BPJS Kesehatan Cab.

PATI
FORMULIR PENGAJUAN KLAIM TINGKAT PERTAMA

Nomor FPK : P2301000017856

Provider : Juwana
Bulan Pelayanan : January 2023

Pelayanan : RJTP

Total Data : 138

Total Tagihan : Rp. 6.825.000

NoKunjungan NAMA TANGGAL TINDAKAN HASIL TENAGA MEDIS BIAYA

113305010123P000091 NUZULIA WULAN RAHMADHANI 02/01/2023 Pelayanan ANC 2 (Dua) SUWARTI Rp. 50.000

113305010123P000100 YULIATI 03/01/2023 Pelayanan KB : Suntik puspitarini Rp. 15.000

113305010123P000101 IIS YULIANA 03/01/2023 Pelayanan KB : Suntik puspitarini Rp. 15.000

113305010123P000121 ENDANG MUSTIKA WATI 03/01/2023 Pelayanan ANC 3 (Tiga) SUWARTI Rp. 50.000

113305010123P000125 RUKAYAH 03/01/2023 Pelayanan ANC 3 (Tiga) SUWARTI Rp. 50.000

113305010123P000129 DINDA RAHMA KARTIKA SARI 03/01/2023 Pelayanan ANC 3 (Tiga) SUWARTI Rp. 50.000

113305010123P000130 NO'FIK 03/01/2023 Pelayanan ANC 3 (Tiga) SUWARTI Rp. 50.000

113305010123P000133 RATNA SUTIYANI 03/01/2023 Pelayanan ANC 3 (Tiga) SUWARTI Rp. 50.000

113305010123P000179 ASTRI OKTAVIA WIDYANINGSIH 04/01/2023 Pelayanan ANC 2 (Dua) SUWARTI Rp. 50.000

113305010123P000201 WATINI 05/01/2023 Pelayanan KB : Cabut IUD / Implant puspitarini Rp. 100.000

113305010123P000201 WATINI 05/01/2023 Pelayanan KB : Suntik puspitarini Rp. 15.000

113305010123P000203 SRI NARTI 05/01/2023 Pelayanan KB : Suntik puspitarini Rp. 15.000

113305010123P000293 WARLIN 07/01/2023 Pelayanan KB : Suntik puspitarini Rp. 15.000

113305010123P000319 RIANA MAQFURATUN 09/01/2023 Pelayanan KB : Suntik puspitarini Rp. 15.000

113305010123P000381 SITI ROHMANA TRI KURNIYAWATI 09/01/2023 Pelayanan ANC 4 (Empat) SUWARTI Rp. 50.000

113305010123P000391 SEPTA EKA MULYANINGTYAS 09/01/2023 Pelayanan ANC 2 (Dua) SUWARTI Rp. 50.000
 NoKunjungan NAMA TANGGAL TINDAKAN HASIL TENAGA MEDIS BIAYA

113305010123P000393 ARINA ROSIDAH 06/01/2023 Pelayanan ANC 3 (Tiga) SUWARTI Rp. 50.000

113305010123P000396 YUYUN ANDILA 09/01/2023 Pelayanan ANC 2 (Dua) SUWARTI Rp. 50.000

113305010123P000445 AMELIA FITRIA ZAHRANI 09/01/2023 Pelayanan ANC 3 (Tiga) SUWARTI Rp. 50.000

113305010123P000452 DEWI WULANDARI 10/01/2023 Pelayanan KB : Suntik puspitarini Rp. 15.000

113305010123P000454 KARTINI 10/01/2023 Pelayanan KB : Suntik puspitarini Rp. 15.000

Pelayanan KB : Cabut & Pemasangan IUD /

113305010123P000458 RENI HIDAYANTI 10/01/2023 puspitarini Rp. 100.000
Implant

113305010123P000499 JESISKA PUTRI REVALINA 08/01/2023 Pelayanan PNC 1 (Satu) UMMI WAHIDAH Rp. 25.000

113305010123P000503 INDAH DWI LESTARI 11/01/2023 Pelayanan PNC 1 (Satu) RUKMANASARI WH Rp. 25.000

113305010123P000508 ALSA IFTI DAMAYANTI 11/01/2023 Pelayanan PNC 1 (Satu) TUT INDRANINGRUM Rp. 25.000

BENING DESISKA
113305010123P000518 NO'FIK 11/01/2023 Pelayanan PNC 1 (Satu) Rp. 25.000
WAHYUNINGRUM

