURJIYEM 42 TH P ABSES KONTROL ULANG Rp 4,000 Rp 4,000
4 BP L 1671074107670088 056/13 MARONA 50 TH P CONJUNGTIVITIS Rp 4,000 Rp 4,000
5 BP L 1671156501020002 056/13 FITRIANTI 12 TH P CHEPALGIA Rp 4,000 Rp 4,000
6 BP L 1671156110840001 120/13 SITI LESTARI 33 TH P DERMATITIS Rp 4,000 Rp 4,000
7 KIA/KB L 1671076305760010 077/14 ENDANG 41 TH P KB PIL Rp 4,000 Rp 4,000
8 BP L 1671074705060001 079/13 NYIMAS 12 TH P FEBRIS Rp 4,000 Rp 4,000
9 BP L 1671157112710007 009/13 NGADIATUN 46 TH P IMPERTIGO Rp 4,000 Rp 4,000
10 BP L 1671155006520001 063/14 NUNAYA 66 TH P HYPERTNSI Rp 4,000 Rp 4,000
11
12
13
14
15
16
17
18
19
20
21
22
23
24
JUMLAH Rp 40,000 Rp 5,000 Rp 45,000
Mengetahui,

NIP NIP : 197710182003121004 NIP : 197211161992022001
TUJUAN NO KK / KTP NO RM NAMA PASIEN UMUR L/P DIAGNOSIS TINDAKAN MEDIS BIAYA (Rp) SESUAI PERDA Ket
1 BP 1671041102880001 77/16 ROKIMAH 65 TH P GASTRITIS Rp 4,000 Rp 4,000
2 MTBS 1671042410120007 021/15 ALI 8 BLN L ALERGI Rp 4,000 Rp 4,000
3 BP 1671046105890004 151/16 RESTY MEILISA 27 TH P GASTRITIS Rp 4,000 Rp 4,000
4 BP 1671075011850017 002/03 NOVIYANTI 32 TH P MYALGIA Rp 4,000 Rp 4,000
5 MTBS 1671156209120005 002/03 SAFIRA WULANDARI 4 TH P FEBRIS Rp 4,000 Rp 4,000
6 GIGI 1606064105590001 648/13 POHORIYAH 58 TH P HYPERTENSI KONTROL ULANG Rp 4,000 Rp 4,000
7 BP 1671072906820008 437/16 FAIZAH 11 TH P CHEPALGIA Rp 4,000 Rp 4,000
8 BP 1671044612750010 335/15 ELI ERNA 40 TH L CONNJUNGTIVITIS Rp 4,000 Rp 4,000
9 BP 1671150704890002 075/15 TENDI MUPRILMAT 28 TH L DERMATITIS Rp 4,000 Rp 4,000
10 GIGI 1671152505110002 168/17 FAREL AKBAR ALFARIZI 6 TH L VII PULPITIS Cbt 1 gg dpan knn atas Rp 4,000 Rp 7,500 Rp 11,500
11 BP 1671150910090003 039/14 ALVIN YUDHA.P 7,5 TH L CHEPALGIA Rp 4,000 Rp 4,000
12 BP 1671157811100001 039/14 CLARISA CLARA ALONA 6,5 TH P COMMONDCOLD Rp 4,000 Rp 4,000
13 KIA PH 1610056010880006 290/15 BARIA ASTUTI 30 TH P P HMIL Rp 4,000 Rp 4,000
14 GIGI 1671155603110001 290/15 WINNY.FLONITA 6 TH P ABSES Rp 4,000 Rp 4,000
15 BP 1671074209580003 455/16 MISMI 62 TH P HHD RS Muhammadiyah Rp 4,000 Rp 4,000
16 KIA 1671072601070039 225/17 WIDIA ERIKA 30 TH P KB PIL Rp 4,000 Rp 4,000
17 BP 1671152808860001 47/13 ZAURA 62 TH L Post of katarak RS Mata masyarakat Rp 4,000 Rp 4,000
18 BP 1671152808860001 247/13 HEPRIDIKA 30 TH P SCIZOFRENIA RS ERBA Rp 4,000 Rp 4,000
19 BP 1671092711830009 52/13 RIVANDRI 5 TH P FEBRIS Rp 4,000 Rp 4,000
20 BP 1671152204110002 007/13 OBET CHANIAGO 6 TH L FEBRIS Rp 4,000 Rp 4,000
21 BP 1671077005920002 661/17 NORA MERITASARI 25 TH P DERMATITIS Rp 4,000 Rp 4,000
22 BP 1607010051284005 76/13 SUSTRISNO 33 TH L GASTRITIS Rp 4,000 Rp 4,000
23 MTBS 1671156305160002 32/13 FATIMAH AZZAHRA 10 BLN P ALERGI Rp 4,000 Rp 4,000
24
JUMLAH Rp 92,000 Rp 7,500 Rp 99,500
Mengetahui,

NIP NIP : 197710182003121004 NIP : 197211161992022001
KLAIM M BULAN 08 JUNI 2017

1 MTBS L 1671065609130004 507/17 SITI SARMILA 3,6 TH P FEBRIS Rp 4,000 Rp 4,000
2 Imunisasi L 1606065910980001 108/16 ATTAR 1 BLN L IMUNISASI Rp 4,000 Rp 4,000
3 Imunisasi L 1671150210080004 050/15 AHMAD RAFA 2,10 BLN L IMUNISASI Rp 4,000 Rp 4,000
4 Imunisasi L 1671151411970001 002/13 ABIZAR 7 BLN L IMUNISASI Rp 4,000 Rp 4,000
5 BP L 1671151402940002 418/16 ARIANSYA 23 TH L GASTRITIS Rp 4,000 Rp 4,000
6 Imunisasi L 1671152710150002 CAKRAWALA 1,6 TH L IMUNISASI Rp 4,000 Rp 4,000
7 Imunisasi L 1671156210090001 296/17 AL MAHIRA 9 BLN P IMUNISASI Rp 4,000 Rp 4,000
8 Imunisasi L 1671070702910011 296/17 BAHIJ 2 TH L IMUNISASI Rp 4,000 Rp 4,000
9 BP L 1671072101080012 054/15 MIRANDA 13 TH P DERMATITIS Rp 4,000 Rp 4,000
10 Imunisasi L 1671151007120001 015/16 HANIPA 26 TH P IMUNISASI Rp 4,000 Rp 4,000
11 KB Suntik L 1671151007120001 015/16 NOPRIYANI 28 TH L KB SUNTIK Rp 4,000 Rp 4,000
12 MTBS L 1671072306000005 129/16 ASIFA 1 TH P FEBRIS Rp 4,000 Rp 4,000
13 Imunisasi L 167107546560003 480/16 SALSA 9 BLN P IMUNISASI Rp 4,000 Rp 4,000
14 Imunisasi L 16711150311110008 096/15 LULU ALIFA ZAKIYA 3,5 BLN P IMUNISASI Rp 4,000 Rp 4,000
15 Imunisasi L 1671151104120003 004/13 ZAKIYA 9 BLN P IMUNISASI Rp 4,000 Rp 4,000
16 Imunisasi L 1671151702170001 039/14 ERLANGGA FEBRIAN 3,5 BLN L IMUNISASI Rp 4,000 Rp 4,000
17 Imunisasi L 1671075110050010 274/14 FATUL AROZAK 1,5 TH L IMUNISASI Rp 4,000 Rp 4,000
18 BP L 1671154310950002 SHERLY OKTARIA 22 TH P GASTRITIS Rp 4,000 Rp 4,000
19 Imunisasi L 1671076504650010 263/15 ALEA 1,8 TH P IMUNISASI Rp 4,000 Rp 4,000
20 BP L 1671040501110001 274/14 M. ILHAM 13,5 TH L DERMATITIS Rp 4,000 Rp 4,000
21 BP L 1671155404410001 ZUBAIDAH 76 TH P HYPERTENSI Rp 4,000 Rp 4,000
22 BP L 1671071901940007 169/14 FIKRI ASPRIANSYAH 6,6 TH L CHEPALGIA Rp 4,000 Rp 4,000
23
24
JUMLAH Rp 88,000 Rp 88,000
Mengetahui,

