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BPJS Kesehatan Cab. SINGKAWANG: Formulir Pengajuan Klaim Tingkat Pertama

This document is a claim form from BPJS Kesehatan Cab. SINGKAWANG containing information about 14 antenatal care (ANC) services provided in March 2019. The total bill amount for these services is Rp 2,800,000. The form includes patient names, dates of service, medical procedures performed, health outcomes, treating medical staff, and costs for each service.

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Yholanda Phoseidoncleitho
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20 views3 pages

BPJS Kesehatan Cab. SINGKAWANG: Formulir Pengajuan Klaim Tingkat Pertama

This document is a claim form from BPJS Kesehatan Cab. SINGKAWANG containing information about 14 antenatal care (ANC) services provided in March 2019. The total bill amount for these services is Rp 2,800,000. The form includes patient names, dates of service, medical procedures performed, health outcomes, treating medical staff, and costs for each service.

Uploaded by

Yholanda Phoseidoncleitho
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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BPJS Kesehatan Cab.

SINGKAWANG
FORMULIR PENGAJUAN KLAIM TINGKAT PERTAMA

Nomor FPK : P1903000037119

Provider : SELAKAU
Bulan Pelayanan : March 2019

Pelayanan : RJTP

Total Data : 14

Total Tagihan : Rp. 2.800.000

NoKunjungan NAMA TANGGAL TINDAKAN HASIL TENAGA MEDIS BIAYA

150311010319Y001061 SAPURA 13/03/2019 Pelayanan ANC 3 (Tiga) 30.00 SUPRIHATIN Rp. 50.000

150311010319Y001061 SAPURA 13/03/2019 Pelayanan ANC 1 (Satu) 11.00 SUPRIHATIN Rp. 50.000

150311010319Y001061 SAPURA 13/03/2019 Pelayanan ANC 2 (Dua) 21.00 SUPRIHATIN Rp. 50.000

150311010319Y001061 SAPURA 13/03/2019 Pelayanan ANC 4 (Empat) 39.00 SUPRIHATIN Rp. 50.000

150311010319Y001062 ATNAH 20/03/2019 Pelayanan ANC 4 (Empat) 37.00 Diah Supriyati Rp. 50.000

150311010319Y001062 ATNAH 20/03/2019 Pelayanan ANC 2 (Dua) 23.00 Diah Supriyati Rp. 50.000

150311010319Y001062 ATNAH 20/03/2019 Pelayanan ANC 1 (Satu) 10.00 Diah Supriyati Rp. 50.000

150311010319Y001062 ATNAH 20/03/2019 Pelayanan ANC 3 (Tiga) 32.00 Diah Supriyati Rp. 50.000

150311010319Y001063 BUN SHU PUN 12/03/2019 Pelayanan ANC 3 (Tiga) 31.00 ETIKA DAMAYANTI, S. Tr. Keb Rp. 50.000

150311010319Y001063 BUN SHU PUN 12/03/2019 Pelayanan ANC 1 (Satu) 10.00 ETIKA DAMAYANTI, S. Tr. Keb Rp. 50.000

150311010319Y001063 BUN SHU PUN 12/03/2019 Pelayanan ANC 2 (Dua) 25.00 ETIKA DAMAYANTI, S. Tr. Keb Rp. 50.000

150311010319Y001063 BUN SHU PUN 12/03/2019 Pelayanan ANC 4 (Empat) 38.00 ETIKA DAMAYANTI, S. Tr. Keb Rp. 50.000

150311010319Y001064 FATMAWATI 04/03/2019 Pelayanan ANC 4 (Empat) 37.00 Diah Supriyati Rp. 50.000

150311010319Y001064 FATMAWATI 04/03/2019 Pelayanan ANC 2 (Dua) 20.00 Diah Supriyati Rp. 50.000

150311010319Y001064 FATMAWATI 04/03/2019 Pelayanan ANC 1 (Satu) 12.00 Diah Supriyati Rp. 50.000

150311010319Y001064 FATMAWATI 04/03/2019 Pelayanan ANC 3 (Tiga) 34.00 Diah Supriyati Rp. 50.000
NoKunjungan NAMA TANGGAL TINDAKAN HASIL TENAGA MEDIS BIAYA

150311010319Y001065 SUSI 14/03/2019 Pelayanan ANC 3 (Tiga) 34.00 Diah Supriyati Rp. 50.000

150311010319Y001065 SUSI 14/03/2019 Pelayanan ANC 1 (Satu) 12.00 Diah Supriyati Rp. 50.000

150311010319Y001065 SUSI 14/03/2019 Pelayanan ANC 2 (Dua) 21.00 Diah Supriyati Rp. 50.000

150311010319Y001065 SUSI 14/03/2019 Pelayanan ANC 4 (Empat) 38.00 Diah Supriyati Rp. 50.000

150311010319Y001066 KURAISA 14/03/2019 Pelayanan ANC 4 (Empat) 35.00 Diah Supriyati Rp. 50.000

150311010319Y001066 KURAISA 14/03/2019 Pelayanan ANC 2 (Dua) 20.00 Diah Supriyati Rp. 50.000

150311010319Y001066 KURAISA 14/03/2019 Pelayanan ANC 1 (Satu) 12.00 Diah Supriyati Rp. 50.000

150311010319Y001066 KURAISA 14/03/2019 Pelayanan ANC 3 (Tiga) 30.00 Diah Supriyati Rp. 50.000