113305010123P000538 NETI HERA WATI 11/01/2023 Pelayanan ANC 2 (Dua) SUWARTI Rp. 50.000

113305010123P000561 LASMI 11/01/2023 Pelayanan KB : Suntik puspitarini Rp. 15.000

113305010123P000565 NUR SHOLIKHAH 11/01/2023 Pelayanan KB : Suntik puspitarini Rp. 15.000

113305010123P000566 SUNITI 11/01/2023 Pelayanan KB : Suntik puspitarini Rp. 15.000

113305010123P000601 LILIK ALIN NIMAH 09/01/2023 Pelayanan PNC 1 (Satu) SRI WAHYUNI Rp. 25.000

113305010123P000612 FAIZATUL MAHMUDAH 10/01/2023 Pelayanan ANC 3 (Tiga) SUWARTI Rp. 50.000

113305010123P000616 UTAMI 11/01/2023 Pelayanan KB : Suntik puspitarini Rp. 15.000

113305010123P000618 SULISTIYOWATI 12/01/2023 Pelayanan KB : Suntik puspitarini Rp. 15.000

LAILA FATKHURROHMAH
113305010123P000619 12/01/2023 Pelayanan KB : Suntik puspitarini Rp. 15.000
KUSMIATUN

113305010123P000621 NOPITRI HANDAYANI 06/01/2023 Pelayanan ANC 3 (Tiga) SUWARTI Rp. 50.000

113305010123P000623 CINDI AVITA 06/01/2023 Pelayanan ANC 3 (Tiga) SUWARTI Rp. 50.000

113305010123P000625 NILA ARIYA ANGGRAENI 09/01/2023 Pelayanan ANC 3 (Tiga) SUWARTI Rp. 50.000

113305010123P000643 WARINI 05/01/2023 Pelayanan ANC 2 (Dua) SUWARTI Rp. 50.000

113305010123P000654 DEWIYANA 12/01/2023 Pelayanan KB : Pemasangan IUD / Implant puspitarini Rp. 100.000

113305010123P000861 MUSLIKAH 14/01/2023 Pelayanan KB : Suntik puspitarini Rp. 15.000

113305010123P000864 ZAHROTUN NI'MAH 16/01/2023 Pelayanan ANC 3 (Tiga) SUWARTI Rp. 50.000

113305010123P000866 CATUR SAYEKTI 16/01/2023 Pelayanan ANC 2 (Dua) SUWARTI Rp. 50.000
 NoKunjungan NAMA TANGGAL TINDAKAN HASIL TENAGA MEDIS BIAYA

113305010123P000868 SINTA KARLITA RAHMADHANI 16/01/2023 Pelayanan ANC 2 (Dua) SUWARTI Rp. 50.000

113305010123P000869 SUCI ANITA 16/01/2023 Pelayanan ANC 3 (Tiga) SUWARTI Rp. 50.000

113305010123P000870 TATIK 16/01/2023 Pelayanan ANC 3 (Tiga) SUWARTI Rp. 50.000

113305010123P000871 AMALIA FATIMATUZ ZAHRO 16/01/2023 Pelayanan ANC 2 (Dua) SUWARTI Rp. 50.000

113305010123P000919 DESI RAHMANDANI 14/01/2023 Pelayanan ANC 3 (Tiga) SUWARTI Rp. 50.000

113305010123P000923 SITI MARDIYAH 13/01/2023 Pelayanan ANC 2 (Dua) SUWARTI Rp. 50.000

113305010123P000925 SITI HARIYANTI 13/01/2023 Pelayanan KB : Suntik puspitarini Rp. 15.000

113305010123P000936 DWI INDAH LESTARI 13/01/2023 Pelayanan ANC 3 (Tiga) SUWARTI Rp. 50.000

113305010123P000976 RIRIN SETYANINGSIH 17/01/2023 Pelayanan KB : Suntik puspitarini Rp. 15.000

113305010123P000987 VITIS VINI VERA 17/01/2023 Pelayanan ANC 3 (Tiga) SUWARTI Rp. 50.000

113305010123P001007 ULFA SITI NUR JANNAH 18/01/2023 Pelayanan KB : Suntik puspitarini Rp. 15.000

113305010123P001128 WIWIK DWI RAHAYU 18/01/2023 Pelayanan ANC 2 (Dua) SUWARTI Rp. 50.000

113305010123P001132 ISKA ARI LISTIYO NINGSIH 18/01/2023 Pelayanan ANC 1 (Satu) SUWARTI Rp. 50.000