NIP NIP : 197710182003121004 NIP : 197211161992022001
KLAIM BULAN : 0 9 JUNI 2017
1 BP L 1671075004820008 026/13 ERNAWATI 34 TH P GASTRITIS Rp 4,000 Rp 4,000
2 BP L 1671075502080001 026/13 PUSPA DWI ARIANTI 9,5 TH P FEBRIS Rp 4,000 Rp 4,000
3 BP L 1671155701070001 081/16 ROSARI MAHARANI 10 TH P CONJUNGTIVITIS Rp 4,000 Rp 4,000
4 KIA L 1606025205930004 046/15 MELLI YANTI 24 TH P P HAMIL ONC Rp 4,000 Rp 4,000
5 GIGI L 1671151007120001 640/17 HERZA 23 TH L ABSES Rp 4,000 Rp 4,000
6 BP L 1671070504580010 338/15 MASIMAN 60 TH L DM Rp 4,000 Rp 4,000
7 BP L '1671100403780002 164/13 MARHAEN 34 TH L HYPERTNSI Rp 4,000 Rp 4,000
8 GIGI L 167115141190001 039/14 M. ASHAR 7 TH L I PERSISTENSI CBt 1 gg susu kiri atas Rp 4,000 Rp 5,000 Rp 9,000
9 MTBS L 167115667130002 039/14 M. TEGAR 4 TH L IMPERTIGO Rp 4,000 Rp 4,000
10 BP L 167116508740001 019/13 SITI AMINAH 43 TH P CHEPALGIA Rp 4,000 Rp 4,000
11 GIGI L 1671150705630001 653/17 SABARUDIN ALI 52 TH L VI GP KIRI BAWA CBt 1 gg grham ke 2 Rp 4,000 Rp 10,000 Rp 14,000
12 KIA KB L 1671074794790013 009/13 PILUS 38 TH L KB SUNTIK DEPO 3 BLN Rp 4,000 Rp 4,000
13 KIA L 1671065610950001 114/17 NASUTION 22 TH L KB PIL Rp 4,000 Rp 4,000
14 BP L 1671074502900004 125/14 HERMAN 12 TH L CHEPALGIA Rp 4,000 Rp 4,000
15 KIA TINDIK 1671070202700017 147/13 SUPARMAN 14 TH L TINDIK Rp 4,000 Rp 4,000
16 BP L 1671071107630007 347/14 MUSA 54 TH L DERMATITIS Rp 4,000 Rp 4,000
17
18
19
20
21
22
23
24
JUMLAH Rp 64,000 Rp 15,000 Rp 79,000
Mengetahui,

NIP NIP : 197710182003121004 NIP : 197211161992022001
KLAI BULAN : 10 JUNI 2017
NO TUJUAN NO KK / KTP NO RM NAMA PASIEN UMUR L/P DIAGNOSIS TINDAKAN MEDIS

1 BP L 1671075111540016 JUAIRIAH 52 TH P CONJUNGTIVITIS Rp 4,000 Rp 4,000
2 GIGI L 1671075110050010 AGUS CHASWANTI 36 TH L IMPERTIGO Rp 4,000 Rp 4,000
3 BP L 1671070212520002 MARSIKIN 65 TH L HYPERTENSI KONTROL ULANG Rp 4,000 Rp 4,000
4 MTBS L 1671154505140005 SYAKINAH 3 TH P FEBRIS Rp 4,000 Rp 4,000
5 BP L 1671075512520002 TARMINAH 52 TH P HYPERTENSI Rp 4,000 Rp 4,000
6 MTBS L 1671166112140001 AKIFAH NAYLA 2 TH P ISPA Rp 4,000 Rp 4,000
7 MTBS L 1671155801150001 FITRIA RAYA 1,4 TH P FEBRIS Rp 4,000 Rp 4,000
8 GIGI L 1671074101650023 TARTILAWATI 52 TH P HYPERTENSI Rp 4,000 Rp 4,000
9 BP L 167115407560001 RISTA 25 TH P GASTRITIS Rp 4,000 Rp 4,000
10 MTBS L 1671075003870005 CIKEI RATU KENCANA 1 MGGU P ALERGI Rp 4,000 Rp 4,000
11 BP L 1671151804120003 RONALDO 5 TH L FEBRIS Rp 4,000 Rp 4,000
12 BP L 1671152707060001 RAIHAN 10 TH L COMMONDCOLD Rp 4,000 Rp 4,000
13 MTBS L 1671075103750006 YOGA SAPUTRA 1,9 TH L FEBRIS Rp 4,000 Rp 4,000
14 BP L 1671075111640016 SULASNAH 42 TH P IMPERTIGO Rp 4,000 Rp 4,000
15
16
17
18
19
20
21
22
23
24
JUMLAH Rp 56,000 Rp 56,000
Mengetahui,

