DAFTAR TANDA TERIMA 60 % KLAIM NON KAPITASI RAWAT INAP

BULAN Desember 2022

MEDIS
NO NAMA/NIP GOL JUMLAH (RP) PPH PSL 21 (RP) JMLH DITERIMA (RP) TANDA TANGAN
1 dr.Lisa Nurul Hidayah III.c Rp 1,457,739.00 Rp 72,886.95 Rp 1,384,852.05 1
19860909 201704 2 002
JUMLAH Rp 1,457,739.00 Rp 72,886.95 Rp 1,384,852.05

PARAMEDIS
NO NAMA/NIP GOL JUMLAH (RP) PPH PSL 21 (RP) JMLH DITERIMA (RP) TANDA TANGAN
1 Dian Gusti Aprima Vista III.a Rp 758,024 Rp 37,901 Rp 720,123 1 485,913.00
Nip. 199206052019032007
2 Budi setyawan Rp 602,532 Rp 602,532 2 485,913 388,730

3 Deka A.Handoko Rp 485,913 Rp 485,913 3 -

272,111.28
4 Ari Purwadi Rp 485,913 Rp 485,913 4 116,619.12

5 Singgih A.S Rp 485,913 Rp 485,913 5

6 Amelia Wijayanti Rp 485,913 Rp 485,913 6

7 Dina Mariana Rp 485,913 Rp 485,913 7

8 Siti Masitoh Rp 485,913 Rp 485,913 8

9 Novrin Rp 485,913 Rp 485,913 9

10 Heriyanto Rp 485,913 Rp 485,913 10

11 Retno Wulandari Rp 485,913 Rp 485,913 11

12 R. Ayu Hamidah Rp 97,183 Rp 4,859.13 Rp 92,323 12

Jumlah Rp 5,830,956 Rp 42,760 Rp 5,788,196

MANAJEMEN
 NO NAMA/NIP GOL JUMLAH (RP) PPH PSL 21 (RP) JMLH DITERIMA (RP) TANDA TANGAN
1 Muhamad fauzi,SKM III.d Rp 583,096 Rp 29,154.78 Rp 553,940.82 1
NIP.19690530 199003 1 003
2 Heti Andriani,SKM III.c Rp 524,786 Rp 26,239.30 Rp 498,546.74 2
Nip.19840219 201001 2 019
3 Vifi Kurniawati,AM.KG III.b Rp 485,913 Rp 24,295.65 Rp 461,617.35 3
NIP.198206022006042011
4 Sulistyaningrum,Str.Keb III.b Rp 174,929 Rp 8,746.43 Rp 166,182.25 4
NIP. 197604152006042007
5 Eka Hertati Apriani,SKM III.a Rp 174,929 Rp 8,746.43 Rp 166,182.25 5
NIP.19790405 201408 2 002

JUMLAH Rp 1,943,652 Rp 97,182.60 Rp 1,846,469.40

APOTEK / GUDANG
NO NAMA/NIP GOL JUMLAH (RP) PPH PSL 21 (RP) JMLH DITERIMA (RP) TANDA TANGAN
1 Apt. Yohana Alpionita S.Farm III.b Rp 164,434 Rp 8,221.70 Rp 164,434 1
NIP.19960829 202203 2 011
2 Maya Oktariawati, S.farm,Apt Rp 121,479 Rp 121,479 2

3 Masmarlinda III.c Rp 100,000 Rp 5,000.00 Rp 100,000 3

NIP. 197805081998032004
4 Rahmiyanti IIIB Rp 100,000 Rp 5,000.00 Rp 100,000 4
NIP. 19770822 200701 2 010

JUMLAH Rp 485,913 Rp 18,221.70 Rp 485,913.00

Mengetahui Yang Membayar

Ka.UPT Puskesmas Nawangsasi Bendahara Pengeluaran

Muhamad Fauzi,SKM Vifi Kurniawati,AM.KG

NIP.19690530 199003 1 003 NIP.19910123 201212 2 001
DAFTAR TANDA TERIMA 60 % KLAIM NON KAPITASI PONED
BULAN DESEMBER 2022
MEDIS
NO NAMA/NIP GOL JUMLAH (RP) PPH PSL 21 (RP) JMLH DITERIMA (RP) TANDA TANGAN
1 dr.Lisa Nurul Hidayah III.c Rp 189,000.00 Rp 9,450.00 Rp 179,550.00 1
19860909 201704 2 002
JUMLAH Rp 189,000.00 Rp 9,450.00 Rp 179,550.00

PARAMEDIS
NO NAMA/NIP GOL JUMLAH (RP) PPH PSL 21 (RP) JMLH DITERIMA (RP) TANDA TANGAN
1 Meilis III a Rp 120,960 Rp 6,048 Rp 114,912 1
NIP.197405162006042003
2 Nurul Karimah, Am.Keb IIIb Rp 75,600 Rp 3,780 Rp 71,820 2
NIP. 198805012010012008
3 Maria Widia Hartini,A.Md.Keb IIIA Rp 75,600 Rp 3,780 Rp 71,820 3
NIP.19770322 200701 2 003
4 Herawati,A.Md.Keb. III/d Rp 75,600 Rp 3,780 Rp 71,820 4
NIP.19730527 199301 2 002
5 Sri Mulasih, Am.Keb IIIa Rp 75,600 Rp 3,780 Rp 71,820 5
NIP.197807122007012010
6 Heny Ayu, Am.Keb Rp 75,600 Rp - Rp 75,600 6

7 Rahma oktaviani, Am.Keb Rp 105,840 Rp - Rp 105,840 7

8 Cahyawati Okti, Am.Keb Rp 75,600 Rp - Rp 75,600 8

9 Fitri Imsaq, S.ST Rp 75,600 Rp - Rp 75,600 9

JUMLAH Rp 756,000 Rp 21,168 Rp 734,832

MANAJEMEN
NIP.19690530 199003 1 003
2 Heti Andriani,SKM III.c Rp 75,600.00 Rp 3,780.00 Rp 71,820.00 2
Nip.19840219 201001 2 019
3 Vifi Kurniawati,AM.KG III.b Rp 63,000.00 Rp 3,150.00 Rp 59,850.00 3
NIP.198206022006042011
4 Sulistyaningrum,Str.Keb III.b Rp 25,200.00 Rp 1,260.00 Rp 23,940.00 4
NIP. 197604152006042007
JUMLAH Rp 252,000.00 Rp 12,600.00 Rp 239,400.00

APOTEK / GUDANG
NO NAMA/NIP GOL JUMLAH (RP) PPH PSL 21 (RP) JMLH DITERIMA (RP) TANDA TANGAN
1 Apt. Yohana Alpionita S.Farm III.b Rp 23,000.00 Rp 1,150.00 Rp 21,850.00 1
NIP.19960829 202203 2 011
2 Maya Oktariawati, S.farm,Apt Rp 17,000.00 Rp 17,000.00 2

3 Masmarlinda III.c Rp 11,500.00 Rp 575.00 Rp 11,500.00 3

NIP. 197805081998032004
4 Rahmiyanti IIIB Rp 11,500.00 Rp 575.00 Rp 11,500.00 4
NIP. 19770822 200701 2 010

JUMLAH Rp 63,000.00 Rp 2,300.00 Rp 61,850.00

Rp 276,569.59
Rp 1,260,000.00

Mengetahui Yang Membayar

Mengetahui Yang Membayar

Ka.UPT Puskesmas Nawangsasi Bendahara Pengeluaran
Muhamad Fauzi,SKM Vifi Kurniawati,AM.KG

NIP.19690530 199003 1 003 NIP.19910123 201212 2 001

Rp 82,336.95
Rp 33,564.78
Rp 30,019.30
Rp 27,445.65
Rp 10,006.43
Rp 10,006.43

Rp 8,221.70
DAFTAR TANDA TERIMA 60 % KLAIM NON KAPITASI RAWAT INAP
BULAN JANUARI 2023

MEDIS
NO NAMA/NIP GOL JUMLAH (RP) PPH PSL 21 (RP) JMLH DITERIMA (RP) 9% Hasil TANDA TANGAN
1 dr.Lisa Nurul Hidayah III.c Rp 1,450,539.00 Rp 72,526.95 Rp 1,378,012.05 Rp 124,021.08 Rp 1,253,990.97 1
19860909 201704 2 002
JUMLAH Rp 1,450,539.00 Rp 72,526.95 Rp 1,378,012.05 Rp 124,021.08 Rp 1,253,990.97

PARAMEDIS
NO NAMA/NIP GOL JUMLAH (RP) PPH PSL 21 (RP) JMLH DITERIMA (RP) 9% Hasil TANDA TANGAN
1 Dian Gusti Aprima Vista III.a Rp 696,259 Rp 34,813 Rp 661,446 Rp 59,530.12 Rp 601,916 1
Nip. 199206052019032007
2 Budi setyawan Rp 553,436 Rp 553,436 Rp 49,809.28 Rp 503,627 2

3 Deka A.Handoko Rp 446,320 Rp 446,320 Rp 40,168.77 Rp 406,151 3

4 Ari Purwadi Rp 446,320 Rp 446,320 Rp 40,168.77 Rp 406,151 4

5 Singgih A.S Rp 446,320 Rp 446,320 Rp 40,168.77 Rp 406,151 5

6 Amelia Wijayanti Rp 446,320 Rp 446,320 Rp 40,168.77 Rp 406,151 6

7 Dina Mariana Rp 446,320 Rp 446,320 Rp 40,168.77 Rp 406,151 7

8 Siti Masitoh Rp 446,320 Rp 446,320 Rp 40,168.77 Rp 406,151 8

9 Novrin Rp 446,320 Rp 446,320 Rp 40,168.77 Rp 406,151 9

10 Heriyanto Rp 446,320 Rp 446,320 Rp 40,168.77 Rp 406,151 10

11 Retno Wulandari Rp 446,320 Rp 446,320 Rp 40,168.77 Rp 406,151 11

12 Diati Vistasari Rp 446,320 Rp 446,320 Rp 40,168.77 Rp 406,151 12

13 R. Ayu Hamidah Rp 89,264 Rp 4,463.20 Rp 84,801 Rp 7,632.07 Rp 77,169 13

Jumlah Rp 5,802,156 Rp 39,276 Rp 5,762,880 Rp 518,659 Rp 5,244,221

MANAJEMEN
NO NAMA/NIP GOL JUMLAH (RP) PPH PSL 21 (RP) JMLH DITERIMA (RP) 9% Hasil TANDA TANGAN
1 Muhamad fauzi,SKM III.d Rp 676,918 Rp 33,845.91 Rp 643,072.29 Rp 57,876.51 Rp 585,196 1
NIP.19690530 199003 1 003
2 Heti Andriani,SKM III.c Rp 580,216 Rp 29,010.78 Rp 551,204.82 Rp 49,608.43 Rp 501,596 2
Nip.19840219 201001 2 019
3 Vifi Kurniawati,AM.KG III.b Rp 483,513 Rp 24,175.65 Rp 459,337.35 Rp 41,340.36 Rp 417,997 3
NIP.198206022006042011
 4 Sulistyaningrum,Str.Keb III.b Rp 193,405 Rp 9,670.26 Rp 183,734.94 Rp 16,536.14 Rp 167,199 4
NIP. 197604152006042007