113305010123P001134 AINUR ROHMAWATI 18/01/2023 Pelayanan ANC 3 (Tiga) SUWARTI Rp. 50.000

113305010123P001139 RAHAYU SETIYAWATI 19/01/2023 Pelayanan KB : Suntik puspitarini Rp. 15.000

113305010123P001141 ARISAH 19/01/2023 Pelayanan KB : Cabut IUD / Implant puspitarini Rp. 100.000

113305010123P001143 SUPATMI 19/01/2023 Pelayanan KB : Suntik puspitarini Rp. 15.000

113305010123P001156 RATNA SUGESTI 18/01/2023 Pelayanan ANC 1 (Satu) SUWARTI Rp. 50.000

113305010123P001178 MUSLICHAH 19/01/2023 Pelayanan ANC 3 (Tiga) SUWARTI Rp. 50.000

113305010123P001180 MUTIARA 19/01/2023 Pelayanan ANC 3 (Tiga) SUWARTI Rp. 50.000

113305010123P001186 NITA REKNO KUNARSIH 19/01/2023 Pelayanan ANC 3 (Tiga) SUWARTI Rp. 50.000

113305010123P001197 SANTI 19/01/2023 Pelayanan ANC 1 (Satu) SUWARTI Rp. 50.000

113305010123P002233 SILASTUTI 16/01/2023 Pelayanan ANC 2 (Dua) SUWARTI Rp. 50.000

113305010123P002257 GINI 24/01/2023 Pelayanan KB : Suntik puspitarini Rp. 20.000

113305010123P002764 ISTIANA 21/01/2023 Pelayanan PNC 1 (Satu) PUNGKI INDRIYANI Rp. 25.000

113305010123P002776 NURUL ROSALIA 21/01/2023 Pelayanan PNC 1 (Satu) SUNARTI Rp. 25.000

113305010123P003134 NOER HIDAYATUS SOLIKAH 23/01/2023 Pelayanan PNC 1 (Satu) Evi Damayanti Rp. 25.000

113305010123P003163 NUR SETIYOWATI 23/01/2023 Pelayanan PNC 1 (Satu) ROSITA EKA CAHYANINGSIH Rp. 25.000
 NoKunjungan NAMA TANGGAL TINDAKAN HASIL TENAGA MEDIS BIAYA

113305010123P003227 YANTI 26/01/2023 Pelayanan KB : Suntik puspitarini Rp. 20.000

113305010123P003251 KARYATI 24/01/2023 Pelayanan PNC 1 (Satu) DEWI MASYITOH Rp. 40.000

113305010123P003253 DITA ANGGI FITANATA 25/01/2023 Pelayanan PNC 1 (Satu) Evi Damayanti Rp. 40.000

113305010123P003620 SUMILAH 27/01/2023 Pelayanan PNC 1 (Satu) PRANIATI Rp. 40.000

113305010123P003664 DWI ANGGRAENI 20/01/2023 Pelayanan ANC 1 (Satu) SUWARTI Rp. 50.000

113305010123P003675 DIAN FARIHA ROSADA 14/01/2023 Pelayanan ANC 2 (Dua) SUWARTI Rp. 50.000

113305010123P003681 ANISA NUR FITRIYANI 17/01/2023 Pelayanan ANC 2 (Dua) SUWARTI Rp. 50.000

113305010123P003683 RUMINI 20/01/2023 Pelayanan ANC 2 (Dua) SUWARTI Rp. 50.000

113305010123P003684 ELPITA DWIYANTI 20/01/2023 Pelayanan ANC 2 (Dua) SUWARTI Rp. 50.000

113305010123P003685 NITA PUJI LESTARI 20/01/2023 Pelayanan ANC 1 (Satu) SUWARTI Rp. 50.000

113305010123P003802 SARI AMBARWATI 28/01/2023 Pelayanan KB : Suntik puspitarini Rp. 20.000

113305010123P003827 NUR SETIYOWATI 22/01/2023 Evakuasi medis / Ambulans Darat 0.00 dr. Sintha Dewi Puspitasari Rp. 50.000

113305010123P003828 AYU RISMAYANTI 23/01/2023 Evakuasi medis / Ambulans Darat 0.00 dr. Ayu Chandra Kumala Dewi Rp. 50.000

113305010123P003829 INWATI 10/01/2023 Evakuasi medis / Ambulans Darat 0.00 dr. ENDANG SETYAWATI Rp. 50.000