NIP NIP : 197710182003121004 NIP : 197211161992022001
KLAIM BULAN : ' 12 JUNI 2017
OK
1 BP L 1671152109780001 076/16 HILDA NOVITA S 17 TH P GASTRITIS Rp 4,000 Rp 4,000
2 BP L 1671150111110021 011/14 SRI MULYANTI 29 TH P CHEPALGIA Rp 4,000 Rp 4,000
3 BP L 1671151309130003 125/16 SONY ALFARABI 8 TH L FEBRIS Rp 4,000 Rp 4,000
4 BP L 1671071406080138 49/13 FAIZ 75 TH L Post of katarak RS Mata masyarakat Rp 4,000 Rp 4,000
5 MTBS L 1671152111120018 28/13 BIMA 3 TH L COMMONDCOLD Rp 4,000 Rp 4,000
6 BP L 1671155402820001 28/13 RUSMIATI 33 TH P COMMONDCOLD Rp 4,000 Rp 4,000
7 BP L 1671091106100004 268/13 BAYU EKA PANDI 18 TH L IMPERTIGO Rp 4,000 Rp 4,000
8 BP L 1671075010950016 162/17 BELLA 22 TH P DERMATITIS Rp 4,000 Rp 4,000
9 MTBS L 1671154210140002 162/17 NADIN 2,7 TH P FEBRIS Rp 4,000 Rp 4,000
10 KIA PH L 1671076311820013 055/13 NUNUNG RAHMAWATI 35 TH P P HAMIL ONC Rp 4,000 Rp 4,000
11 BP L 1671073229210001 457/16 ZUBAIDAH 76 TH P Post of katarak RS Mata masyarakat Rp 4,000 Rp 4,000
12 KIA PH L 1671151011110003 457/16 EVLIN 23 TH P P HAMIL ONC Rp 4,000 Rp 4,000
13 GIGI L 1671154203740001 168/16 ARI 17 TH L ABSES Rp 4,000 Rp 4,000
14 BP L 1671154409000001 123/17 RANI SILVIA 17 TH P GASTRITIS Rp 4,000 Rp 4,000
15 KIA PH L 1671071210060014 059/14 RIRI 18 TH P P HAMIL Rp 4,000 Rp 4,000
16 BP L 1671074603970005 088/14 RISKA 20 TH P DERMATITIS Rp 4,000 Rp 4,000
17 BP L 1671071107630007 347/14 MUSA 54 TH L II GP Kiri atas Cbt 1 gg grham ke 2 Rp 4,000 Rp 10.000 Rp 14,000
18
19
20
21
22
23
24
JUMLAH Rp 68,000 Rp 1.0000 Rp 78.000
Mengetahui,

NIP NIP : 197710182003121004 NIP : 197211161992022001
KLAIM BU ULAN ; '13 JUNI 2017

1 MTBS 1671152905120000 169/17 M.FAHRI ALDIANSYAH 5 TH L FEBRIS Rp 4,000 Rp 4,000
2 MTBS 16711609031150001 447/16 ADLI JULIANSYAH 10 BLN L ISPA Rp 4,000 Rp 4,000
3 KIA 1671072905070079 238/17 DINA 20 TH L KB PIL Rp 4,000 Rp 4,000
4 BP 1671077112590078 227/16 ASNA 57 TH P HYPERTENSI Rp 4,000 Rp 4,000
5 BP 1671158910950001 040/13 OKTA ERMITA SARI 2 TH P DEMAM Rp 4,000 Rp 4,000
6 BP 1671076012630011 040/13 MARIAM 50 TH P HYPERTENSI Rp 4,000 Rp 4,000
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
JUMLAH Rp 24,000 Rp 24,000
Mengetahui,

NIP NIP : 197710182003121004 NIP : 197211161992022001
NO TUJUAN NO KK / KTP NO RM NAMA PASIEN UMUR L/P DIAGNOSIS `````` BIAYA (Rp) SESUAI PERDA Ket
1 BP L 1671075406560003 38/13 ROSINI 62 TH P CONJUNGTIVITIS Rp 4,000 Rp 4,000
2 GIGI L 1671151808830002 633/17 RUMINAH 48 TH P VII ART / Tmbl fuji kana atas Rp 4,000 Rp 15,000 Rp 19,000
3 GIGI L 1671151512110024 648/13 POHORIYAH 50 TH P I Gangrng radix cb 1 gg dpn kiri atas Rp 4,000 Rp 7,500 Rp 11,500
4 BP L 1671045303800006 274/14 ANTO 36 TH L REUMATIK Rp 4,000 Rp 4,000
5 MTBS L 1671150906120001 019/13 AHMAD LUTHFI 5 TH L CHEPALGIA Rp 4,000 Rp 4,000
6 MTBS L 1671156209120005 02/13 SAFIRA 4 TH P FEBRIS Rp 4,000 Rp 4,000
7 MTBS L 1671154059700001 234/15 M.REIHAN 7 BLN L IMUNISASI Rp 4,000 Rp 4,000
8 BP L 1671155201940001 333/13 PERAWATI 25 TH P MYALGIA Rp 4,000 Rp 4,000
9 BP L 1671150806630001 100/17 TAUFIK 54 TH L HYPERTENSI Rp 4,000 Rp 4,000
10 BP L 1671155708140002 72/15 KHAIRUL 49 TH L ALERGI Rp 4,000 Rp 4,000
11 BP L 1671076810800024 205/14 SESILIANTI 37 TH P GASTRITIS Rp 4,000 Rp 4,000
12 MTBS L 1671150104170008 77/15 SAHRIL GUNAWAN 4,5 TH P FEBRIS Rp 4,000 Rp 4,000
13
14
15
16
17
18
19
20
21
22
23
24
JUMLAH Rp 48,000 Rp 22,500 Rp 70,500
Mengetahui,

NIP NIP : 197710182003121004 NIP : 197211161992022001
KLAIM BULAN 15 JUNI 2017

1 BP L 1671074403650007 30/14 SUSMI MURNI 52 TH P HIPERTENSI Rp 4,000 Rp 4,000
2 MTBS L 1671154902150002 641/17 MELDAWATI 1.6 TH P FEBRIS Rp 4,000 Rp 4,000
3 IMUNISASI 1671076505660007 05/17 M.AZRIL 9 BLN L IMUNISASI Rp 4,000 Rp 4,000
4 GIGI L 1671154505840002 369/14 RIKA RIANITA 33 TH P ABSES Rp 4,000 Rp 4,000
5 IMUNISASI 1671155908160003 02/13 KEYLA AISYAH 7 BLN P IMUNISASI Rp 4,000 Rp 4,000
6 IMUNISASI 1671155403070001 324/15 M.RIZKI 2MGG L IMUNISASI Rp 4,000 Rp 4,000
7 TT B 1671076605910003 14/13 ISMI NURYENTI 26 TH P SUNTIK TT Rp 4,000 Rp 4,000
8 GIGI L 1671070204080061 75/16 PIPI PITRIANI 29 TH P ABSES Rp 4,000 Rp 4,000
9 BP L 1671156212920002 130/17 JAYANTI 23 TH P DERMATITIS Rp 4,000 Rp 4,000
10 IMUNISASI 1671152408160012 451/16 RIZKI SAPUTRA 9 BLN L IMUNISASI Rp 4,000 Rp 4,000
11 KIA B 1671071712060048 35/14 MENIYATI 35 TH P KB PIL Rp 4,000 Rp 4,000
12 IMUNISASI 1671152006130012 168/17 RASYID 2 BLN L IMUNISASI Rp 4,000 Rp 4,000
13 BP L 1671152204110002 07/13 OBET 6 TH L CHEPALFIA Rp 4,000 Rp 4,000
14 MTBS L 1671154901150002 12/15 AINIYA 2,4 TH P FEBRIS Rp 4,000 Rp 4,000
15 IMUNISASI 1671071807900005 219/17 ALESHA 5 BLN P IMUNISASI Rp 4,000 Rp 4,000
16 IMUNISASI 1671151009130001 263/15 ALEA 1,8 TH P IMUNISASI Rp 4,000 Rp 4,000
17 MTBS L 1671154305770003 274/14 FATHUL AROZAK 1,6 TH L FEBRIS Rp 4,000 Rp 4,000
18 BP L 1671074551680007 555/16 MAIMUNAH 49 TH P HIPERTENSI Rp 4,000 Rp 4,000
19 IMUNISASI 1671154309900002 643/15 AL-GHAZALI 2 BLN L IMUNISASI Rp 4,000 Rp 4,000
20 IMUNISASI 1671042106890007 24/13 AL-MEIR 4 BLN L IMUNISASI Rp 4,000 Rp 4,000
21 MTBS L 1671076810770007 79/13 AL-ABIDA 1,5 TH P ISPA Rp 4,000 Rp 4,000
22 IMUNISASI 1671073229210001 79/13 ALYSA 3 BLN P IMUNISASI Rp 4,000 Rp 4,000
23 GIGI L 1671151011110003 257/17 HERAMAYA 35 TH P ABSES Rp 4,000 Rp 4,000
24 BP L 167104530380006 274/14 ISMIATI 37 TH P GASTRITIS Rp 4,000 Rp 4,000
JUMLAH Rp 96,000 Rp 96,000
Mengetahui,