JUMLAH Rp 1,934,052 Rp 96,702.60 Rp 1,837,349.40 Rp 165,361.45 Rp 1,671,988

APOTEK / GUDANG
NO NAMA/NIP GOL JUMLAH (RP) PPH PSL 21 (RP) JMLH DITERIMA (RP) 9% Hasil TANDA TANGAN
1 Apt. Yohana Alpionita S.Farm III.b Rp 140,878 Rp 7,043.90 Rp 140,878 Rp 12,679.02 Rp 128,199 1
NIP.19960829 202203 2 011
2 Maya Oktariawati, S.farm,Apt Rp 120,879 Rp 120,879 Rp 10,879.11 Rp 110,000 2

3 Masmarlinda III.c Rp 110,878 Rp 5,543.90 Rp 110,878 Rp 9,979.02 Rp 100,899 3

NIP. 197805081998032004
4 Rahmiyanti IIIB Rp 110,878 Rp 5,543.90 Rp 110,878 Rp 9,979.02 Rp 100,899 4
NIP. 19770822 200701 2 010
JUMLAH Rp 483,513 Rp 18,132 Rp 483,513 Rp 43,516 Rp 439,997
DAFTAR TANDA TERIMA 60 % KLAIM NON KAPITASI PONED
BULAN JANUARI 2023
MEDIS
NO NAMA/NIP GOL JUMLAH (RP) PPH PSL 21 (RP) JMLH DITERIMA (RP) 9% Hasil TANDA TANGAN
1 dr.Lisa Nurul Hidayah III.c Rp 207,000.00 Rp 10,350.00 Rp 196,650.00 Rp 17,698.50 Rp 178,951.50 1
19860909 201704 2 002
JUMLAH Rp 207,000.00 Rp 10,350.00 Rp 196,650.00 Rp 17,698.50 Rp 178,951.50

PARAMEDIS
NO NAMA/NIP GOL JUMLAH (RP) PPH PSL 21 (RP) JMLH DITERIMA (RP) 9% Hasil TANDA TANGAN
1 Meilis III a Rp 132,480 Rp 6,624 Rp 125,856 Rp 11,327.04 Rp 114,529 1
NIP.197405162006042003
2 Nurul Karimah, Am.Keb IIIb Rp 82,800 Rp 4,140 Rp 78,660 Rp 7,079.40 Rp 71,581 2
NIP. 198805012010012008
3 Maria Widia Hartini,A.Md.Keb IIIA Rp 82,800 Rp 4,140 Rp 78,660 Rp 7,079.40 Rp 71,581 3
NIP.19770322 200701 2 003
4 Arista Aditama,A.Md.Keb. II/c Rp 82,800 Rp - Rp 82,800 Rp 7,452.00 Rp 75,348 4
NIP.199304042022032013
5 Sri Mulasih, Am.Keb IIIa Rp 82,800 Rp 4,140 Rp 78,660 Rp 7,079.40 Rp 71,581 5
NIP.197807122007012010
6 Heny Ayu, Am.Keb Rp 82,800 Rp - Rp 82,800 Rp 7,452.00 Rp 75,348 6

7 Rahma oktaviani, Am.Keb Rp 115,920 Rp - Rp 115,920 Rp 10,432.80 Rp 105,487 7

8 Cahyawati Okti, Am.Keb Rp 82,800 Rp - Rp 82,800 Rp 7,452.00 Rp 75,348 8

9 Welnia,Amd.Keb Rp 82,800 Rp - Rp 82,800 Rp 7,452.00 Rp 75,348

JUMLAH Rp 828,000 Rp 19,044 Rp 808,956 Rp 72,806 Rp 736,150

MANAJEMEN
NO NAMA/NIP GOL JUMLAH (RP) PPH PSL 21 (RP) JMLH DITERIMA (RP) 9% Hasil TANDA TANGAN
1 Muhamad fauzi,SKM III.d Rp 96,600.00 Rp 4,830.00 Rp 91,770.00 Rp 8,259.30 Rp 83,510.70 1
NIP.19690530 199003 1 003
2 Heti Andriani,SKM III.c Rp 82,800.00 Rp 4,140.00 Rp 78,660.00 Rp 7,079.40 Rp 71,580.60 2
Nip.19840219 201001 2 019
3 Vifi Kurniawati,AM.KG III.b Rp 69,000.00 Rp 3,450.00 Rp 65,550.00 Rp 5,899.50 Rp 59,650.50 3
NIP.198206022006042011
4 Sulistyaningrum,Str.Keb III.b Rp 27,600.00 Rp 1,380.00 Rp 26,220.00 Rp 2,359.80 Rp 23,860.20 4
NIP. 197604152006042007
JUMLAH Rp 276,000.00 Rp 13,800.00 Rp 262,200.00 Rp 23,598.00 Rp 238,602.00

APOTEK / GUDANG
NO NAMA/NIP GOL JUMLAH (RP) PPH PSL 21 (RP) JMLH DITERIMA (RP) 9% Hasil TANDA TANGAN
1 Apt. Yohana Alpionita S.Farm III.b Rp 22,080.00 Rp 1,104.00 Rp 20,976.00 Rp 1,887.84 Rp 19,088.16 1
NIP.19960829 202203 2 011
2 Maya Oktariawati, S.farm,Apt Rp 19,320.00 Rp 19,320.00 Rp 1,738.80 Rp 17,581.20 2

3 Masmarlinda III.c Rp 13,800.00 Rp 690.00 Rp 13,800.00 Rp 1,242.00 Rp 12,558.00 3

NIP. 197805081998032004
4 Rahmiyanti IIIB Rp 13,800.00 Rp 690.00 Rp 13,800.00 Rp 1,242.00 Rp 12,558.00 4
NIP. 19770822 200701 2 010
JUMLAH Rp 69,000.00 Rp 2,484.00 Rp 67,896.00 Rp 6,110.64 Rp 61,785.36

Mengetahui Yang Membayar

Ka UPT Puskesmas Nawangsasi Bendahara Pengeluaran

Muhamad Fauzi,SKM Vifi Kurniawati,AM.KG

NIP.19690530 199003 1 003 NIP.19910123 201212 2 001
Rp 1,657,539.00 227669.4 Rp 82,876.95

Rp 1,450,539.00

5,802,156 446,319.69

- 446,319.69 357,056

-
249,939.03
107,116.73

Rp 5,802,156

1934052
Rp 773,518.20 Rp 38,675.91
Rp 663,015.60 Rp 33,150.78
Rp 552,513.00 Rp 27,625.65
Rp 221,005.20 Rp 11,050.26
Rp 221,005.20 Rp 11,050.26
 483513

120878.25
Rp 140,199.00 Rp 7,043.90

276000
828000
82800
49680
33120

63000

15750
69000
13800
8280
5520
DAFTAR TANDA TERIMA 60 % KLAIM NON KAPITASI RAWAT INAP
BULAN Februari 2023

MEDIS
NO NAMA/NIP GOL JUMLAH (RP) PPH PSL 21 (RP) JMLH DITERIMA (RP) TANDA TANGAN
1 dr.Lisa Nurul Hidayah III.c Rp 1,341,639.00 Rp 67,081.95 Rp 1,274,557.05 1
19860909 201704 2 002
JUMLAH Rp 1,341,639.00 Rp 67,081.95 Rp 1,274,557.05

PARAMEDIS
NO NAMA/NIP GOL JUMLAH (RP) PPH PSL 21 (RP) JMLH DITERIMA (RP) TANDA TANGAN
1 Dian Gusti Aprima Vista III.a Rp 643,987 Rp 32,199 Rp 611,787 1
Nip. 199206052019032007
2 Budi setyawan Rp 511,887 Rp 511,887 2

3 Deka A.Handoko Rp 435,746 Rp 435,746 3

4 Ari Purwadi Rp 435,746 Rp 435,746 4

5 Singgih A.S Rp 435,746 Rp 435,746 5

6 Amelia Wijayanti Rp 435,746 Rp 435,746 6

7 Dina Mariana Rp 435,746 Rp 435,746 7

8 Siti Masitoh Rp 435,746 Rp 435,746 8

9 Novrin Rp 435,746 Rp 435,746 9

10 Heriyanto Rp 435,746 Rp 435,746 10

11 Retno Wulandari Rp 435,746 Rp 435,746 11

12 Diati Vistasari Rp 206,406 Rp 206,406 12

13 R. Ayu Hamidah Rp 82,562 Rp 4,128.12 Rp 78,434 13

 Jumlah Rp 5,366,556 Rp 36,327 Rp 5,330,229

MANAJEMEN
NO NAMA/NIP GOL JUMLAH (RP) PPH PSL 21 (RP) JMLH DITERIMA (RP) TANDA TANGAN
1 Muhamad fauzi,SKM III.d Rp 626,098 Rp 31,304.91 Rp 594,793.29 1
NIP.19690530 199003 1 003
2 Heti Andriani,SKM III.c Rp 536,656 Rp 26,832.78 Rp 509,822.82 2
Nip.19840219 201001 2 019
3 Vifi Kurniawati,AM.KG III.b Rp 447,213 Rp 22,360.65 Rp 424,852.35 3
NIP.198206022006042011
4 Dian Gusti Aprima Vista III.a Rp 178,885 Rp 8,944.26 Rp 169,940.94 4
Nip. 199206052019032007