113305010123P003830 SITI HANDAYANI 09/01/2023 Evakuasi medis / Ambulans Darat 0.00 dr. Setiyo Riyatno Rp. 147.500

113305010123P003831 LITA AGUSTIN FIRNANDA 03/01/2023 Evakuasi medis / Ambulans Darat 0.00 dr. Sintha Dewi Puspitasari Rp. 147.500

113305010123P003832 NOVITA DEVI KRISTIANTI 21/01/2023 Evakuasi medis / Ambulans Darat 0.00 dr. Sintha Dewi Puspitasari Rp. 147.500

113305010123P003833 ULFATIN NADLIROH 04/01/2023 Evakuasi medis / Ambulans Darat 0.00 dr. Setiyo Riyatno Rp. 147.500

113305010123P003834 SUPARNI 12/01/2023 Evakuasi medis / Ambulans Darat 0.00 dr. ENDANG SETYAWATI Rp. 147.500

113305010123P003835 DESI RAHMANDANI 04/01/2023 Evakuasi medis / Ambulans Darat 0.00 dr. Setiyo Riyatno Rp. 147.500

113305010123P003985 KHOIRUN NISA 29/01/2023 Pelayanan PNC 1 (Satu) SRI WAHYUNI Rp. 40.000

113305010123P004013 SRI LESTARI 28/01/2023 Pelayanan PNC 1 (Satu) Katri sunarsih Rp. 40.000

113305010123P004025 SRI WAYUTI 28/01/2023 Pelayanan PNC 1 (Satu) APRILIYA SARI RAHMAWATI Rp. 40.000

113305010123P004306 NETTY SORTAULINA SIJABAT 31/01/2023 Pelayanan KB : Suntik puspitarini Rp. 20.000

113305010123P004308 MUTIARA 30/01/2023 Evakuasi medis / Ambulans Darat 0.00 dr. Sintha Dewi Puspitasari Rp. 147.500

113305010123P004309 SUWARNI 30/01/2023 Evakuasi medis / Ambulans Darat 0.00 dr. Sintha Dewi Puspitasari Rp. 147.500

113305010123Y000018 NOVITA 02/01/2023 Pelayanan ANC 3 (Tiga) SUWARTI Rp. 50.000

113305010123Y000019 NOER HIDAYATUS SOLIKAH 02/01/2023 Pelayanan ANC 3 (Tiga) SUWARTI Rp. 50.000
 NoKunjungan NAMA TANGGAL TINDAKAN HASIL TENAGA MEDIS BIAYA

113305010123Y000021 DARWANTI 02/01/2023 Pelayanan ANC 2 (Dua) SUWARTI Rp. 50.000

113305010123Y000070 SELLI FATMA WATI 02/01/2023 Pelayanan ANC 3 (Tiga) SUWARTI Rp. 50.000

113305010123Y000071 SUMILAH 02/01/2023 Pelayanan ANC 4 (Empat) SUWARTI Rp. 50.000

113305010123Y000072 ANIS LISTIANINGSIH 02/01/2023 Pelayanan ANC 2 (Dua) SUWARTI Rp. 50.000

113305010123Y000073 RARA ANGGUN NABILA 02/01/2023 Pelayanan ANC 3 (Tiga) SUWARTI Rp. 50.000

113305010123Y000074 WARSI 02/01/2023 Pelayanan ANC 2 (Dua) SUWARTI Rp. 50.000

113305010123Y000120 SUPANGATI 03/01/2023 Pelayanan ANC 2 (Dua) SUWARTI Rp. 50.000

113305010123Y000122 SUSIYATI 03/01/2023 Pelayanan ANC 3 (Tiga) SUWARTI Rp. 50.000

113305010123Y000132 WIWIN HANDANINGSIH 03/01/2023 Pelayanan ANC 2 (Dua) SUWARTI Rp. 50.000

113305010123Y000171 NOVITA DEVI KRISTIANTI 04/01/2023 Pelayanan ANC 3 (Tiga) SUWARTI Rp. 50.000

113305010123Y000231 DWI LESTARI 05/01/2023 Pelayanan ANC 3 (Tiga) SUWARTI Rp. 50.000

113305010123Y000232 KHAYATUL AZIZAH 05/01/2023 Pelayanan ANC 4 (Empat) SUWARTI Rp. 50.000

113305010123Y000414 LUTFIATIN NUR SHOLIHAH 09/01/2023 Pelayanan ANC 2 (Dua) SUWARTI Rp. 50.000