NIP NIP : 197710182003121004 NIP : 197211161992022001
Tindakan Jumlah
1 BP L 1671120507080001 274/14 FEBRIAN MAHESA 9 TH L GASTRITIS Rp 4,000 Rp 4,000
2 BP L 1671040501110001 274/14 M.ILHAM 6.5 TH L commond cold Rp 4,000 Rp 4,000
3 MTBS L 1671154303140001 274/14 AISYAH PUTRI 3.3 TH P commond cold Rp 4,000 Rp 4,000
4 GIGI 1671154203740001 516/17 M.DICKY 15 TH L ABSES Rp 4,000 Rp 4,000
5 BP L 1671071404410002 01/13 M.SENEN 76 TH L HYPERTENSI Rp 4,000 Rp 4,000
6 IMUNISASI 1671092262100001 225/14 RIRI 9 BLN P IMUNISASI Rp 4,000 Rp 4,000
7 BP L 1671182267000003 19/13 DIAN DAMAYANTI 37 TH P FEBRIS Rp 4,000 Rp 4,000
8 BP L 1671285620310003 374 M.ZAKI 7 TH L FEBRIS Rp 4,000 Rp 4,000
9 BP L 1671154911890001 374 M.HAIKAL 11 TH L CHEPALGIA Rp 4,000 Rp 4,000
10 IMUNISASI 1671154112160001 42/17 M.ILYAS 8 BLN L IMUNISASI Rp 4,000 Rp 4,000
11 IMUNISASI 1671152110150008 42/17 NADIN 6 BLN P IMUNISASI Rp 4,000 Rp 4,000
12
13
14
15
16
17
18
19
20
21
22
23
24
JUMLAH Rp 44,000 Rp 44,000
Mengetahui,

NIP NIP : 197710182003121004 NIP : 197211161992022001
KLAIM BULAN
ULAN : 16 JUNI 2017

1 BP L 1671077112730077 98/17 M.FAIZ 13 TH L CHEPALGIA Rp 4,000 Rp 4,000
2 BP L 1671150310110003 56/13 FERDIANSYAH 6 TH L FEBRIS Rp 4,000 Rp 4,000
3 BP L 1671150210080001 33/16 AIDIL 8 TH L CHEPALGIA Rp 4,000 Rp 4,000
4 GIGI 1671096610080002 664/17 VELA RAHMAWATI 9 TH P ABSES Rp 4,000 Rp 4,000
5 BP L 1671076505660007 31/17 CIK IPAH 50 TH P HYPERTENSI Rp 4,000 Rp 4,000
6 GIGI 1671072619100002 648/13 POHORIAH 50 TH P ABSES KONTROL ULANG Rp 4,000 Rp 4,000
7 KIA 1606014306790004 648/13 NILAMESI 38 TH P P HMIL Rp 4,000 Rp 4,000
8 KIA KB 1671154612850001 79/16 DAHLIA 32 TH P KB PIK Rp 4,000 Rp 4,000
9 MTBS 1671150506150605 28/13 M.BIMA ADITYA 2 TH L CHEPALGIA Rp 4,000 Rp 4,000
10 BP L 1671076106720005 79/13 ROSMALA DEWI 45 TH P IMPERTIGO Rp 4,000 Rp 4,000
11 BP L 1671155410900001 39/14 AMRINA ROSADA 27 TH P DERMATITIS Rp 4,000 Rp 4,000
12 BP L 1671051401780005 207/14 M.MUNASIR 39 TH L IMPERTIGO Rp 4,000 Rp 4,000
13 BP L 1671055302080002 207/14 LIZAH NOVA ELISAH 9 TH P FEBRIS Rp 4,000 Rp 4,000
14 MTBS 1671181910020003 624/17 SELLY 1.6 TH P FEBRIS Rp 4,000 Rp 4,000
15 BP L 1671182926010002 47/17 VANIA RENITA 11 TH P CHEPALGIA Rp 4,000 Rp 4,000
16
17
18
19
20
21
22
23
24
JUMLAH Rp 60,000 Rp 60,000
Mengetahui,

NIP NIP : 197710182003121004 NIP : 197211161992022001
1 BP L 1671158304786001 128/13 TINI 42 TH P ALERGI Rp 4,000 Rp 4,000
2 GIGI 1671152708110001 227/16 FAIZ 6 TH L I PERSISTENSI Cbt 1 gg susu kiri awa Rp 4,000 Rp 5,000 Rp 9,000
3 GIGI 1671077004790003 33/15 MARTITA TARI 39 TH P V GR cbt 1 gg grham kiri atas Rp 4,000 Rp 10,000 Rp 14,000
4 BP L 1671041004120002 48/17 APRILIANDO 5 TH L CHEPALGIA Rp 4,000 Rp 4,000
5 GIGI 1671162639270003 32/13 NOVI 22 TH P IV GR cbt 1 gg grham kiri atas Rp 4,000 Rp 10,000 Rp 14,000
6 GIGI 1671132629110003 648/17 POHORIAH 50 TH P HYPERTENSI Rp 4,000 Rp 4,000
7 BP L 1671076006860008 25/14 TINNA 31 TH P GASTRITIS Rp 4,000 Rp 4,000
8 BP L 1671089226710003 73/13 SIPON 73 TH L Post of katarak RS Mata masyarakat Rp 4,000 Rp 4,000
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
JUMLAH Rp 32,000 Rp 25,000 Rp 57,000
Mengetahui,