JUMLAH Rp 1,788,852 Rp 89,442.60 Rp 1,699,409.40

APOTEK / GUDANG
NO NAMA/NIP GOL JUMLAH (RP) PPH PSL 21 (RP) JMLH DITERIMA (RP) TANDA TANGAN
1 Apt. Yohana Alpionita S.Farm III.b Rp 134,804 Rp 6,740.20 Rp 134,804 1
NIP.19960829 202203 2 011
2 Maya Oktariawati, S.farm,Apt Rp 120,803 Rp 120,803 2

3 Masmarlinda III.c Rp 95,803 Rp 4,790.15 Rp 95,803 3

NIP. 197805081998032004
4 Rahmiyanti IIIB Rp 95,803 Rp 4,790.15 Rp 95,803 4
NIP. 19770822 200701 2 010
JUMLAH Rp 447,213 Rp 16,321 Rp 447,213
Rp 209,172.51
DAFTAR TANDA TERIMA 60 % KLAIM NON KAPITASI PONED
BULAN Februari 2023
MEDIS
NO NAMA/NIP GOL JUMLAH (RP) PPH PSL 21 (RP) JMLH DITERIMA (RP) TANDA TANGAN
1 dr.Lisa Nurul Hidayah III.c Rp 270,000.00 Rp 13,500.00 Rp 256,500.00 1
19860909 201704 2 002
JUMLAH Rp 270,000.00 Rp 13,500.00 Rp 256,500.00

PARAMEDIS
NO NAMA/NIP GOL JUMLAH (RP) PPH PSL 21 (RP) JMLH DITERIMA (RP) TANDA TANGAN
1 Meilis III a Rp 172,800 Rp 8,640 Rp 164,160 1
NIP.197405162006042003
2 Nurul Karimah, Am.Keb IIIb Rp 108,000 Rp 5,400 Rp 102,600 2
NIP. 198805012010012008
3 Maria Widia Hartini,A.Md.Keb IIIA Rp 108,000 Rp 5,400 Rp 102,600 3
NIP.19770322 200701 2 003
4 Arista Aditama,A.Md.Keb. II/c Rp 108,000 Rp - Rp 108,000 4
NIP.199304042022032013
5 Sri Mulasih, Am.Keb IIIa Rp 108,000 Rp 5,400 Rp 102,600 5
NIP.197807122007012010
6 Heny Ayu, Am.Keb Rp 108,000 Rp - Rp 108,000 6

7 Rahma oktaviani, Am.Keb Rp 151,200 Rp - Rp 151,200 7

8 Cahyawati Okti, Am.Keb Rp 108,000 Rp - Rp 108,000 8

9 Welnia,Amd.Keb Rp 108,000 Rp - Rp 108,000

JUMLAH Rp 1,080,000 Rp 24,840 Rp 1,055,160

MANAJEMEN
NO NAMA/NIP GOL JUMLAH (RP) PPH PSL 21 (RP) JMLH DITERIMA (RP) TANDA TANGAN
1 Muhamad fauzi,SKM III.d Rp 126,000.00 Rp 6,300.00 Rp 119,700.00 1
NIP.19690530 199003 1 003
2 Heti Andriani,SKM III.c Rp 108,000.00 Rp 5,400.00 Rp 102,600.00 2
Nip.19840219 201001 2 019
3 Vifi Kurniawati,AM.KG III.b Rp 90,000.00 Rp 4,500.00 Rp 85,500.00 3
NIP.198206022006042011
4 Dian Gusti Aprima Vista III.a Rp 36,000.00 Rp 1,800.00 Rp 34,200.00 4
Nip. 199206052019032007
JUMLAH Rp 360,000.00 Rp 18,000.00 Rp 342,000.00

APOTEK / GUDANG
NO NAMA/NIP GOL JUMLAH (RP) PPH PSL 21 (RP) JMLH DITERIMA (RP) TANDA TANGAN
1 Apt. Yohana Alpionita S.Farm III.b Rp 28,800.00 Rp 1,440.00 Rp 27,360.00 1
NIP.19960829 202203 2 011
2 Maya Oktariawati, S.farm,Apt Rp 25,200.00 Rp 25,200.00 2

3 Masmarlinda III.c Rp 18,000.00 Rp 900.00 Rp 18,000.00 3

NIP. 197805081998032004
4 Rahmiyanti IIIB Rp 18,000.00 Rp 900.00 Rp 18,000.00 4
NIP. 19770822 200701 2 010
JUMLAH Rp 90,000.00 Rp 3,240.00 Rp 88,560.00
Rp 59,580.00

Mengetahui Yang Membayar

Ka UPT Puskesmas Nawangsasi Bendahara Pengeluaran

Muhamad Fauzi,SKM Vifi Kurniawati,AM.KG

NIP.19690530 199003 1 003 NIP.19910123 201212 2 001
DAFTAR TANDA TERIMA 60 % KLAIM NON KAPITASI ANC
BULAN Februari 2023
MEDIS
NO NAMA/NIP GOL JUMLAH (RP) PPH PSL 21 (RP) JMLH DITERIMA (RP) TANDA TANGAN
1 dr.Lisa Nurul Hidayah III.c Rp 57,600.00 Rp 2,880.00 Rp 54,720.00 1
19860909 201704 2 002
JUMLAH Rp 57,600.00 Rp 2,880.00 Rp 54,720.00

PARAMEDIS
NO NAMA/NIP GOL JUMLAH (RP) PPH PSL 21 (RP) JMLH DITERIMA (RP) TANDA TANGAN
1 Meilis III a Rp 96,800 Rp 4,840 Rp 91,960 1
NIP.197405162006042003
2 Fitri imsaq Rp 56,800 2

3 Rahma oktaviani, Am.Keb Rp 76,800 3

JUMLAH Rp 96,800 Rp 4,840 Rp 225,560

MANAJEMEN
NO NAMA/NIP GOL JUMLAH (RP) PPH PSL 21 (RP) JMLH DITERIMA (RP) TANDA TANGAN
1 Muhamad fauzi,SKM III.d Rp 33,600.00 Rp 1,680.00 Rp 31,920.00 1
NIP.19690530 199003 1 003
2 Heti Andriani,SKM III.c Rp 28,800.00 Rp 1,440.00 Rp 27,360.00 2
Nip.19840219 201001 2 019
3 Vifi Kurniawati,AM.KG III.b Rp 24,000.00 Rp 1,200.00 Rp 22,800.00 3
NIP.198206022006042011
4 Dian Gusti Aprima Vista III.a Rp 9,600.00 Rp 480.00 Rp 9,120.00 4
Nip. 199206052019032007
JUMLAH Rp 96,000.00 Rp 4,800.00 Rp 91,200.00
Rp 12,520.00
Mengetahui Yang Membayar
Ka UPT Puskesmas Nawangsasi Bendahara Pengeluaran

Muhamad Fauzi,SKM Vifi Kurniawati,AM.KG

NIP.19690530 199003 1 003 NIP.19910123 201212 2 001
Rp 1,611,639.00 227669.4 Rp 80,581.95

Rp 1,341,639.00

5,366,556 412,812.00

- 412,812.00 330,250

-
231,174.72
99,074.88

206,406.00
22,934.00
 Rp 5,366,556

1788852
Rp 752,098.20 Rp 37,604.91
Rp 644,655.60 Rp 32,232.78
Rp 537,213.00 Rp 26,860.65
Rp 214,885.20 Rp 10,744.26
Rp 214,885.20 Rp 10,744.26

447213

111803.25
Rp 146,003.00 Rp 6,740.20
360000

1080000
108000
64800
43200
63000

15750
90000
18000
10800
7200 230400
76800

96000
Rp 281,272.51
no nama gol pokok pph21 pokok
1 Apt. Yohana Alpionita S.Farm III.b 134,804.00 6,740.20 134,804.00
1 Apt. Yohana Alpionita S.Farm III.b 28,800.00 1,440.00 28,800.00
1 Dian Gusti Aprima Vista III.a 643,986.72 32,199.34 643,986.72
4 Dian Gusti Aprima Vista III.a 36,000.00 1,800.00 36,000.00
4 Dian Gusti Aprima Vista III.a 9,600.00 480.00 9,600.00
4 Dian Gusti Aprima Vista III.a 178,885.20 8,944.26 178,885.20
1 dr.Lisa Nurul Hidayah III.c 1,341,639.00 67,081.95 1,341,639.00
1 dr.Lisa Nurul Hidayah III.c 57,600.00 2,880.00 57,600.00
1 dr.Lisa Nurul Hidayah III.c 270,000.00 13,500.00 270,000.00
2 Heti Andriani,SKM III.c 536,655.60 26,832.78 536,655.60
2 Heti Andriani,SKM III.c 108,000.00 5,400.00 108,000.00
2 Heti Andriani,SKM III.c 28,800.00 1,440.00 28,800.00
3 Maria Widia Hartini,A.Md.Keb IIIA 108,000.00 5,400.00 108,000.00
3 Masmarlinda III.c 95,803.00 4,790.15 95,803.00
3 Masmarlinda III.c 18,000.00 900.00 18,000.00
1 Meilis III a 172,800.00 8,640.00 172,800.00
1 Meilis III a 96,800.00 4,840.00 96,800.00
1 Muhamad fauzi,SKM III.d 626,098.20 31,304.91 626,098.20
1 Muhamad fauzi,SKM III.d 126,000.00 6,300.00 126,000.00
1 Muhamad fauzi,SKM III.d 33,600.00 1,680.00 33,600.00
2 Nurul Karimah, Am.Keb IIIb 108,000.00 5,400.00 108,000.00
13 R. Ayu Hamidah 82,562.40 4,128.12 82,562.40
4 Rahmiyanti IIIB 95,803.00 4,790.15 95,803.00
4 Rahmiyanti IIIB 18,000.00 900.00 18,000.00
5 Sri Mulasih, Am.Keb IIIa 108,000.00 5,400.00 108,000.00
3 Vifi Kurniawati,AM.KG III.b 24,000.00 1,200.00 24,000.00
3 Vifi Kurniawati,AM.KG III.b 447,213.00 22,360.65 447,213.00
3 Vifi Kurniawati,AM.KG III.b 90,000.00 4,500.00 90,000.00
pph21 pokok pph21
6,740.20 163,604.00 8,180.20 163,604.00 8,180.00
1,440.00 - -
32,199.34 868,471.92 43,423.60 868,472.00 43,424.00
1,800.00 - -
480.00 - -
8,944.26 - -
67,081.95 1,669,239.00 83,461.95 1,669,239.00 83,462.00
2,880.00 - -
13,500.00 - -
26,832.78 673,455.60 33,672.78 673,456.00 33,673.00
5,400.00 - -
1,440.00 - -
5,400.00 108,000.00 5,400.00 108,000.00 5,400.00
4,790.15 113,803.00 5,690.15 113,803.00 5,690.00
900.00 - -
8,640.00 269,600.00 13,480.00 269,600.00 13,480.00
4,840.00 - -
31,304.91 785,698.20 39,284.91 785,698.00 39,285.00
6,300.00 - -
1,680.00 - -
5,400.00 108,000.00 5,400.00 108,000.00 5,400.00
4,128.12 82,562.40 4,128.12 82,562.00 4,128.00
4,790.15 113,803.00 5,690.15 113,803.00 5,690.00
900.00 - -
5,400.00 108,000.00 5,400.00 108,000.00 5,400.00
1,200.00 561,213.00 28,060.65 561,213.00 28,061.00
22,360.65
4,500.00

