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  • Formulir Pengajuan Klaim Tingkat Pertama: BPJS Kesehatan Cab. SINGARAJA

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    Joey Tria Juventini
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    The document is a claim form from Puskesmas Seririt II submitted to BPJS Kesehatan for January 2015. It includes details of 8 deliveries performed at the facility between January 3rd and 30th. The total billing amount for the procedures is 4,800,000 Indonesian Rupiah.

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    The document is a claim form from Puskesmas Seririt II submitted to BPJS Kesehatan for January 2015. It includes details of 8 deliveries performed at the facility between January 3rd and 30th. The total billing amount for the procedures is 4,800,000 Indonesian Rupiah.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    Download as pdf or txt
    11 views1 page

    Formulir Pengajuan Klaim Tingkat Pertama: BPJS Kesehatan Cab. SINGARAJA

    Uploaded by

    Joey Tria Juventini
    The document is a claim form from Puskesmas Seririt II submitted to BPJS Kesehatan for January 2015. It includes details of 8 deliveries performed at the facility between January 3rd and 30th. The total billing amount for the procedures is 4,800,000 Indonesian Rupiah.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    of 1

    BPJS Kesehatan Cab.

    SINGARAJA

    FORMULIR PENGAJUAN KLAIM TINGKAT PERTAMA


    Nomor FPK

    P1501000007643

    Provider

    Puskesmas Seririt II

    Bulan Pelayanan

    January, 2015

    Pelayanan

    RITP

    Total Data

    Total Tagihan

    4,800,000

    NO TRANSAKSI

    NAMA PESERTA

    TGL MASUK

    TGL PULANG

    TINDAKAN

    220108020115Y000293

    LUH REDANI

    03/01/201

    04/01/2015

    Paket persalinan per vaginam normal

    Biaya
    600,000

    220108020115Y000294

    PUTU KRISDAN YANTI

    04/01/201

    05/01/2015

    Paket persalinan per vaginam normal

    600,000

    220108020115Y000295

    LUH SARIANI

    08/01/201

    09/01/2015

    Paket persalinan per vaginam normal

    600,000

    220108020115Y000296

    NI LUH YUSMITA

    10/01/201

    11/01/2015

    Paket persalinan per vaginam normal

    600,000

    220108020115Y000297

    kadek erna widiantari

    10/01/201

    11/01/2015

    Paket persalinan per vaginam normal

    600,000

    220108020115Y000298

    PUTU SUKERTI

    10/01/201

    11/01/2015

    Paket persalinan per vaginam normal

    600,000

    220108020115Y000299

    KOMANG ARI NOVIANI

    17/01/201

    18/01/2015

    Paket persalinan per vaginam normal

    600,000

    220108020115Y000300

    NI NENGAH SUMANTRI

    29/01/201

    30/01/2015

    Paket persalinan per vaginam normal

    600,000

    Tanggal terima
    Verifikator,

    09/02/2015 12.08.35

    Tanggal, 09 February 2015


    Pengaju Klaim,

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