BPJS Kesehatan Cab.

BOGOR
FORMULIR PENGAJUAN KLAIM TINGKAT PERTAMA

Nomor FPK : P2210000020370

Provider : Elis Trisnawati, A.Md.Keb

Bulan Pelayanan : October 2022

Pelayanan : RITP

Total Data : 24

Total Tagihan : Rp. 16.800.000

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

B00086581022P000001 RINI AISYAH (0001719021677) 02/10/2022 03/10/2022 Paket Persalinan per Vaginam normal (oleh Bidan) Elis Trisnawati, A.Md.Keb Rp. 700.000

B00086581022P000002 TINI (0001233442618) 03/10/2022 03/10/2022 Paket Persalinan per Vaginam normal (oleh Bidan) Elis Trisnawati, A.Md.Keb Rp. 700.000

B00086581022P000003 RINI RACHMAWATI (0000630582715) 03/10/2022 03/10/2022 Paket Persalinan per Vaginam normal (oleh Bidan) Elis Trisnawati, A.Md.Keb Rp. 700.000

B00086581022P000004 KARLINA (0001238266089) 03/10/2022 04/10/2022 Paket Persalinan per Vaginam normal (oleh Bidan) Elis Trisnawati, A.Md.Keb Rp. 700.000

B00086581022P000005 SITI NURLAELA EFFENDI (0001310371053) 08/10/2022 09/10/2022 Paket Persalinan per Vaginam normal (oleh Bidan) Elis Trisnawati, A.Md.Keb Rp. 700.000

B00086581022P000006 SITI NURYANAH (0000383916227) 11/10/2022 11/10/2022 Paket Persalinan per Vaginam normal (oleh Bidan) Elis Trisnawati, A.Md.Keb Rp. 700.000

B00086581022P000007 NURHASANAH (0002243612441) 14/10/2022 15/10/2022 Paket Persalinan per Vaginam normal (oleh Bidan) Elis Trisnawati, A.Md.Keb Rp. 700.000

B00086581022P000008 ONENG MASPUPAH (0002856306273) 19/10/2022 19/10/2022 Paket Persalinan per Vaginam normal (oleh Bidan) Elis Trisnawati, A.Md.Keb Rp. 700.000

B00086581022P000009 IMAS (0000382708912) 02/10/2022 03/10/2022 Paket Persalinan per Vaginam normal (oleh Bidan) Elis Trisnawati, A.Md.Keb Rp. 700.000

B00086581022P000010 ANIDA ALYA CAHYANI (0000381850986) 04/10/2022 04/10/2022 Paket Persalinan per Vaginam normal (oleh Bidan) Elis Trisnawati, A.Md.Keb Rp. 700.000

B00086581022P000011 EROS ROSMIATI (0001653417077) 07/10/2022 07/10/2022 Paket Persalinan per Vaginam normal (oleh Bidan) Elis Trisnawati, A.Md.Keb Rp. 700.000

B00086581022P000012 SITI ISNAWATI (0000382389311) 11/10/2022 11/10/2022 Paket Persalinan per Vaginam normal (oleh Bidan) Elis Trisnawati, A.Md.Keb Rp. 700.000

SITI ROBI'ATUL ADAWIYAH

B00086581022P000013 11/10/2022 11/10/2022 Paket Persalinan per Vaginam normal (oleh Bidan) Elis Trisnawati, A.Md.Keb Rp. 700.000
(0000383101648)

B00086581022P000014 SANTI SUSANTI (0001653493307) 12/10/2022 12/10/2022 Paket Persalinan per Vaginam normal (oleh Bidan) Elis Trisnawati, A.Md.Keb Rp. 700.000

AMELIA AGUSTINA DEWIYANI

B00086581022P000015 15/10/2022 15/10/2022 Paket Persalinan per Vaginam normal (oleh Bidan) Elis Trisnawati, A.Md.Keb Rp. 700.000
(0001774375108)

B00086581022P000016 FITRIE MEILANI (0003039268509) 18/10/2022 19/10/2022 Paket Persalinan per Vaginam normal (oleh Bidan) Elis Trisnawati, A.Md.Keb Rp. 700.000

B00086581022P000017 RENI FEBRIANTI (0000499304406) 15/10/2022 15/10/2022 Paket Persalinan per Vaginam normal (oleh Bidan) Elis Trisnawati, A.Md.Keb Rp. 700.000
 NO KUNJUNGAN NAMA PESERTA TGL MASUK TGL PULANG TINDAKAN TENAGA MEDIS BIAYA

B00086581022P000018 WULAN SWALISA (0001249149982) 22/10/2022 23/10/2022 Paket Persalinan per Vaginam normal (oleh Bidan) Elis Trisnawati, A.Md.Keb Rp. 700.000

B00086581022P000019 ENENG MINA SAPINAH (0002480970699) 23/10/2022 23/10/2022 Paket Persalinan per Vaginam normal (oleh Bidan) Elis Trisnawati, A.Md.Keb Rp. 700.000

B00086581022P000020 ADE TIA MAULIDA (0000059918534) 26/10/2022 26/10/2022 Paket Persalinan per Vaginam normal (oleh Bidan) Elis Trisnawati, A.Md.Keb Rp. 700.000

B00086581022P000021 LISA RAHAYU (0001233674673) 27/10/2022 28/10/2022 Paket Persalinan per Vaginam normal (oleh Bidan) Elis Trisnawati, A.Md.Keb Rp. 700.000

B00086581022P000022 SITI NUR MAULIDA (0001610676145) 28/10/2022 29/10/2022 Paket Persalinan per Vaginam normal (oleh Bidan) Elis Trisnawati, A.Md.Keb Rp. 700.000

B00086581022P000023 RUTIKA DEWI (0000500223633) 29/10/2022 29/10/2022 Paket Persalinan per Vaginam normal (oleh Bidan) Elis Trisnawati, A.Md.Keb Rp. 700.000

B00086581022P000024 TINA NURHAYATI (0002288651523) 30/10/2022 31/10/2022 Paket Persalinan per Vaginam normal (oleh Bidan) Elis Trisnawati, A.Md.Keb Rp. 700.000

Tanggal terima FPK, Tanggal, 05/11/2022

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