281,272.51
DAFTAR TANDA TERIMA 60 % KLAIM NON KAPITASI RAWAT INAP
BULAN Februari 2023

MEDIS
NO NAMA/NIP GOL JUMLAH (RP) TANDA TANGAN
1 dr.Lisa Nurul Hidayah III.c Rp 1,255,731.60 1
19860909 201704 2 002
JUMLAH Rp 1,255,731.60

PARAMEDIS
NO NAMA/NIP GOL JUMLAH (RP) TANDA TANGAN
1 Dian Gusti Aprima Vista III.a Rp 602,751 1
Nip. 199206052019032007
2 Budi setyawan Rp 479,110 2

3 Deka A.Handoko Rp 407,844 3

4 Ari Purwadi Rp 407,844 4

5 Singgih A.S Rp 407,844 5

6 Amelia Wijayanti Rp 407,844 6

7 Dina Mariana Rp 407,844 7

8 Siti Masitoh Rp 407,844 8

9 Novrin Rp 407,844 9

10 Heriyanto Rp 407,844 10

11 Retno Wulandari Rp 407,844 11

12 Diati Vistasari Rp 193,189 12

13 R. Ayu Hamidah Rp 77,276 13

Jumlah Rp 5,022,926

MANAJEMEN
NO NAMA/NIP GOL JUMLAH (RP) TANDA TANGAN
1 Muhamad fauzi,SKM III.d Rp 586,008 1
NIP.19690530 199003 1 003
2 Heti Andriani,SKM III.c Rp 502,293 2
Nip.19840219 201001 2 019
3 Vifi Kurniawati,AM.KG III.b Rp 418,577 3
NIP.198206022006042011
4 Dian Gusti Aprima Vista III.a Rp 167,431 4
Nip. 199206052019032007

JUMLAH Rp 1,674,309

APOTEK / GUDANG
NO NAMA/NIP GOL JUMLAH (RP) TANDA TANGAN
1 Apt. Yohana Alpionita S.Farm III.b Rp 126,645 1
NIP.19960829 202203 2 011
2 Maya Oktariawati, S.farm,Apt Rp 110,644 2

3 Masmarlinda III.c Rp 90,644 3

NIP. 197805081998032004
4 Rahmiyanti IIIB Rp 90,644 4
NIP. 19770822 200701 2 010
JUMLAH Rp 418,577

Mengetahui Bendahara Pengeluaran Pembantu

Ka UPT Puskesmas Nawangsasi

Vifi Kurniawati,AMKG
Muhamad Fauzi,SKM Nip.199101232012122001
NIP.19690530 199003 1 003
DAFTAR TANDA TERIMA 60 % KLAIM NON KAPITASI PONED
BULAN Februari 2023
MEDIS
NO NAMA/NIP GOL JUMLAH (RP) TANDA TANGAN
1 dr.Lisa Nurul Hidayah III.c Rp 251,100.00 1
19860909 201704 2 002
JUMLAH Rp 251,100.00

PARAMEDIS
NO NAMA/NIP GOL JUMLAH (RP) TANDA TANGAN
1 Meilis III a Rp 160,704 1
NIP.197405162006042003
2 Nurul Karimah, Am.Keb IIIb Rp 100,440 2
NIP. 198805012010012008
3 Maria Widia Hartini,A.Md.Keb IIIA Rp 100,440 3
NIP.19770322 200701 2 003
4 Arista Aditama,A.Md.Keb. II/c Rp 100,440 4
NIP.199304042022032013
5 Sri Mulasih, Am.Keb IIIa Rp 100,440 5
NIP.197807122007012010
6 Heny Ayu, Am.Keb Rp 100,440 6

7 Rahma oktaviani, Am.Keb Rp 140,616 7

8 Cahyawati Okti, Am.Keb Rp 100,440 8

9 Welnia,Amd.Keb Rp 100,440 9

JUMLAH Rp 1,004,400

MANAJEMEN
NO NAMA/NIP GOL JUMLAH (RP) TANDA TANGAN
1 Muhamad fauzi,SKM III.d Rp 117,180 1
NIP.19690530 199003 1 003
2 Heti Andriani,SKM III.c Rp 100,440 2
Nip.19840219 201001 2 019
3 Vifi Kurniawati,AM.KG III.b Rp 83,700 3
NIP.198206022006042011
4 Dian Gusti Aprima Vista III.a Rp 33,480 4
Nip. 199206052019032007
JUMLAH Rp 334,800

APOTEK / GUDANG
NO NAMA/NIP GOL JUMLAH (RP) TANDA TANGAN
1 Apt. Yohana Alpionita S.Farm III.b Rp 30,925 1
NIP.19960829 202203 2 011
2 Maya Oktariawati, S.farm,Apt Rp 20,925 2
3 Masmarlinda III.c Rp 15,925 3
NIP. 197805081998032004
4 Rahmiyanti IIIB Rp 15,925 4
NIP. 19770822 200701 2 010
JUMLAH Rp 83,700.00

Mengetahui Bendahara Pengeluaran Pembantu

Ka UPT Puskesmas Nawangsasi

Vifi Kurniawati,AMKG
Muhamad Fauzi,SKM Nip.199101232012122001
NIP.19690530 199003 1 003
DAFTAR TANDA TERIMA 60 % KLAIM NON KAPITASI ANC
BULAN Februari 2023
MEDIS
NO NAMA/NIP GOL JUMLAH (RP) TANDA TANGAN
1 dr.Lisa Nurul Hidayah III.c Rp 53,593 1
19860909 201704 2 002
JUMLAH Rp 53,593

PARAMEDIS
NO NAMA/NIP GOL JUMLAH (RP) TANDA TANGAN
1 Meilis III a Rp 85,749 1
NIP.197405162006042003
2 Fitri imsaq Rp 53,593 2

3 Rahma oktaviani, Am.Keb Rp 75,030 3

JUMLAH Rp 214,372

MANAJEMEN
NO NAMA/NIP GOL JUMLAH (RP) TANDA TANGAN
1 Muhamad fauzi,SKM III.d Rp 31,263 1
NIP.19690530 199003 1 003
2 Heti Andriani,SKM III.c Rp 26,797 2
Nip.19840219 201001 2 019
3 Vifi Kurniawati,AM.KG III.b Rp 22,331 3
NIP.198206022006042011
4 Dian Gusti Aprima Vista III.a Rp 8,932 4
Nip. 199206052019032007
JUMLAH Rp 89,322

Mengetahui
Ka UPT Puskesmas Nawangsasi Bendahara Pengeluaran Pembantu

Muhamad Fauzi,SKM Vifi Kurniawati,AMKG

NIP.19690530 199003 1 003 Nip.199101232012122001
DAFTAR TANDA TERIMA 60 % KLAIM NON KAPITASI RAWAT INAP
BULAN Maret 2023

MEDIS
NO NAMA/NIP GOL JUMLAH (RP) PPH PSL 21 (RP) JMLH DITERIMA (RP) TANDA TANGAN
1 dr.Lisa Nurul Hidayah III.c Rp 2,551,239.00 Rp 127,561.95 Rp 2,423,677.05 1
19860909 201704 2 002
JUMLAH Rp 2,551,239.00 Rp 127,561.95 Rp 2,423,677.05

PARAMEDIS
NO NAMA/NIP GOL JUMLAH (RP) PPH PSL 21 (RP) JMLH DITERIMA (RP) TANDA TANGAN
1 Dian Gusti Aprima Vista III.a Rp 1,224,595 Rp 61,230 Rp 1,163,365 1
Nip. 199206052019032007
2 Budi setyawan Rp 973,396 Rp 973,396 2