NIP NIP : 197710182003121004 NIP : 197211161992022001
KLAIM BULAN
ULAN : 19 JUNI I 2017
1 BP L 1671070111060004 09/14 NOVRI 10 TH L CHEPALGIA Rp 4,000 Rp 4,000
2 GIGI L 1671070207880007 177/13 CANDRA LEKA 28 TH L DERMATITIS Rp 4,000 Rp 4,000
3 BP L 1671152904720002 173/14 SYAIPUL 45 TH L IMPERTIGO Rp 4,000 Rp 4,000
4 MTBS L 1671071804070086 483/16 AZRIL 3 TH L FEBRIS Rp 4,000 Rp 4,000
5 GIGI L 1671096610080002 664/17 VELA 8 TH P ABSES Rp 4,000 Rp 4,000
6 KIA B 1603076001830004 74/16 HERLINDA 34 TH P KEPUTIHAN Rp 4,000 Rp 4,000
7 GIGI L 1671071311070016 56/17 NABILA 19 TH P ABSES KONTROL ULANG Rp 4,000 Rp 4,000
8 BP L 1671074106930011 457/16 ZUBAIDAH 76 TH P HHD RS Muhammadiyah Rp 4,000 Rp 4,000
9 MTBS L 1671074906710002 26/14 M.HAIKAL 3 BLN L ISPA Rp 4,000 Rp 4,000
10 BP L 1671155809150001 25/16 SURTINI 75 TH P Post of katarak RS Mata masyarakat Rp 4,000 Rp 4,000
11 GIGI L 1671155603110001 290/15 WINNY ALVIONITA 6 TH P ABSES Rp 4,000 Rp 4,000
12 KIA B 1671071007070027 271/13 ANI ROBBAYANI 21 TH P KB PIL Rp 4,000 Rp 4,000
13 GIGI L 1671152505090002 44/17 JERY JONATHAN 8 TH L ABSES Rp 4,000 Rp 4,000
14 BP L 1671076106720005 79/13 ROSMALA DEWI 45 TH P GASTRITIS Rp 4,000 Rp 4,000
15 KIA L 1671075708840023 131/17 ANI SUSANTI 32 TH P KB SUNTIK Rp 4,000 Rp 4,000
16 BP L 1671072629110001 79/13 NURBAITI 20 TH P DERMATITIS Rp 4,000 Rp 4,000
17 GIGI L 1671152402130002 44/15 SUARTI 53 TH P ABSES ONTROL ULANG Rp 4,000 Rp 4,000
18 MTBS L 1671155301100002 668/17 ANNAYA 3,5 TH P COMMOND COLD Rp 4,000 Rp 4,000
19 GIGI L 1671155808850003 431/16 NING AYU 31 TH P ABSES Rp 4,000 Rp 4,000
20 BP L 1671092711830009 135/16 JIMMI KALTER 32 TH L GASTRITIS Rp 4,000 Rp 4,000
21 MTBS L 1671155103150001 135/16 ISABEL 2 TH P FEBRIS Rp 4,000 Rp 4,000
22 BP L 1671151703810001 46/14 BENNY SASTRA.W 36 TH L DERMATITIS Rp 4,000 Rp 4,000
23 BP L 1671155204690001 47/14 MARIYU 48 TH P IMPERTIGO Rp 4,000 Rp 4,000
24 BP L 1607010051284005 76/13 SUSTRISNO 33 TH L IMPERTIGO Rp 4,000 Rp 4,000
JUMLAH Rp 96,000 Rp 96,000
Mengetahui,

NIP NIP : 197710182003121004 NIP : 197211161992022001
1 BP L 1671070212520002 249/14 MARSIKIN 65 TH L HYPERTENSI Rp 4,000 Rp 4,000
2 KIA PH L 1671156111930002 523/16 RIKA RAHIM 24 TH P P HAMIL ONC Rp 4,000 Rp 4,000
3 MTBS L 1671156004150002 523/16 KIRANI 11 BLN P ISPA Rp 4,000 Rp 4,000
4 GIGI L 1671074407700009 85/13 RUSMELI 47 TH P ABSES KONTROL Rp 4,000 Rp 4,000
5 GIGI L 1671152410090001 85/13 M.FATIH 7,5 TH L II persistensi cbt 1 gg susu kiri atas Rp 4,000 Rp 5,000 Rp 9,000
6 GIGI L 1671153010100002 73/15 ARI LUGIANA 7 TH L I persistensi cbt 1 gg susu kiri atas Rp 4,000 Rp 5,000 Rp 9,000
7 MTBS L 1671071405940011 503/17 M.RIDHO 9 BLN L ALERGI Rp 4,000 Rp 4,000
8 BP L 1671076108720005 79/13 ROSMALA DEWI 45 TH P MYALGIA Rp 4,000 Rp 4,000
9 KIA PH L 1671154904940001 04/13 LILI APRILIA 23 TH P P HAMIL Rp 4,000 Rp 4,000
10 BP L 1671155905830002 293/17 AZZA 6,5 TH L CHEPALGIA Rp 4,000 Rp 4,000
11 BP L 1671076108760005 293/17 HOMSIAH 42 TH P MYALGIA Rp 4,000 Rp 4,000
12 KIA PH L 1671076311820013 551/13 NUNUNG RAHMAWATI 35 TH P P HMIL Rp 4,000 Rp 4,000
13 MTBS L 1671073112530060 91/15 PERONIKA 3,4 TH L FEBRIS Rp 4,000 Rp 4,000
14 MTBS L 1671156305160002 91/15 RAGIL 9 BLN L FEBRIS Rp 4,000 Rp 4,000
15 KB SUNTIK 1671076810770007 39/14 ARMILA WATI 39 TH P KB SUNTIK Rp 4,000 Rp 4,000
16 KB L 1672225704910003 112/16 EKA 28 TH P KB SUNTIK Rp 4,000 Rp 4,000
17 BP L 1671056710020003 ROMA PIRYANDO 25 TH L DERMATITIS Rp 4,000 Rp 4,000
18 BP L 1671152808880001 247/17 HEPRIDIKA 30 TH L GASTRITIS Rp 4,000 Rp 4,000
19 BP L 1671154110090004 30/13 INDRIYANI 9 TH P CHEPALGIA Rp 4,000 Rp 4,000
20 BP L 1671072619210003 15/15 YANDRI 40 TH L IMPERTIGO Rp 4,000 Rp 4,000
21
22
23
24
JUMLAH Rp 80,000 Rp 10,000 Rp90,000
Mengetahui,

