BPJS Claim Submission Feb 2019

This document is a claim form submitted by Raja Basa Indah provider to BPJS Kesehatan Cab. BANDAR LAMPUNG for promotional services provided in February 2019 totaling 900,000. It includes 36 transactions ranging from February 6th to 20th for Individual Health Education (IVA) services each costing 25,000 to beneficiaries such as Sadirah, Susi Elia A, and Sukma Pariana.

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BPJS Claim Submission Feb 2019

Uploaded by

Wulan Abadi

We take content rights seriously. If you suspect this is your content, claim it here.

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Download as PDF, TXT or read online on Scribd

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BPJS Kesehatan Cab.

BANDAR LAMPUNG
FORMULIR PENGAJUAN KLAIM

Nomor FPK : L1902000003902

Provider : RAJA BASA INDAH
Bulan Pelayanan : February, 2019
Pelayanan : Promotif

Total Data : 36

Total Tagihan : 900,000

NO TRANSAKSI TANGGAL NAMA PESERTA JENIS KLAIM Biaya

08011001L1902122014 11/02/2019 SADIRAH IVA 25,000
08011001L1902122016 11/02/2019 SUSI ELIA A IVA 25,000
08011001L1902122017 11/02/2019 SUKMA PARLIANA IVA 25,000
08011001L1902122019 11/02/2019 ELI KURNIAWATI IVA 25,000
08011001L1902122020 11/02/2019 ERMAWATI IVA 25,000
08011001L1902122025 11/02/2019 ERNI SUSANTI IVA 25,000
08011001L1902122029 13/02/2019 yuni fitria IVA 25,000
08011001L1902122030 13/02/2019 WATI IVA 25,000
08011001L1902122031 13/02/2019 endang fahwati IVA 25,000
08011001L1902122032 13/02/2019 LILIS SURYANI IVA 25,000
08011001L1902122033 13/02/2019 ika nalurita IVA 25,000
08011001L1902122074 14/02/2019 ANI LIANI SARI IVA 25,000
08011001L1902122075 14/02/2019 SOLHAWATI IVA 25,000
08011001L1902122077 14/02/2019 EKA SUSILAWATI IVA 25,000
08011001L1902122079 14/02/2019 ANITA SARI IVA 25,000
08011001L1902122093 20/02/2019 AGUSTINIWATI IVA 25,000
08011001L1902122095 20/02/2019 EVA WATI IVA 25,000
08011001L1902122097 20/02/2019 FITRIA MAYA SARI IVA 25,000
08011001L1902122111 06/02/2019 YANTI IVA 25,000
08011001L1902122120 06/02/2019 RUNTAH IVA 25,000
08011001L1902122126 06/02/2019 RUSMINA IVA 25,000
08011001L1902122138 06/02/2019 ANA YANTINA IVA 25,000
08011001L1902122144 06/02/2019 HAYUNA IVA 25,000
08011001L1902122146 06/02/2019 SAROH IVA 25,000
08011001L1902128418 18/02/2019 RAHMAHWATI IVA 25,000
08011001L1902128419 18/02/2019 INDAH ROSIDAH FITRIANI IVA 25,000
08011001L1902128420 18/02/2019 MAISAROH IVA 25,000
08011001L1902128421 18/02/2019 ASMINAR IVA 25,000
08011001L1902128424 18/02/2019 YULIAH IVA 25,000
08011001L1902128434 18/02/2019 SAHARA SIHOMBING IVA 25,000
08011001L1902128435 18/02/2019 suratmi IVA 25,000
08011001L1902128436 18/02/2019 YANI IVA 25,000
08011001L1902130111 14/02/2019 RATNA NINGSIH IVA 25,000
08011001L1902130112 14/02/2019 ELI YANA IVA 25,000
08011001L1902130113 06/02/2019 EVI ULFA DORA IVA 25,000
08011001L1902130115 07/02/2019 SUPRI YANTI IVA 25,000
Tanggal,
Pengaju Klaim,

04/04/2019 10.37.39