3 Deka A.Handoko Rp 828,608 Rp 828,608 3

4 Ari Purwadi Rp 828,608 Rp 828,608 4

5 Singgih A.S Rp 828,608 Rp 828,608 5

6 Amelia Wijayanti Rp 828,608 Rp 828,608 6

7 Dina Mariana Rp 828,608 Rp 828,608 7

8 Siti Masitoh Rp 828,608 Rp 828,608 8

9 Novrin Rp 828,608 Rp 828,608 9

10 Heriyanto Rp 828,608 Rp 828,608 10

11 Retno Wulandari Rp 828,608 Rp 828,608 11

12 Diati Vistasari Rp 392,498 Rp 392,498 12

 13 R. Ayu Hamidah Rp 156,999 Rp 7,849.97 Rp 149,149 13

Jumlah Rp 10,204,956 Rp 69,080 Rp 10,135,876

MANAJEMEN
NO NAMA/NIP GOL JUMLAH (RP) PPH PSL 21 (RP) JMLH DITERIMA (RP) TANDA TANGAN
1 Muhamad fauzi,SKM III.d Rp 1,190,578 Rp 59,528.91 Rp 1,131,049.29 1
NIP.19690530 199003 1 003
2 Heti Andriani,SKM III.c Rp 1,020,496 Rp 51,024.78 Rp 969,470.82 2
Nip.19840219 201001 2 019
3 Vifi Kurniawati,AM.KG III.b Rp 850,413 Rp 42,520.65 Rp 807,892.35 3
NIP.198206022006042011
4 Dian Gusti Aprima Vista III.a Rp 340,165 Rp 17,008.26 Rp 323,156.94 4
Nip. 199206052019032007

JUMLAH Rp 3,401,652 Rp 170,082.60 Rp 3,231,569.40

APOTEK / GUDANG
NO NAMA/NIP GOL JUMLAH (RP) PPH PSL 21 (RP) JMLH DITERIMA (RP) TANDA TANGAN
1 Apt. Yohana Alpionita S.Farm III.b Rp 232,604 Rp 11,630.20 Rp 232,604 1
NIP.19960829 202203 2 011
2 Maya Oktariawati, S.farm,Apt Rp 216,603 Rp 216,603 2

3 Masmarlinda III.c Rp 200,603 Rp 10,030.15 Rp 200,603 3

NIP. 197805081998032004
4 Rahmiyanti IIIB Rp 200,603 Rp 10,030.15 Rp 200,603 4
NIP. 19770822 200701 2 010
JUMLAH Rp 850,413 Rp 31,691 Rp 850,413
Rp 398,414.75
DAFTAR TANDA TERIMA 60 % KLAIM NON KAPITASI PONED
BULAN Maret 2023
MEDIS
NO NAMA/NIP GOL JUMLAH (RP) PPH PSL 21 (RP) JMLH DITERIMA (RP) TANDA TANGAN
1 dr.Lisa Nurul Hidayah III.c Rp 270,000.00 Rp 13,500.00 Rp 256,500.00 1
19860909 201704 2 002
JUMLAH Rp 270,000.00 Rp 13,500.00 Rp 256,500.00

PARAMEDIS
NO NAMA/NIP GOL JUMLAH (RP) PPH PSL 21 (RP) JMLH DITERIMA (RP) TANDA TANGAN
1 Meilis III a Rp 172,800 Rp 8,640 Rp 164,160 1
NIP.197405162006042003
2 Nurul Karimah, Am.Keb IIIb Rp 108,000 Rp 5,400 Rp 102,600 2
NIP. 198805012010012008
3 Maria Widia Hartini,A.Md.Keb IIIA Rp 108,000 Rp 5,400 Rp 102,600 3
NIP.19770322 200701 2 003
4 Arista Aditama,A.Md.Keb. II/c Rp 108,000 Rp - Rp 108,000 4
NIP.199304042022032013
5 Sri Mulasih, Am.Keb IIIa Rp 108,000 Rp 5,400 Rp 102,600 5
NIP.197807122007012010
6 Heny Ayu, Am.Keb Rp 108,000 Rp - Rp 108,000 6

7 Rahma oktaviani, Am.Keb Rp 151,200 Rp - Rp 151,200 7

8 Cahyawati Okti, Am.Keb Rp 108,000 Rp - Rp 108,000 8

9 Welnia,Amd.Keb Rp 108,000 Rp - Rp 108,000

JUMLAH Rp 1,080,000 Rp 24,840 Rp 1,055,160

MANAJEMEN
NO NAMA/NIP GOL JUMLAH (RP) PPH PSL 21 (RP) JMLH DITERIMA (RP) TANDA TANGAN
1 Muhamad fauzi,SKM III.d Rp 126,000.00 Rp 6,300.00 Rp 119,700.00 1
NIP.19690530 199003 1 003
2 Heti Andriani,SKM III.c Rp 108,000.00 Rp 5,400.00 Rp 102,600.00 2
Nip.19840219 201001 2 019
3 Vifi Kurniawati,AM.KG III.b Rp 90,000.00 Rp 4,500.00 Rp 85,500.00 3
NIP.198206022006042011
4 Dian Gusti Aprima Vista III.a Rp 36,000.00 Rp 1,800.00 Rp 34,200.00 4
Nip. 199206052019032007
JUMLAH Rp 360,000.00 Rp 18,000.00 Rp 342,000.00

APOTEK / GUDANG
NO NAMA/NIP GOL JUMLAH (RP) PPH PSL 21 (RP) JMLH DITERIMA (RP) TANDA TANGAN
1 Apt. Yohana Alpionita S.Farm III.b Rp 28,800.00 Rp 1,440.00 Rp 27,360.00 1
NIP.19960829 202203 2 011
2 Maya Oktariawati, S.farm,Apt Rp 25,200.00 Rp 25,200.00 2

3 Masmarlinda III.c Rp 18,000.00 Rp 900.00 Rp 18,000.00 3

NIP. 197805081998032004
4 Rahmiyanti IIIB Rp 18,000.00 Rp 900.00 Rp 18,000.00 4
NIP. 19770822 200701 2 010
JUMLAH Rp 90,000.00 Rp 3,240.00 Rp 88,560.00
Rp 59,580.00

Mengetahui Yang Membayar

Ka UPT Puskesmas Nawangsasi Bendahara Pengeluaran

Muhamad Fauzi,SKM Vifi Kurniawati,AM.KG

NIP.19690530 199003 1 003 NIP.19910123 201212 2 001
DAFTAR TANDA TERIMA 60 % KLAIM NON KAPITASI ANC
BULAN Maret 2023
MEDIS
NO NAMA/NIP GOL JUMLAH (RP) PPH PSL 21 (RP) JMLH DITERIMA (RP) TANDA TANGAN
1 dr.Lisa Nurul Hidayah III.c Rp 129,600.00 Rp 6,480.00 Rp 123,120.00 1
19860909 201704 2 002
JUMLAH Rp 129,600.00 Rp 6,480.00 Rp 123,120.00

PARAMEDIS
NO NAMA/NIP GOL JUMLAH (RP) PPH PSL 21 (RP) JMLH DITERIMA (RP) TANDA TANGAN
1 Meilis III a Rp 202,800 Rp 10,140 Rp 192,660 1
NIP.197405162006042003
2 Fitri imsaq Rp 142,800 Rp 56,800 2

3 Rahma oktaviani, Am.Keb Rp 172,800 Rp 76,800 3

JUMLAH Rp 518,400 Rp 10,140 Rp 326,260

MANAJEMEN
NO NAMA/NIP GOL JUMLAH (RP) PPH PSL 21 (RP) JMLH DITERIMA (RP) TANDA TANGAN
1 Muhamad fauzi,SKM III.d Rp 75,600.00 Rp 3,780.00 Rp 71,820.00 1
NIP.19690530 199003 1 003
2 Heti Andriani,SKM III.c Rp 64,800.00 Rp 3,240.00 Rp 61,560.00 2
Nip.19840219 201001 2 019
3 Vifi Kurniawati,AM.KG III.b Rp 54,000.00 Rp 2,700.00 Rp 51,300.00 3
NIP.198206022006042011
4 Dian Gusti Aprima Vista III.a Rp 21,600.00 Rp 1,080.00 Rp 20,520.00 4
Nip. 199206052019032007
JUMLAH Rp 216,000.00 Rp 10,800.00 Rp 205,200.00
Rp 27,420.00
Mengetahui Yang Membayar
Ka UPT Puskesmas Nawangsasi Bendahara Pengeluaran

Muhamad Fauzi,SKM Vifi Kurniawati,AM.KG

NIP.19690530 199003 1 003 NIP.19910123 201212 2 001
Rp 2,821,239.00 227669.4 Rp 141,061.95

Rp 2,551,239.00

10,204,956 784,996.62

- 784,996.62 627,997

-
439,598.10
188,399.19

392,498.31
43,610.92
 Rp 10,204,956

3401652
Rp 1,316,578.20 Rp 65,828.91
Rp 1,128,495.60 Rp 56,424.78
Rp 940,413.00 Rp 47,020.65
Rp 376,165.20 Rp 18,808.26
Rp 376,165.20 Rp 18,808.26

850413

212603.25
Rp 241,803.00 Rp 11,630.20
 360000

1080000
108000
64800
43200

63000

15750
 518400
172800

90000
18000
10800
7200 216000
Rp 485,414.75
NO NAMA/NIP JUMLAH (RP) PPH PSL 21 (RP)
1 Apt. Yohana Alpionita S.F 232,604.00 11,630.20 232,604.00 11,630.00
1 Apt. Yohana Alpionita S.F 28,800.00 1,440.00 28,800.00 1,440.00
1 Dian Gusti Aprima Vista 1,224,594.72 61,229.74 1,224,595.00 61,230.00
4 Dian Gusti Aprima Vista 340,165.20 17,008.26 340,165.00 17,008.00
4 Dian Gusti Aprima Vista 36,000.00 1,800.00 36,000.00 1,800.00
4 Dian Gusti Aprima Vista 21,600.00 1,080.00 21,600.00 1,080.00
1 dr.Lisa Nurul Hidayah 2,551,239.00 127,561.95 2,551,239.00 127,562.00
1 dr.Lisa Nurul Hidayah 270,000.00 13,500.00 270,000.00 13,500.00
1 dr.Lisa Nurul Hidayah 129,600.00 6,480.00 129,600.00 6,480.00
2 Heti Andriani,SKM 1,020,495.60 51,024.78 1,020,496.00 51,025.00
2 Heti Andriani,SKM 108,000.00 5,400.00 108,000.00 5,400.00
2 Heti Andriani,SKM 64,800.00 3,240.00 64,800.00 3,240.00
3 Maria Widia Hartini,A.Md. 108,000.00 5,400.00 108,000.00 5,400.00
3 Masmarlinda 200,603.00 10,030.15 200,603.00 10,030.00
3 Masmarlinda 18,000.00 900.00 18,000.00 900.00
1 Meilis 172,800.00 8,640.00 172,800.00 8,640.00
1 Meilis 202,800.00 10,140.00 202,800.00 10,140.00
1 Muhamad fauzi,SKM 1,190,578.20 59,528.91 1,190,578.00 59,529.00
1 Muhamad fauzi,SKM 126,000.00 6,300.00 126,000.00 6,300.00
1 Muhamad fauzi,SKM 75,600.00 3,780.00 75,600.00 3,780.00
2 Nurul Karimah, Am.Keb 108,000.00 5,400.00 108,000.00 5,400.00
13 R. Ayu Hamidah 156,999.32 7,849.97 156,999.00 7,850.00
4 Rahmiyanti 200,603.00 10,030.15 200,603.00 10,030.00
4 Rahmiyanti 18,000.00 900.00 18,000.00 900.00
5 Sri Mulasih, Am.Keb 108,000.00 5,400.00 108,000.00 5,400.00
3 Vifi Kurniawati,AM.KG 850,413.00 42,520.65 850,413.00 42,521.00
3 Vifi Kurniawati,AM.KG 90,000.00 4,500.00 90,000.00 4,500.00
3 Vifi Kurniawati,AM.KG 54,000.00 2,700.00 54,000.00 2,700.00
 261,404.00 13,070.00 261,404.00 13,070.00