NIP NIP : 197710182003121004 NIP : 197211161992022001
KLAIM BULAN
ULAN 21 JUNI 2017
1 GIGI L 1671154603120001 15/13 PUTRI AURA 7 TH P ABSES Rp 4,000 Rp 4,000
2 BP L 1671044612760010 355/15 ELI ERNA 40 TH P MYALGIA Rp 4,000 Rp 4,000
3 GIGI L 1671071008900009 54/13 YUNUS AGUSTIAN 26 TH L V GR Kiiri bawa cbt 1 gg grham ke 1 Rp 4,000 Rp 10,000 Rp 14,000
4 GIGI L 1671155207100003 13-Nov SHAKIRA PUTRI 7 TH P ABSES Rp 4,000 Rp 4,000
5 BP L 1671075802640001 13/14 DINDA 13 TH P CHEPALGIA Rp 4,000 Rp 4,000
6 BP L 1671071606040009 94/14 HANDI LEKSI 13 TH L COMMONDCOLD Rp 4,000 Rp 4,000
7 MTBS L 1671156305160002 32/13 FAIMAAZAHRA 1 TH P ISPA Rp 4,000 Rp 4,000
8 KB PIL 1671075412820007 LITA SURYANI 33 TH P KB PIL Rp 4,000 Rp 4,000
9 BP L 1671156111930002 669/13 HHAMSIA 57 TH P HYPERTENSI Rp 4,000 Rp 4,000
10 BP L 1671071203580008 536/17 M SUYITO 58 TH L CONJUNGTIVITIS Rp 4,000 Rp 4,000
11 MTBS L 1671074811620003 227 /16 AZRIL RAFIF 9 BLN L ALERGI Rp 4,000 Rp 4,000
12 BP L 1671075802640001 148/13 PUTRI ANDINI 9 TH P GASTRITIS Rp 4,000 Rp 4,000
13 BP L 1671156109660001 45/13 FATMA WATI 45 TH P GASTRITIS Rp 4,000 Rp 4,000
14 BP L 1671072510770006 102/13 MUHTADUN 50 TH P IMPERTIGO Rp 4,000 Rp 4,000
15 BP L 1671150310110003 56/13 FERDIANSYAH 6 TH L CHEPALGIA Rp 4,000 Rp 4,000
16 BP L 1671150210080001 33/16 AIDIL 8 TH L FEBRIS Rp 4,000 Rp 4,000
17
18
19
20
21
22
23
24
JUMLAH Rp 64,000 Rp 10,000 Rp 74,000
Mengetahui,

NIP NIP : 197710182003121004 NIP : 197211161992022001
KLAIM BULAN : '22 JUNI 2017

1 BP L 1671072912660003 60/17 REO 28 H L ALERGI Rp 4,000 Rp 4,000
2 IMUNISASI 1671072629110001 12/13 QUTWA 1.5 TH P IMUNISASI Rp 4,000 Rp 4,000
3 BP L 1671155409700002 55/15 KOMSIAH 46 TH P REUMATIK Rp 4,000 Rp 4,000
4 IMUNISASI 1671076809920003 45/17 DAREL 3 BLN L IMUNISASI Rp 4,000 Rp 4,000
5 IMUNISASI 1671182934550002 641/17 ZALWA 1 BLN P IMUNISASI Rp 4,000 Rp 4,000
6 IMUNISASI 1671167712330004 62/15 DANIEL 9 BLN L IMUNISASI Rp 4,000 Rp 4,000
7 KB SNTIK 1671046307930006 395/15 FITRI ANDILIANA 23 TH P KB SUNTIK DEPO Rp 4,000 Rp 4,000
8 IMUNISASI 1671065543220003 503/17 M RIDHO 9 BLN L IMUNISASI Rp 4,000 Rp 4,000
9 MTBS L 1671165423020003 545/16 JIHAN 1.11 THP ISPA Rp 4,000 Rp 4,000
10 IMUNISASI 1671064543220005 219/17 ALESHA 5 BLN P IMUNISASI Rp 4,000 Rp 4,000
11 IMUNISASI 1671074524330006 AISYAH 10 BLNL IMUNISASI Rp 4,000 Rp 4,000
12 MTBS L 1671195646770002 270/15 M RAFA 1.5 TH L FEBRIS Rp 4,000 Rp 4,000
13 MTBS L 1671185659010006 32/16 ALFATAH 11 BLNL ISPA Rp 4,000 Rp 4,000
14 KIA L 1671155805850003 298/17 SYAMSIDAR 31 TH P KB PIL Rp 4,000 Rp 4,000
15 IMUNISASI 1671165754310004 127/13 FIRMANSYAH 40 HARL IMUNISASI Rp 4,000 Rp 4,000
16 BP L 1671075111640016 35/13 JUAIRIA 53 TH P HYPERTENSI Rp 4,000 Rp 4,000
17 BP L 1671152108890001 283/17 IBNU HAJAR 28 TH L GASTRITIS Rp 4,000 Rp 4,000
18 BP L 1671061401000009 72/15 M RUSDI 17 TH L DERMATITIS Rp 4,000 Rp 4,000
19
20
21
22
23
24
JUMLAH Rp 72,000 Rp 72,000
Mengetahui,

NIP NIP : 197710182003121004 NIP : 197211161992022001
KLAIM BULAN
ULAN : 23 JUNI 2017

1 BP L 1671156707080001 109/16 NURAINI 30 TH P CONJUNGTIVITIS Rp 4,000 Rp 4,000
2 BP L 1671076501720010 15-Jun DUDEK 45 H P HIPERTENSI Rp 4,000 Rp 4,000
3 BP L 167145367220001 164/15 ANA NOVELA 22 TH P FEBRIS Rp 4,000 Rp 4,000
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
JUMLAH Rp 12,000 Rp 12,000
Mengetahui,

NIP NIP : 197710182003121004 NIP : 197211161992022001
Tindakan Jumlah
1 GIGI L 1671071706080071 290/17 RASYA 9 TH P ABSES Rp 4,000 Rp 4,000
2 KB SNTIK L 1671150203120002 39/14 ARMILA WATI 39 TH P KB SNTIK Rp 4,000 Rp 4,000
3 MTBS L 1671092619110003 1CA 4.5 TH P FEBRIS Rp 4,000 Rp 4,000
4 GIGI L 16710711062210001 108/16 NABILA 16 TH P ABSES Rp 4,000 Rp 4,000
5 GIGI L 16710711062210001 108/16 DENI 44 TH L ABSES Rp 4,000 Rp 4,000
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
JUMLAH Rp 20,000 Rp 20,000
Mengetahui,

