BPJS Kesehatan Cab.

SELONG
FORMULIR PENGAJUAN KLAIM

Nomor FPK : L1704000000270

Provider : KOPANG
Bulan Pelayanan : April, 2017
Pelayanan : Promotif

Total Data : 76

Total Tagihan : 1,900,000

NO TRANSAKSI TANGGAL NAMA PESERTA JENIS KLAIM Biaya

23020901L1704067496 21/04/201 NURUL FITRIAH IVA 25,000
23020901L1704067497 21/04/201 DIAN WAHIDA RAHMI IVA 25,000
23020901L1704067513 21/04/201 PAIZAH IVA 25,000
23020901L1704067854 21/04/201 BAIQ HENNY SETIAWATI IVA 25,000
23020901L1704067861 21/04/201 MARNIATI IVA 25,000
23020901L1704067929 21/04/201 SUMARNI IVA 25,000
23020901L1704067979 21/04/201 B. SUDIANI / NB32020 IVA 25,000
23020901L1704067989 21/04/201 MURNI IVA 25,000
23020901L1704067998 21/04/201 INAQ AZIL PRATAMA IVA 25,000
23020901L1704068018 21/04/201 NURAINI IVA 25,000
23020901L1704068028 21/04/201 MURNIATI IVA 25,000
23020901L1704068038 21/04/201 MADANIAH IVA 25,000
23020901L1704068069 21/04/201 BAIQ LAELATI DWI PUTRI IVA 25,000
23020901L1704068073 21/04/201 ROSITAH IVA 25,000
23020901L1704068085 21/04/201 SULTIAH IVA 25,000
23020901L1704068092 21/04/201 HULDIANI IVA 25,000
23020901L1704068099 21/04/201 MAHNIM IVA 25,000
23020901L1704068110 21/04/201 RAUHUL HASANAH IVA 25,000
23020901L1704068171 21/04/201 novi emilia wati IVA 25,000
23020901L1704068236 21/04/201 NURUL IVA 25,000
23020901L1704068260 21/04/201 BUDIANA IVA 25,000
23020901L1704068300 21/04/201 SUBAESAH IVA 25,000
23020901L1704068309 21/04/201 MARISAH IVA 25,000
23020901L1704068392 21/04/201 NURAINI IVA 25,000
23020901L1704068402 21/04/201 NURUL YAKIN IVA 25,000
23020901L1704068703 21/04/201 WENI WIDIA WATI IVA 25,000
23020901L1704068736 21/04/201 SENAH IVA 25,000
23020901L1704068796 21/04/201 SURYATI IVA 25,000
23020901L1704068842 21/04/201 SUNARNI IVA 25,000
23020901L1704068857 21/04/201 IRAWATI IVA 25,000
23020901L1704068937 21/04/201 ISTISARAH IVA 25,000
23020901L1704068999 21/04/201 SAPURAH IVA 25,000
23020901L1704069026 21/04/201 MASIRAH IVA 25,000
23020901L1704069049 21/04/201 ATON IVA 25,000
23020901L1704069063 21/04/201 RATNAWATI IVA 25,000
23020901L1704069077 21/04/201 UMMI KALSUM IVA 25,000
23020901L1704069155 21/04/201 WARTINI IVA 25,000
23020901L1704069177 21/04/201 DEWI IVA 25,000
23020901L1704069189 21/04/201 REHANUN IVA 25,000
23020901L1704069208 21/04/201 JAMA YAH IVA 25,000
23020901L1704069220 21/04/201 INAQ SARIYAH IVA 25,000
23020901L1704069240 21/04/201 MASRIANAH IVA 25,000
23020901L1704069251 21/04/201 NURMINAH IVA 25,000
23020901L1704069267 21/04/201 MURNI IVA 25,000
23020901L1704069288 21/04/201 BQ SUKMA SARI DEWI IVA 25,000
23020901L1704069328 21/04/201 MERI SUSANTI IVA 25,000
NO TRANSAKSI TANGGAL NAMA PESERTA JENIS KLAIM Biaya
23020901L1704069349 21/04/201 NURMAYANI IVA 25,000
23020901L1704069411 21/04/201 B. MUSTIKA NILA PAHRIYAH, SP.I IVA 25,000
23020901L1704069435 21/04/201 ROHMATUL MUAYYANAH IVA 25,000
23020901L1704069463 21/04/201 ISTIARAH IVA 25,000
23020901L1704069538 21/04/201 SINARIATI IVA 25,000
23020901L1704069565 21/04/201 ROHANI IVA 25,000
23020901L1704069579 21/04/201 EFI SUSANTI IVA 25,000
23020901L1704069586 21/04/201 SUARNI IVA 25,000
23020901L1704069640 21/04/201 INAQ RINA IVA 25,000
23020901L1704069688 21/04/201 SUPNIATI IVA 25,000
23020901L1704069701 21/04/201 SERIAH IVA 25,000
23020901L1704069708 21/04/201 AMIRAH IVA 25,000
23020901L1704069736 21/04/201 LENI MARLINA IVA 25,000
23020901L1704069759 21/04/201 ANA IVA 25,000
23020901L1704069840 21/04/201 SANIAH IVA 25,000
23020901L1704069848 21/04/201 SITI rohmah IVA 25,000
23020901L1704069933 21/04/201 ROSDIANA IVA 25,000
23020901L1704070000 21/04/201 ZOHAERATUN IVA 25,000
23020901L1704070073 21/04/201 MURTINI IVA 25,000
23020901L1704070080 21/04/201 BAIQ PATMAWATI IVA 25,000
23020901L1704070163 21/04/201 RATNASARI IVA 25,000
23020901L1704070213 21/04/201 MULIATIK IVA 25,000
23020901L1704070227 21/04/201 IYAH IVA 25,000
23020901L1704070251 21/04/201 NURUL IVA 25,000
23020901L1704070285 21/04/201 ANIM IVA 25,000
23020901L1704070294 21/04/201 MAHAENI IVA 25,000
23020901L1704070349 21/04/201 ZAKIAH IVA 25,000
23020901L1704070359 21/04/201 ISNAINI IVA 25,000
23020901L1704070371 21/04/201 MUINAH IVA 25,000
23020901L1704070398 21/04/201 MINAH IVA 25,000
 Tanggal,
Pengaju Klaim,

26/04/2017 11.26.45