1,622,360.00 81,118.00 1,622,360.00 81,118.00

2,950,839.00 147,542.00 2,950,839.00 147,542.00

1,193,296.00 59,665.00 1,193,296.00 59,665.00

108,000.00 5,400.00 108,000.00 5,400.00

218,603.00 10,930.00 218,603.00 10,930.00

375,600.00 18,780.00 375,600.00 18,780.00

1,392,178.00 69,609.00 1,392,178.00 69,609.00

108,000.00 5,400.00 108,000.00 5,400.00

156,999.00 7,850.00 156,999.00 7,850.00
218,603.00 10,930.00 218,603.00 10,930.00

108,000.00 5,400.00 108,000.00 5,400.00

994,413.00 49,721.00 994,413.00 49,721.00

485,415.00
DAFTAR TANDA TERIMA 60 % KLAIM NON KAPITASI RAWAT INAP
BULAN Februari 2023

MEDIS
NO NAMA/NIP GOL JUMLAH (RP) TANDA TANGAN
1 dr.Lisa Nurul Hidayah III.c Rp 2,387,819.85 1
19860909 201704 2 002
JUMLAH Rp 2,387,819.85

PARAMEDIS
NO NAMA/NIP GOL JUMLAH (RP) TANDA TANGAN
1 Dian Gusti Aprima Vista III.a Rp 602,751 1
Nip. 199206052019032007
2 Budi setyawan Rp 479,110 2

3 Deka A.Handoko Rp 407,844 3

4 Ari Purwadi Rp 407,844 4

5 Singgih A.S Rp 407,844 5

6 Amelia Wijayanti Rp 407,844 6

7 Dina Mariana Rp 407,844 7

8 Siti Masitoh Rp 407,844 8

9 Novrin Rp 407,844 9

10 Heriyanto Rp 407,844 10

11 Retno Wulandari Rp 407,844 11

12 Diati Vistasari Rp 193,189 12

13 R. Ayu Hamidah Rp 77,276 13

Jumlah Rp 5,022,926

MANAJEMEN
NO NAMA/NIP GOL JUMLAH (RP) TANDA TANGAN
1 Muhamad fauzi,SKM III.d Rp 586,008 1
NIP.19690530 199003 1 003
2 Heti Andriani,SKM III.c Rp 502,293 2
Nip.19840219 201001 2 019
3 Vifi Kurniawati,AM.KG III.b Rp 418,577 3
NIP.198206022006042011
4 Dian Gusti Aprima Vista III.a Rp 167,431 4
Nip. 199206052019032007

JUMLAH Rp 1,674,309

APOTEK / GUDANG
NO NAMA/NIP GOL JUMLAH (RP) TANDA TANGAN
1 Apt. Yohana Alpionita S.Farm III.b Rp 126,645 1
NIP.19960829 202203 2 011
2 Maya Oktariawati, S.farm,Apt Rp 110,644 2

3 Masmarlinda III.c Rp 90,644 3

NIP. 197805081998032004
4 Rahmiyanti IIIB Rp 90,644 4
NIP. 19770822 200701 2 010
JUMLAH Rp 418,577

Mengetahui Bendahara Pengeluaran Pembantu

Ka UPT Puskesmas Nawangsasi

Vifi Kurniawati,AMKG
Muhamad Fauzi,SKM Nip.199101232012122001
NIP.19690530 199003 1 003
DAFTAR TANDA TERIMA 60 % KLAIM NON KAPITASI PONED
BULAN Februari 2023
MEDIS
NO NAMA/NIP GOL JUMLAH (RP) TANDA TANGAN
1 dr.Lisa Nurul Hidayah III.c Rp 251,100.00 1
19860909 201704 2 002
JUMLAH Rp 251,100.00

PARAMEDIS
NO NAMA/NIP GOL JUMLAH (RP) TANDA TANGAN
1 Meilis III a Rp 160,704 1
NIP.197405162006042003
2 Nurul Karimah, Am.Keb IIIb Rp 100,440 2
NIP. 198805012010012008
3 Maria Widia Hartini,A.Md.Keb IIIA Rp 100,440 3
NIP.19770322 200701 2 003
4 Arista Aditama,A.Md.Keb. II/c Rp 100,440 4
NIP.199304042022032013
5 Sri Mulasih, Am.Keb IIIa Rp 100,440 5
NIP.197807122007012010
6 Heny Ayu, Am.Keb Rp 100,440 6

7 Rahma oktaviani, Am.Keb Rp 140,616 7

8 Cahyawati Okti, Am.Keb Rp 100,440 8

9 Welnia,Amd.Keb Rp 100,440 9

JUMLAH Rp 1,004,400

MANAJEMEN
NO NAMA/NIP GOL JUMLAH (RP) TANDA TANGAN
1 Muhamad fauzi,SKM III.d Rp 117,180 1
NIP.19690530 199003 1 003
2 Heti Andriani,SKM III.c Rp 100,440 2
Nip.19840219 201001 2 019
3 Vifi Kurniawati,AM.KG III.b Rp 83,700 3
NIP.198206022006042011
4 Dian Gusti Aprima Vista III.a Rp 33,480 4
Nip. 199206052019032007
JUMLAH Rp 334,800

APOTEK / GUDANG
NO NAMA/NIP GOL JUMLAH (RP) TANDA TANGAN
1 Apt. Yohana Alpionita S.Farm III.b Rp 30,925 1
NIP.19960829 202203 2 011
2 Maya Oktariawati, S.farm,Apt Rp 20,925 2
3 Masmarlinda III.c Rp 15,925 3
NIP. 197805081998032004
4 Rahmiyanti IIIB Rp 15,925 4
NIP. 19770822 200701 2 010
JUMLAH Rp 83,700.00

Mengetahui Bendahara Pengeluaran Pembantu

Ka UPT Puskesmas Nawangsasi

Vifi Kurniawati,AMKG
Muhamad Fauzi,SKM Nip.199101232012122001
NIP.19690530 199003 1 003
DAFTAR TANDA TERIMA 60 % KLAIM NON KAPITASI ANC
BULAN Februari 2023
MEDIS
NO NAMA/NIP GOL JUMLAH (RP) TANDA TANGAN
1 dr.Lisa Nurul Hidayah III.c Rp 53,593 1
19860909 201704 2 002
JUMLAH Rp 53,593

PARAMEDIS
NO NAMA/NIP GOL JUMLAH (RP) TANDA TANGAN
1 Meilis III a Rp 85,749 1
NIP.197405162006042003
2 Fitri imsaq Rp 53,593 2

3 Rahma oktaviani, Am.Keb Rp 75,030 3

JUMLAH Rp 214,372

MANAJEMEN
NO NAMA/NIP GOL JUMLAH (RP) TANDA TANGAN
1 Muhamad fauzi,SKM III.d Rp 31,263 1
NIP.19690530 199003 1 003
2 Heti Andriani,SKM III.c Rp 26,797 2
Nip.19840219 201001 2 019
3 Vifi Kurniawati,AM.KG III.b Rp 22,331 3
NIP.198206022006042011
4 Dian Gusti Aprima Vista III.a Rp 8,932 4
Nip. 199206052019032007
JUMLAH Rp 89,322

Mengetahui
Ka UPT Puskesmas Nawangsasi Bendahara Pengeluaran Pembantu

Muhamad Fauzi,SKM Vifi Kurniawati,AMKG

NIP.19690530 199003 1 003 Nip.199101232012122001
Rp 2,638,919.85 227669.4 #REF!

#REF!

5,022,926 386,378.95

- 386,378.95 309,103

-
216,372.21
92,730.95

193,189.48
21,465.50

#REF!