NIP NIP : 197710182003121004 NIP : 197211161992022001
KLAIM BULAN
ULAN : 24 JANUARI 2017

1 BP L 167113654241000 518/16 AGUS FAISAL 12 TH L CHELPALGIA Rp 4,000 Rp 4,000
2 KIA L 1671164352030002 RINDA SUSI 41 TH P BUKA INPLAN Rp 4,000 Rp 4,000
3 KIRKES L 1671070508770018 SUNAR 39 TH L KIRKES Rp 4,000 Rp 4,000
4 KB SNTIK L 1671020604100032 109/13 RUSNI 34 TH P KB SNTIK Rp 4,000 Rp 4,000
5 MTBS L 1671020604100032 109/13 ALIF 2 TH L FEBRIS Rp 4,000 Rp 4,000
6 BP L 1671020604100032 109/13 INDAH 6 TH P COMNJUNGTIVITIS Rp 4,000 Rp 4,000
7 BP L 1671071601080120 236/14 M ZIDAN 6,5 TH L CHELPALGIA Rp 4,000 Rp 4,000
8 GIGI L 1671071601080120 236/14 TRILIANI 34 TH P IMPERTIGO Rp 4,000 Rp 4,000
9 GIGI L 1671150111000112 13-Jun RIA ANDINI 16 TH L ABSES Rp 4,000 Rp 4,000
10 GIGI L ,1671156234530003 72/16 IKE PA NTIKA 26 TH P IV Tmbl semntra kiri atas Rp 4,000 Rp 7,500 Rp 11,500
11 GIGI L 1671152005130018 267/15 SELVY 7 TH P III PERSISTENSI Kann bawa Rp 4,000 Rp 5,000 Rp 9,000
12 BP L 1671071405080048 32/13 SUSI 30 TH P GASTRITIS Rp 4,000 Rp 4,000
13 BP L 1671062534210001 234/14 ADIT 18TH L DERMATITIS Rp 4,000 Rp 4,000
14 BP L 1671028543270002 TIARA 16 TH P COMMCND COLD Rp 4,000 Rp 4,000
15 MTBS L 167115230110010 086/16 FAREZA 3 TH L FEBRIS Rp 4,000 Rp 4,000
16 SUSUK BUKA L 1671072905070079 37/14 HIRFAWANTI 32 TH P BUKA INPLAN Rp 4,000 Rp 4,000
17 BP L 1671172009070046 20/13 ZALEHA 54TH P HYPERTENSI Rp 4,000 Rp 4,000
18 BP L 1671065428010003 20/13 ABEL 9 TH P CHELPALGIA Rp 4,000 Rp 4,000
19 KB SNTIK L 1671151701130001 36/16 ENI ASMARITA 43 TH P KB SNTIK Rp 4,000 Rp 4,000
20 BP L 16710704030680026 32/13 FATIMA 53 TH P HYPERTENSI Rp 4,000 Rp 4,000
21 BP L 1671071911070004 133/16 ERNA WATI 46 TH P DERMATITIS Rp 4,000 Rp 4,000
22 GIGI L 1671151510120017 105/16 ELSA 33 TH P 8 PERIOD knn atas cbt 1 gg grham ke 2 Rp 4,000 Rp 10,000 Rp 14,000
23 MTBS L 1671167524630003 71/14 SUCI 5 BLN P ALERGI Rp 4,000 Rp 4,000
24 MTBS L 1671035423030004 71/14 AYU 4 TH P FEBRIS Rp 4,000 Rp 4,000
JUMLAH Rp 96,000 Rp 22.500 Rp 118.500
Mengetahui,

NIP NIP : 197710182003121004 NIP : 197211161992022001
NAMA PPK : PUSKESMAS PEMBANTU SRIJAYA (PKM PUNTI KAYU)
KLAIM BULAN : 25 JANUARI 2017
BIAYA (Rp) SESUAI PERDA

NO TUJUAN NO KK / KTP NO RM NAMA PASIEN UMUR L/P DIAGNOSIS TINDAKAN MEDIS Ket
1 BP L 1671053246060003 106/15 ALDIHARYANTO 16 TH L IMPERTIGO Rp 4,000 Rp 4,000
2 BP L 1671186432030001 NETTI 56 TH P HYPERTENSI Rp 4,000 Rp 4,000
3 MTBS L 1671151405130011 34/13 SAKIRA 4 TH P FEBRIS Rp 4,000 Rp 4,000
4 BP L 1671151405130011 34/13 SRI DWI 22 TH P CONJUNGTIVITIS Rp 4,000 Rp 4,000
5 P HMIL L 1671076611720011 154/14 ROYANA 45 TH P P HMIL Rp 4,000 Rp 4,000
6 BP L 1671070100740050 42/15 AZIS 77 TH L HYPERTENSI Rp 4,000 Rp 4,000
7 BP L 1671071411070090 27/13 REKI MARTA 22 TH P GASTRITIS Rp 4,000 Rp 4,000
8 P HMIL L 1671151202130002 525/16 SITI ROHILA 30 TH P P HMIL Rp 4,000 Rp 4,000
9 BP L 1671157112530003 104/17 YUZARNI 63 TH P Post of katarak Rp 4,000 Rp 4,000
10 BP L 167074606460004 13-Mar SRILESTARI 71 TH P HYPERTENSI Rp 4,000 Rp 4,000
11 BP L 1671025436530002 120/13 FATA ALIF 8 TH L DERMATITIS Rp 4,000 Rp 4,000
12 GIGI L 1671071004080018 69/14 LINDA WATI 31 TH ABSES Rp 4,000 Rp 4,000
13 MTBS L 1671071004080018 69/14 AZKIA 4 TH P CHEPALGIA Rp 4,000 Rp 4,000
14 BP L 1671042345640003 DEVI 32 TH P GASTRITIS Rp 4,000 Rp 4,000
15 BP 167115480184000 ELSA 33 TH P DERMATITIS Rp 4,000 Rp 4,000
16 MTBS 1671156804120001 OKTARIA 3,5 TH P FEBRIS Rp 4,000 Rp 4,000
17 BP L 1671070401130014 FADLI OKTARIADI 4 TH L COMMONDCOLD Rp 4,000 Rp 4,000
18 BP L 1671084102860010 78/17 VIVI FEBRIZA 30 TH P DERMATITIS Rp 4,000 Rp 4,000
19 MTBS L 1671084102860010 78/17 M.RAFIF ALKHALIFI 6 BLN L ALERGI Rp 4,000 Rp 4,000
20 BP L 1671072203830013 SUPRAYOGA 33 TH L HIMPERTIGO Rp 4,000 Rp 4,000
21
22
23
24
JUMLAH Rp 80,000 Rp 80,000
Mengetahui,
Tim Verifikasi Jamsoskes Palembang
Dinas Kesehatan Kota Palembang Plt. Kepala Puskesmas Punti Kayu Bendahara Penerimaan Pembantu
NIP Makmur Salpator P , SKM , MKM Hermilina, AM. Keb.

NIP : 197710182003121004 NIP : 197211161992022001
JAMINAN SOSIAL KESEHATAN SUMSEL SEMESTA
KOTA PALEMBANG REKAPITULASI KLAIM BIAYA PESERTA JAMSOSKES SEMESTA KOTA PALEMBANG
Nama PPK / PUSKESMAS :: PUNTI KAYU
F.3 PPK
KLAIM BULAN JUNI 2017
NO JUMLAH JUMLAH RAWAT JALANJUMLAH KLAIM PESERTA