150311010319Y001067 YULIArNA 11/03/2019 Pelayanan ANC 3 (Tiga) 34.00 SUPRIHATIN Rp. 50.000

150311010319Y001067 YULIArNA 11/03/2019 Pelayanan ANC 1 (Satu) 11.00 SUPRIHATIN Rp. 50.000

150311010319Y001067 YULIArNA 11/03/2019 Pelayanan ANC 2 (Dua) 20.00 SUPRIHATIN Rp. 50.000

150311010319Y001067 YULIArNA 11/03/2019 Pelayanan ANC 4 (Empat) 38.00 SUPRIHATIN Rp. 50.000

150311010319Y001068 TRI WAHYUNI ARA 18/03/2019 Pelayanan ANC 4 (Empat) 38.00 SUPRIHATIN Rp. 50.000

150311010319Y001068 TRI WAHYUNI ARA 18/03/2019 Pelayanan ANC 2 (Dua) 20.00 SUPRIHATIN Rp. 50.000

150311010319Y001068 TRI WAHYUNI ARA 18/03/2019 Pelayanan ANC 1 (Satu) 10.00 SUPRIHATIN Rp. 50.000

150311010319Y001068 TRI WAHYUNI ARA 18/03/2019 Pelayanan ANC 3 (Tiga) 34.00 SUPRIHATIN Rp. 50.000

150311010319Y001069 ANNA 04/03/2019 Pelayanan ANC 3 (Tiga) 34.00 SUPRIHATIN Rp. 50.000

150311010319Y001069 ANNA 04/03/2019 Pelayanan ANC 1 (Satu) 7.00 SUPRIHATIN Rp. 50.000

150311010319Y001069 ANNA 04/03/2019 Pelayanan ANC 2 (Dua) 16.00 SUPRIHATIN Rp. 50.000

150311010319Y001069 ANNA 04/03/2019 Pelayanan ANC 4 (Empat) 41.00 SUPRIHATIN Rp. 50.000

150311010319Y001070 SYARIFAH RAMLAH 01/03/2019 Pelayanan ANC 4 (Empat) 37.00 Nurhajizah Amd, Keb Rp. 50.000

150311010319Y001070 SYARIFAH RAMLAH 01/03/2019 Pelayanan ANC 2 (Dua) 21.00 Nurhajizah Amd, Keb Rp. 50.000

150311010319Y001070 SYARIFAH RAMLAH 01/03/2019 Pelayanan ANC 1 (Satu) 8.00 Nurhajizah Amd, Keb Rp. 50.000

150311010319Y001070 SYARIFAH RAMLAH 01/03/2019 Pelayanan ANC 3 (Tiga) 29.00 Nurhajizah Amd, Keb Rp. 50.000

150311010319Y001071 AGUSTINA 04/03/2019 Pelayanan ANC 3 (Tiga) 36.00 MAUHIDA Rp. 50.000

150311010319Y001071 AGUSTINA 04/03/2019 Pelayanan ANC 1 (Satu) 12.00 MAUHIDA Rp. 50.000

150311010319Y001071 AGUSTINA 04/03/2019 Pelayanan ANC 2 (Dua) 27.00 MAUHIDA Rp. 50.000

150311010319Y001071 AGUSTINA 04/03/2019 Pelayanan ANC 4 (Empat) 38.00 MAUHIDA Rp. 50.000
NoKunjungan NAMA TANGGAL TINDAKAN HASIL TENAGA MEDIS BIAYA

150311010319Y001072 LIZA 12/03/2019 Pelayanan ANC 4 (Empat) 37.00 Nurhajizah Amd, Keb Rp. 50.000

150311010319Y001072 LIZA 12/03/2019 Pelayanan ANC 2 (Dua) 24.00 Nurhajizah Amd, Keb Rp. 50.000

150311010319Y001072 LIZA 12/03/2019 Pelayanan ANC 1 (Satu) 11.00 Nurhajizah Amd, Keb Rp. 50.000

150311010319Y001072 LIZA 12/03/2019 Pelayanan ANC 3 (Tiga) 33.00 Nurhajizah Amd, Keb Rp. 50.000

150311010319Y001073 DEBIANA 12/03/2019 Pelayanan ANC 3 (Tiga) 32.00 Nurhajizah Amd, Keb Rp. 50.000

150311010319Y001073 DEBIANA 12/03/2019 Pelayanan ANC 1 (Satu) 10.00 Nurhajizah Amd, Keb Rp. 50.000

150311010319Y001073 DEBIANA 12/03/2019 Pelayanan ANC 2 (Dua) 23.00 Nurhajizah Amd, Keb Rp. 50.000

150311010319Y001073 DEBIANA 12/03/2019 Pelayanan ANC 4 (Empat) 36.00 Nurhajizah Amd, Keb Rp. 50.000

150311010319Y001074 MELI 19/03/2019 Pelayanan ANC 4 (Empat) 40.00 Nurhajizah Amd, Keb Rp. 50.000

150311010319Y001074 MELI 19/03/2019 Pelayanan ANC 2 (Dua) 20.00 Nurhajizah Amd, Keb Rp. 50.000

150311010319Y001074 MELI 19/03/2019 Pelayanan ANC 1 (Satu) 12.00 Nurhajizah Amd, Keb Rp. 50.000

150311010319Y001074 MELI 19/03/2019 Pelayanan ANC 3 (Tiga) 36.00 Nurhajizah Amd, Keb Rp. 50.000

Tanggal terima FPK, Tanggal, 27/09/2019


Verifikator Pengaju Klaim

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