1674308.8
Rp 703,188.08 #REF!
Rp 602,732.64 #REF!
Rp 502,277.20 #REF!
Rp 200,910.88 #REF!
Rp 200,910.88 #REF!

418577.2

104644.3
Rp 131,569.00 #REF!

#REF!
 1004400
100440
60264
40176

Rp -

1080000
108000
64800
43200

334800

83700

20925

214372.8
 53593.2
32155.92
21437.28

90000
18000
10800
7200

89322

230400
76800
DAFTAR TANDA TERIMA 60 % KLAIM NON KAPITASI RAWAT INAP
BULAN April 2023

MEDIS
NO NAMA/NIP GOL JUMLAH (RP) PPH PSL 21 (RP) JMLH DITERIMA (RP) TANDA TANGAN
1 dr.Lisa Nurul Hidayah III.c Rp 869,139.00 Rp 43,456.95 Rp 825,682.05 1
19860909 201704 2 002
JUMLAH Rp 869,139.00 Rp 43,456.95 Rp 825,682.05

PARAMEDIS
NO NAMA/NIP GOL JUMLAH (RP) PPH PSL 21 (RP) JMLH DITERIMA (RP) TANDA TANGAN
1 Dian Gusti Aprima Vista III.a Rp 417,187 Rp 20,859 Rp 396,327 1
Nip. 199206052019032007
2 Budi setyawan Rp 331,610 Rp 331,610 2

3 Deka A.Handoko Rp 282,284 Rp 282,284 3

4 Ari Purwadi Rp 282,284 Rp 282,284 4

5 Singgih A.S Rp 282,284 Rp 282,284 5

6 Amelia Wijayanti Rp 282,284 Rp 282,284 6

7 Dina Mariana Rp 282,284 Rp 282,284 7

8 Siti Masitoh Rp 282,284 Rp 282,284 8

9 Novrin Rp 282,284 Rp 282,284 9

10 intan Rp 282,284 Rp 282,284 10

11 Retno Wulandari Rp 282,284 Rp 282,284 11

12 Diati Vistasari Rp 133,714 Rp 133,714 12

13 R. Ayu Hamidah Rp 53,485 Rp 2,674.27 Rp 50,811 13

 Jumlah Rp 3,476,556 Rp 23,534 Rp 3,453,022

MANAJEMEN
NO NAMA/NIP GOL JUMLAH (RP) PPH PSL 21 (RP) JMLH DITERIMA (RP) TANDA TANGAN
1 dr.Lisa Nurul Hidayah III.c Rp 405,598 Rp 20,279.91 Rp 385,318.29 1
19860909 201704 2 002
2 Heti Andriani,SKM III.c Rp 347,656 Rp 17,382.78 Rp 330,272.82 2
Nip.19840219 201001 2 019
3 Vifi Kurniawati,AM.KG III.b Rp 289,713 Rp 14,485.65 Rp 275,227.35 3
NIP.198206022006042011
4 Dian Gusti Aprima Vista III.a Rp 115,885 Rp 5,794.26 Rp 110,090.94 4
Nip. 199206052019032007

JUMLAH Rp 1,158,852 Rp 57,942.60 Rp 1,100,909.40

APOTEK / GUDANG
NO NAMA/NIP GOL JUMLAH (RP) PPH PSL 21 (RP) JMLH DITERIMA (RP) TANDA TANGAN
1 Apt. Yohana Alpionita S.Farm III.b Rp 86,429 Rp 4,321.45 Rp 86,429 1
NIP.19960829 202203 2 011
2 Maya Oktariawati, S.farm,Apt Rp 72,428 Rp 72,428 2

3 Masmarlinda III.c Rp 65,428 Rp 3,271.40 Rp 65,428 3

NIP. 197805081998032004
4 Rahmiyanti IIIB Rp 65,428 Rp 3,271.40 Rp 65,428 4
NIP. 19770822 200701 2 010
JUMLAH Rp 289,713 Rp 10,864 Rp 289,713
Rp 135,797
DAFTAR TANDA TERIMA 60 % KLAIM NON KAPITASI PONED
BULAN April 2023
MEDIS
NO NAMA/NIP GOL JUMLAH (RP) PPH PSL 21 (RP) JMLH DITERIMA (RP) TANDA TANGAN
1 dr.Lisa Nurul Hidayah III.c Rp 360,000.00 Rp 18,000.00 Rp 342,000.00 1
19860909 201704 2 002
JUMLAH Rp 360,000.00 Rp 18,000.00 Rp 342,000.00

PARAMEDIS
NO NAMA/NIP GOL JUMLAH (RP) PPH PSL 21 (RP) JMLH DITERIMA (RP) TANDA TANGAN
1 Meilis III a Rp 230,400 Rp 11,520 Rp 218,880 1
NIP.197405162006042003
2 Nurul Karimah, Am.Keb IIIb Rp 144,000 Rp 7,200 Rp 136,800 2
NIP. 198805012010012008
3 Maria Widia Hartini,A.Md.Keb IIIA Rp 144,000 Rp 7,200 Rp 136,800 3
NIP.19770322 200701 2 003
4 Arista Aditama,A.Md.Keb. II/c Rp 144,000 Rp - Rp 144,000 4
NIP.199304042022032013
5 Sri Mulasih, Am.Keb IIIa Rp 144,000 Rp 7,200 Rp 136,800 5
NIP.197807122007012010
6 Heny Ayu, Am.Keb Rp 144,000 Rp - Rp 144,000 6

7 Rahma oktaviani, Am.Keb Rp 201,600 Rp - Rp 201,600 7

8 Cahyawati Okti, Am.Keb Rp 144,000 Rp - Rp 144,000 8

9 Welnia,Amd.Keb Rp 144,000 Rp - Rp 144,000

JUMLAH Rp 1,440,000 Rp 33,120 Rp 1,406,880

MANAJEMEN
NO NAMA/NIP GOL JUMLAH (RP) PPH PSL 21 (RP) JMLH DITERIMA (RP) TANDA TANGAN
1 dr.Lisa Nurul Hidayah III.c Rp 168,000 Rp 8,400 Rp 159,600.00 1
19860909 201704 2 002
2 Heti Andriani,SKM III.c Rp 144,000 Rp 7,200 Rp 136,800.00 2
Nip.19840219 201001 2 019
3 Vifi Kurniawati,AM.KG III.b Rp 120,000 Rp 6,000 Rp 114,000.00 3
NIP.198206022006042011
4 Dian Gusti Aprima Vista III.a Rp 48,000 Rp 2,400 Rp 45,600.00 4
Nip. 199206052019032007
JUMLAH Rp 480,000 Rp 24,000 Rp 456,000.00

APOTEK / GUDANG
NO NAMA/NIP GOL JUMLAH (RP) PPH PSL 21 (RP) JMLH DITERIMA (RP) TANDA TANGAN
1 Apt. Yohana Alpionita S.Farm III.b Rp 40,000.00 Rp 2,000 Rp 38,000.00 1
NIP.19960829 202203 2 011
2 Maya Oktariawati, S.farm,Apt Rp 30,000.00 Rp 30,000.00 2

3 Masmarlinda III.c Rp 25,000.00 Rp 1,250 Rp 25,000.00 3

NIP. 197805081998032004
4 Rahmiyanti IIIB Rp 25,000.00 Rp 1,250 Rp 25,000.00 4
NIP. 19770822 200701 2 010
JUMLAH Rp 120,000.00 Rp 4,500 Rp 118,000.00
Rp 79,620

Mengetahui Yang Membayar

Ka UPT Puskesmas Nawangsasi Bendahara Pengeluaran

dr.Lisa Nurul Hidayah Vifi Kurniawati,AM.KG

19860909 201704 2 002 NIP.19910123 201212 2 001
DAFTAR TANDA TERIMA 60 % KLAIM NON KAPITASI ANC
BULAN April 2023
MEDIS
NO NAMA/NIP GOL JUMLAH (RP) PPH PSL 21 (RP) JMLH DITERIMA (RP) TANDA TANGAN
1 dr.Lisa Nurul Hidayah III.c Rp 158,400.00 Rp 7,920.00 Rp 150,480.00 1
19860909 201704 2 002
JUMLAH Rp 158,400.00 Rp 7,920.00 Rp 150,480.00

PARAMEDIS
NO NAMA/NIP GOL JUMLAH (RP) PPH PSL 21 (RP) JMLH DITERIMA (RP) TANDA TANGAN
1 Meilis III a Rp 232,200 Rp 11,610 Rp 220,590 1
NIP.197405162006042003
2 Fitri imsaq Rp 190,200 Rp 56,800 2

3 Rahma oktaviani, Am.Keb Rp 211,200 Rp 76,800 3

JUMLAH Rp 633,600 Rp 11,610 Rp 354,190

MANAJEMEN
NO NAMA/NIP GOL JUMLAH (RP) PPH PSL 21 (RP) JMLH DITERIMA (RP) TANDA TANGAN
1 dr.Lisa Nurul Hidayah III.c Rp 92,400 Rp 4,620 Rp 87,780.00 1
19860909 201704 2 002
2 Heti Andriani,SKM III.c Rp 79,200 Rp 3,960 Rp 75,240.00 2
Nip.19840219 201001 2 019
3 Vifi Kurniawati,AM.KG III.b Rp 66,000 Rp 3,300 Rp 62,700.00 3
NIP.198206022006042011
4 Dian Gusti Aprima Vista III.a Rp 26,400 Rp 1,320 Rp 25,080.00 4
Nip. 199206052019032007
JUMLAH Rp 264,000 Rp 13,200 Rp 250,800.00
Rp 32,730
Mengetahui Yang Membayar
Ka UPT Puskesmas Nawangsasi Bendahara Pengeluaran
dr.Lisa Nurul Hidayah Vifi Kurniawati,AM.KG
19860909 201704 2 002 NIP.19910123 201212 2 001
Rp 1,229,139.00 227669.4 Rp 61,456.95

Rp 869,139.00

3,476,556 267,427.38

- 267,427.38 213,942

-
149,759.34
64,182.57

133,713.69
14,857.08
 Rp 3,476,556

1158852
Rp 573,598.20 Rp 28,679.91
Rp 491,655.60 Rp 24,582.78
Rp 409,713.00 Rp 20,485.65
Rp 163,885.20 Rp 8,194.26
Rp 163,885.20 Rp 8,194.26