KUNJUNGA
TANGGAL N JUMLAH RJTP RJTL NO SERI KARCIS NO KARCIS TINDAKAN TOTAL BIAYA
( Rp 4000,-) Spesialistik (RP)
1 26 Mei 2017 17 Rp 68.000 672.757 - 672.773 007.139 ( 10.000 ) + 103.098 ( 5000 ) Rp 83.000
2 27 Mei 2017 7 Rp 28.000 672.774 - 672.780 - Rp 28.000
3 29 Mei 2017 21 Rp 84.000 672.781 - 672.801 - Rp 84.000
4 30 Mei 2017 17 Rp 68.000 672.802 - 672.818 005.561 ( 7.500 ) + 007.140 ( 10.000 ) Rp 85.500
5 31 Mei 2017 11 Rp 44.000 672.819 - 672.829 - Rp 44.000
6 02 Juni 2017 14 Rp 56.000 672.830 - 672.843 - Rp 56.000
7 03 Juni 2017 7 Rp 28.000 672.844 - 672.850 - Rp 28.000
8 05 Juni 2017 24 Rp 96.000 672.851 - 672.874 103.099 - 103.100 ( 10.000 ) Rp 106.000
9 06 Juni 2017 10 Rp 40.000 672.875 - 672.884 103.101 ( 5000 ) Rp 45.000
10 07 Juni 2017 23 Rp 92.000 672.885 - 672.907 005.562 ( 7.500 ) Rp 99.500
11 08 Juni 2017 22 Rp 88.000 672.908 - 672.929 - Rp 88.000
12 09 Juni 2017 16 Rp 64.000 672.930 - 672.945 103.102 ( 5000 ) + 007.141 ( 10.000 ) Rp 79.000
13 10 Juni 2017 14 Rp 56.000 672.946 - 672.959 - Rp 56.000
14 12 Juni 2017 17 Rp 68.000 672.960 - 672.976 007.142 ( 10.000 ) Rp 78.000
15 13 Juni 2017 6 Rp 24.000 672.977 - 672.982 - Rp 24.000
16 14 Juni 2017 12 Rp 48.000 672.983 - 672.994 005.563 ( 7500) + 047.176 ( 15.000 ) Rp 70.500
17 15 Juni 2017 35 Rp 140.000 672.995 - 673.029 - Rp 140.000
18 16 Juni 2017 15 Rp 60.000 673.030 - 673.044 - Rp 6 0.000
19 17 Juni 2017 8 R 32.000 673.045 - 673.052 103.103 ( 5000 ) + 007.143 -007.144 ( 20.000 ) RP 57.000
20 19 Juni 2017 24 Rp 96.000 673.053 - 673.076 - Rp 96.000
21 20 Juni 2017 20 Rp 80.000 673.077 - 673.096 103.104 - 103.145 ( 10.000) Rp 90.000
22 21 Juni 2017 16 Rp 64.000 673.097 - 673.112 007.145 ( 10.000 ) Rp 74.000
23 22 Juni 2017 18 Rp 72.000 673.113 - 673.130 - Rp 72.000
24 23 Juni 2017 3 Rp 12.000 673.131 - 673.133 - Rp 12.000
25 24 Juni 2017 5 Rp 20.000 673.134 - 673.138 - Rp 20.000
26
27
JUMLAH 382 Rp 1.528.000 Rp 147.500 Rp 1.675.500
Mengetahui Palembang 27 JUNI 2017
Kesehatan Kota Palembang Plt. Kepala Puskesmas Punti Kayu Bendahara Penerimaan Pembantu
…………………………………. Makmur Salpator P , SKM , MKM Hermilina.AM.Keb.

NIP. NIP : 197710182003121004 Nip : 197211161992022001
DAFTAR REGISTER KUNJUNGAN BPJS/KIS/ASKES
PUSKESMAS PUNTI KAYU PALEMBANG

BULAN :
NO. NO. KARTU BPJS NIK NAMA PASIEN NAMA KEPALA KELUARGA POLI TUJUAN UMUR L/P NO. RM ALAMAT No.HP PRB Prolanis

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JAMINAN SOSIAL KESEHATAN SEMESTA SUMSEL

KOTA PALEMBANG REKAPITULASI KUNJUNGAN PASIEN JAMSOSKES SEMSESTA

BIAYA (Rp) SESUAI PERDA

Makmur Salpator P , SKM , MKM Hermilina, AM. Keb.

Makmur Salpator P , SKM , MKM Hermilina, AM. Keb.

NO BIAYA (Rp) SESUAI PERDA

Makmur Salpator P , SKM , MKM Hermilina, AM. Keb.

Makmur Salpator P , SKM , MKM Hermilina, AM. Keb.

Makmur Salpator P , SKM , MKM Hermilina, AM. Keb.

TUJUAN NO KK / KTP NO RM NAMA PASIEN UMUR L/P DIAGNOSIS TINDAKAN MEDIS

Makmur Salpator P , SKM , MKM Hermilina, AM. Keb.

TUJUAN NO KK / KTP NO RM NAMA PASIEN UMUR L/P DIAGNOSIS TINDAKAN MEDIS

Makmur Salpator P , SKM , MKM Hermilina, AM. Keb.

Makmur Salpator P , SKM , MKM Hermilina, AM. Keb.

NO BIAYA (Rp) SESUAI PERDA

Makmur Salpator P , SKM , MKM Hermilina, AM. Keb.

Makmur Salpator P , SKM , MKM Hermilina, AM. Keb.

NO BIAYA (Rp) SESUAI PERDA

Makmur Salpator P , SKM , MKM Hermilina, AM. Keb.

Makmur Salpator P , SKM , MKM Hermilina, AM. Keb.

NO TUJUAN NO KK / KTP NO RM NAMA PASIEN UMUR L/P DIAGNOSIS TINDAKAN MEDIS

Makmur Salpator P , SKM , MKM Hermilina, AM. Keb.

Makmur Salpator P , SKM , MKM Hermilina, AM. Keb.

NO TUJUAN NO KK / KTP NO RM NAMA PASIEN UMUR L/P DIAGNOSIS TINDAKAN MEDIS

Makmur Salpator P , SKM , MKM Hermilina, AM. Keb.

Makmur Salpator P , SKM , MKM Hermilina, AM. Keb.

NO BIAYA (Rp) SESUAI PERDA

Makmur Salpator P , SKM , MKM Hermilina, AM. Keb.

Makmur Salpator P , SKM , MKM Hermilina, AM. Keb.

NO BIAYA (Rp) SESUAI PERDA

Makmur Salpator P , SKM , MKM Hermilina, AM. Keb.

Makmur Salpator P , SKM , MKM Hermilina, AM. Keb.

Makmur Salpator P , SKM , MKM Hermilina, AM. Keb.

Makmur Salpator P , SKM , MKM Hermilina, AM. Keb.

Makmur Salpator P , SKM , MKM Hermilina, AM. Keb.

NO TUJUAN NO KK / KTP NO RM NAMA PASIEN UMUR L/P DIAGNOSIS TINDAKAN MEDIS

Makmur Salpator P , SKM , MKM Hermilina, AM. Keb.

NO BIAYA (Rp) SESUAI PERDA

Makmur Salpator P , SKM , MKM Hermilina, AM. Keb.

Makmur Salpator P , SKM , MKM Hermilina, AM. Keb.

NO BIAYA (Rp) SESUAI PERDA

Makmur Salpator P , SKM , MKM Hermilina, AM. Keb.

BIAYA (Rp) SESUAI PERDA

NIP Makmur Salpator P , SKM , MKM Hermilina, AM. Keb.

NO JUMLAH JUMLAH RAWAT JALANJUMLAH KLAIM PESERTA

…………………………………. Makmur Salpator P , SKM , MKM Hermilina.AM.Keb.

PUSKESMAS PUNTI KAYU PALEMBANG

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