113305010123Y000415 PRIETTA KHANIA KUSUMA PUTRI 09/01/2023 Pelayanan ANC 1 (Satu) SUWARTI Rp. 50.000

113305010123Y000416 DETRI DIAN SRI WAHYUNI 09/01/2023 Pelayanan ANC 3 (Tiga) SUWARTI Rp. 50.000

113305010123Y000417 KARYATI 09/01/2023 Pelayanan ANC 3 (Tiga) SUWARTI Rp. 50.000

113305010123Y000418 WAHYUNI 09/01/2023 Pelayanan ANC 1 (Satu) SUWARTI Rp. 50.000

113305010123Y000474 DINA HIDAYATUL MUNAWAROH 10/01/2023 Pelayanan ANC 3 (Tiga) SUWARTI Rp. 50.000

113305010123Y000475 DINA FITRIANINGSIH 10/01/2023 Pelayanan ANC 3 (Tiga) SUWARTI Rp. 50.000

113305010123Y000476 SUWARNI 10/01/2023 Pelayanan ANC 3 (Tiga) SUWARTI Rp. 50.000

113305010123Y000480 TIARA VALENTINA KUSUMA DHEA 10/01/2023 Pelayanan ANC 1 (Satu) SUWARTI Rp. 50.000

113305010123Y000482 FITRIA FEBRIYANTI 10/01/2023 Pelayanan ANC 2 (Dua) SUWARTI Rp. 50.000

113305010123Y000573 AULIA LISTIANINGSIH 11/01/2023 Pelayanan ANC 2 (Dua) SUWARTI Rp. 50.000

113305010123Y000574 ERMA DIANA 11/01/2023 Pelayanan ANC 2 (Dua) SUWARTI Rp. 50.000

113305010123Y000575 NURUL KHOLIFATUN NI'MAH 11/01/2023 Pelayanan ANC 2 (Dua) SUWARTI Rp. 50.000

113305010123Y000659 BELLYANA SRI YUNIARTI 12/01/2023 Pelayanan ANC 3 (Tiga) SUWARTI Rp. 50.000

113305010123Y000666 SUHENSI IKA INDAH 12/01/2023 Pelayanan ANC 3 (Tiga) SUWARTI Rp. 50.000

113305010123Y000667 ENDANG TRIYANI 12/01/2023 Pelayanan ANC 3 (Tiga) SUWARTI Rp. 50.000
 NoKunjungan NAMA TANGGAL TINDAKAN HASIL TENAGA MEDIS BIAYA

113305010123Y000668 ERINA PUJI LESTARI 12/01/2023 Pelayanan ANC 3 (Tiga) SUWARTI Rp. 50.000

113305010123Y000669 MIFNAWATI 12/01/2023 Pelayanan ANC 3 (Tiga) SUWARTI Rp. 50.000

113305010123Y000710 ADELIA CANDRA PUTRI 13/01/2023 Pelayanan ANC 1 (Satu) SUWARTI Rp. 50.000

113305010123Y000770 ALIYATUR ROFIAH 14/01/2023 Pelayanan ANC 3 (Tiga) SUWARTI Rp. 50.000

113305010123Y000889 IKA DIAH AYU 16/01/2023 Pelayanan ANC 1 (Satu) SUWARTI Rp. 50.000

113305010123Y000891 IHDA RAHMAWATI 16/01/2023 Pelayanan ANC 3 (Tiga) SUWARTI Rp. 50.000

113305010123Y000894 IZA MUNAWAROH 16/01/2023 Pelayanan ANC 3 (Tiga) SUWARTI Rp. 50.000

113305010123Y000962 SOFI LESTARI 17/01/2023 Pelayanan ANC 3 (Tiga) SUWARTI Rp. 50.000

113305010123Y000978 SUPARMI 17/01/2023 Pelayanan ANC 2 (Dua) SUWARTI Rp. 50.000

113305010123Y001046 AINNAUL MARDLIYAH 18/01/2023 Pelayanan ANC 2 (Dua) SUWARTI Rp. 50.000

113305010123Y001181 EKA APRI HAYU PARASTI 19/01/2023 Pelayanan ANC 3 (Tiga) SUWARTI Rp. 50.000

113305010123Y001202 SRI LESTARI 19/01/2023 Pelayanan ANC 4 (Empat) SUWARTI Rp. 50.000

Tanggal terima FPK, Tanggal, 06/02/2023

Verifikator Pengaju Klaim