289713

72428.25
Rp 102,428.00 Rp 4,321.45
480000

1440000
144000
86400
57600
120000

30000
 90000
18000 633600
10800 211200
7200

264000

Rp 248,147
NO NAMA/NIP JUMLAH (RP) PPH PSL 21 (RP)
1 Apt. Yohana Alpionita 86,429.00 4,321.45 86429 4321.45 86429 4321
1 Apt. Yohana Alpionita 40,000.00 2,000.00 40000 2000 40000 2000
1 Dian Gusti Aprima Vis 417,186.72 20,859.34 417186.7 20859.34 417187 20859
4 Dian Gusti Aprima Vis 115,885.20 5,794.26 115885.2 5794.26 115885 5794
4 Dian Gusti Aprima Vis 48,000.00 2,400.00 48000 2400 48000 2400
4 Dian Gusti Aprima Vis 26,400.00 1,320.00 26400 1320 26400 1320
1 dr.Lisa Nurul Hidayah 869,139.00 43,456.95 869139 43456.95 869139 43457
1 dr.Lisa Nurul Hidayah 405,598.20 20,279.91 405598.2 20279.91 405598 20280
1 dr.Lisa Nurul Hidayah 360,000.00 18,000.00 360000 18000 360000 18000
1 dr.Lisa Nurul Hidayah 168,000.00 8,400.00 168000 8400 168000 8400
1 dr.Lisa Nurul Hidayah 158,400.00 7,920.00 158400 7920 158400 7920
1 dr.Lisa Nurul Hidayah 92,400.00 4,620.00 92400 4620 92400 4620
2 Heti Andriani,SKM 347,655.60 17,382.78 347655.6 17382.78 347656 17383
2 Heti Andriani,SKM 144,000.00 7,200.00 144000 7200 144000 7200
2 Heti Andriani,SKM 79,200.00 3,960.00 79200 3960 79200 3960
3 Maria Widia Hartini, 144,000.00 7,200.00 144000 7200 144000 7200
3 Masmarlinda 65,428.00 3,271.40 65428 3271.4 65428 3271
3 Masmarlinda 25,000.00 1,250.00 25000 1250 25000 1250
1 Meilis 230,400.00 11,520.00 230400 11520 230400 11520
1 Meilis 232,200.00 11,610.00 232200 11610 232200 11610
2 Nurul Karimah, Am.K 144,000.00 7,200.00 144000 7200 144000 7200
13 R. Ayu Hamidah 53,485.48 2,674.27 53485.48 2674.274 53485 2674
4 Rahmiyanti 65,428.00 3,271.40 65428 3271.4 65428 3271
4 Rahmiyanti 25,000.00 1,250.00 25000 1250 25000 1250
5 Sri Mulasih, Am.Keb 144,000.00 7,200.00 144000 7200 144000 7200
3 Vifi Kurniawati,AM.K 289,713.00 14,485.65 289713 14485.65 289713 14486
3 Vifi Kurniawati,AM.K 120,000.00 6,000.00 120000 6000 120000 6000
3 Vifi Kurniawati,AM.K 66,000.00 3,300.00 66000 3300 66000 3300
 86,429.00 4,321.00 126,429.00 6,321.00 126429 6321
40,000.00 2,000.00
417,187.00 20,859.00 607,472.00 30,373.00 607472 30373
115,885.00 5,794.00
48,000.00 2,400.00
26,400.00 1,320.00
869,139.00 43,457.00 2,053,537.00 102,677.00 2053537 102677
405,598.00 20,280.00
360,000.00 18,000.00
168,000.00 8,400.00
158,400.00 7,920.00
92,400.00 4,620.00
347,656.00 17,383.00 570,856.00 28,543.00 570856 28543
144,000.00 7,200.00
79,200.00 3,960.00
144,000.00 7,200.00 144,000.00 7,200.00 144000 7200
65,428.00 3,271.00 90,428.00 4,521.00 90428 4521
25,000.00 1,250.00
230,400.00 11,520.00 462,600.00 23,130.00 462600 23130
232,200.00 11,610.00
144,000.00 7,200.00 144,000.00 7,200.00 144000 7200
53,485.00 2,674.00 53,485.00 2,674.00 53485 2674
65,428.00 3,271.00 90,428.00 4,521.00 90428 4521
25,000.00 1,250.00
144,000.00 7,200.00 144,000.00 7,200.00 144000 7200
289,713.00 14,486.00 475,713.00 23,786.00 475713 23786
120,000.00 6,000.00
66,000.00 3,300.00
248146
DAFTAR TANDA TERIMA 60 % KLAIM NON KAPITASI RAWAT INAP
BULAN Februari 2023

MEDIS
NO NAMA/NIP GOL JUMLAH (RP) TANDA TANGAN
1 dr.Lisa Nurul Hidayah III.c Rp 1,255,731.60 1
19860909 201704 2 002
JUMLAH Rp 1,255,731.60

PARAMEDIS
NO NAMA/NIP GOL JUMLAH (RP) TANDA TANGAN
1 Dian Gusti Aprima Vista III.a Rp 602,751 1
Nip. 199206052019032007
2 Budi setyawan Rp 479,110 2

3 Deka A.Handoko Rp 407,844 3

4 Ari Purwadi Rp 407,844 4

5 Singgih A.S Rp 407,844 5

6 Amelia Wijayanti Rp 407,844 6

7 Dina Mariana Rp 407,844 7

8 Siti Masitoh Rp 407,844 8

9 Novrin Rp 407,844 9

10 Heriyanto Rp 407,844 10

11 Retno Wulandari Rp 407,844 11

12 Diati Vistasari Rp 193,189 12

13 R. Ayu Hamidah Rp 77,276 13

Jumlah Rp 5,022,926

MANAJEMEN
NO NAMA/NIP GOL JUMLAH (RP) TANDA TANGAN
1 Muhamad fauzi,SKM III.d Rp 586,008 1
NIP.19690530 199003 1 003
2 Heti Andriani,SKM III.c Rp 502,293 2
Nip.19840219 201001 2 019
3 Vifi Kurniawati,AM.KG III.b Rp 418,577 3
NIP.198206022006042011
4 Dian Gusti Aprima Vista III.a Rp 167,431 4
Nip. 199206052019032007

JUMLAH Rp 1,674,309

APOTEK / GUDANG
NO NAMA/NIP GOL JUMLAH (RP) TANDA TANGAN
1 Apt. Yohana Alpionita S.Farm III.b Rp 126,645 1
NIP.19960829 202203 2 011
2 Maya Oktariawati, S.farm,Apt Rp 110,644 2

3 Masmarlinda III.c Rp 90,644 3

NIP. 197805081998032004
4 Rahmiyanti IIIB Rp 90,644 4
NIP. 19770822 200701 2 010
JUMLAH Rp 418,577

Mengetahui Bendahara Pengeluaran Pembantu

Ka UPT Puskesmas Nawangsasi

Vifi Kurniawati,AMKG
Muhamad Fauzi,SKM Nip.199101232012122001
NIP.19690530 199003 1 003
DAFTAR TANDA TERIMA 60 % KLAIM NON KAPITASI PONED
BULAN Februari 2023
MEDIS
NO NAMA/NIP GOL JUMLAH (RP) TANDA TANGAN
1 dr.Lisa Nurul Hidayah III.c Rp 251,100.00 1
19860909 201704 2 002
JUMLAH Rp 251,100.00

PARAMEDIS
NO NAMA/NIP GOL JUMLAH (RP) TANDA TANGAN
1 Meilis III a Rp 160,704 1
NIP.197405162006042003
2 Nurul Karimah, Am.Keb IIIb Rp 100,440 2
NIP. 198805012010012008
3 Maria Widia Hartini,A.Md.Keb IIIA Rp 100,440 3
NIP.19770322 200701 2 003
4 Arista Aditama,A.Md.Keb. II/c Rp 100,440 4
NIP.199304042022032013
5 Sri Mulasih, Am.Keb IIIa Rp 100,440 5
NIP.197807122007012010
6 Heny Ayu, Am.Keb Rp 100,440 6

7 Rahma oktaviani, Am.Keb Rp 140,616 7

8 Cahyawati Okti, Am.Keb Rp 100,440 8

9 Welnia,Amd.Keb Rp 100,440 9

JUMLAH Rp 1,004,400

MANAJEMEN
NO NAMA/NIP GOL JUMLAH (RP) TANDA TANGAN
1 Muhamad fauzi,SKM III.d Rp 117,180 1
NIP.19690530 199003 1 003
2 Heti Andriani,SKM III.c Rp 100,440 2
Nip.19840219 201001 2 019
3 Vifi Kurniawati,AM.KG III.b Rp 83,700 3
NIP.198206022006042011
4 Dian Gusti Aprima Vista III.a Rp 33,480 4
Nip. 199206052019032007
JUMLAH Rp 334,800

APOTEK / GUDANG
NO NAMA/NIP GOL JUMLAH (RP) TANDA TANGAN
1 Apt. Yohana Alpionita S.Farm III.b Rp 30,925 1
NIP.19960829 202203 2 011
2 Maya Oktariawati, S.farm,Apt Rp 20,925 2
3 Masmarlinda III.c Rp 15,925 3
NIP. 197805081998032004
4 Rahmiyanti IIIB Rp 15,925 4
NIP. 19770822 200701 2 010
JUMLAH Rp 83,700.00

Mengetahui Bendahara Pengeluaran Pembantu

Ka UPT Puskesmas Nawangsasi

Vifi Kurniawati,AMKG
Muhamad Fauzi,SKM Nip.199101232012122001
NIP.19690530 199003 1 003
DAFTAR TANDA TERIMA 60 % KLAIM NON KAPITASI ANC
BULAN Februari 2023
MEDIS
NO NAMA/NIP GOL JUMLAH (RP) TANDA TANGAN
1 dr.Lisa Nurul Hidayah III.c Rp 53,593 1
19860909 201704 2 002
JUMLAH Rp 53,593

PARAMEDIS
NO NAMA/NIP GOL JUMLAH (RP) TANDA TANGAN
1 Meilis III a Rp 85,749 1
NIP.197405162006042003
2 Fitri imsaq Rp 53,593 2

3 Rahma oktaviani, Am.Keb Rp 75,030 3

JUMLAH Rp 214,372

MANAJEMEN
NO NAMA/NIP GOL JUMLAH (RP) TANDA TANGAN
1 Muhamad fauzi,SKM III.d Rp 31,263 1
NIP.19690530 199003 1 003
2 Heti Andriani,SKM III.c Rp 26,797 2
Nip.19840219 201001 2 019
3 Vifi Kurniawati,AM.KG III.b Rp 22,331 3
NIP.198206022006042011
4 Dian Gusti Aprima Vista III.a Rp 8,932 4
Nip. 199206052019032007
JUMLAH Rp 89,322

Mengetahui
Ka UPT Puskesmas Nawangsasi Bendahara Pengeluaran Pembantu

Muhamad Fauzi,SKM Vifi Kurniawati,AMKG

NIP.19690530 199003 1 003 Nip.199101232012122001