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  • Formulir Pengajuan Klaim: BPJS Kesehatan Cab. CIMAHI

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    Dipta Mulyadi Hardy
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    This document is a claim form submitted by CIKALONG WETAN provider to BPJS Kesehatan for promotional healthcare services provided in August 2017. It includes 18 transactions totaling 450,000 in claims. Each transaction lists the patient name, date of service, and a 25,000 fee for an IVA (promotional) service. The form was submitted on October 30, 2017.

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    This document is a claim form submitted by CIKALONG WETAN provider to BPJS Kesehatan for promotional healthcare services provided in August 2017. It includes 18 transactions totaling 450,000 in claims. Each transaction lists the patient name, date of service, and a 25,000 fee for an IVA (promotional) service. The form was submitted on October 30, 2017.

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    © All Rights Reserved
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    14 views2 pages

    Formulir Pengajuan Klaim: BPJS Kesehatan Cab. CIMAHI

    Uploaded by

    Dipta Mulyadi Hardy
    This document is a claim form submitted by CIKALONG WETAN provider to BPJS Kesehatan for promotional healthcare services provided in August 2017. It includes 18 transactions totaling 450,000 in claims. Each transaction lists the patient name, date of service, and a 25,000 fee for an IVA (promotional) service. The form was submitted on October 30, 2017.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    of 2

    BPJS Kesehatan Cab.

    CIMAHI
    FORMULIR PENGAJUAN KLAIM

    Nomor FPK : L1708000004493


    Provider : CIKALONG WETAN
    Bulan Pelayanan : August, 2017
    Pelayanan : Promotif

    Total Data : 18

    Total Tagihan : 450,000

    NO TRANSAKSI TANGGAL NAMA PESERTA JENIS KLAIM Biaya


    10021701L1708195692 02/08/201 NENG TUTI ROHAITI IVA 25,000
    10021701L1708195693 03/08/201 DEDAH IVA 25,000
    10021701L1708195694 03/08/201 AI NURHAYATI IVA 25,000
    10021701L1708195697 03/08/201 LENI IVA 25,000
    10021701L1708195699 03/08/201 AAH BAROKAH IVA 25,000
    10021701L1708195701 10/08/201 DEWI KANIA IVA 25,000
    10021701L1708195703 10/08/201 WIWI IVA 25,000
    10021701L1708195705 10/08/201 MIFTA NURMALA IVA 25,000
    10021701L1708195708 10/08/201 KOKOM KOMALASARI IVA 25,000
    10021701L1708195746 16/08/201 FARISKA MELIASARI IVA 25,000
    10021701L1708195752 19/08/201 SUSIYANI IVA 25,000
    10021701L1708195753 24/08/201 AI HAYATI IVA 25,000
    10021701L1708195754 24/08/201 TARIAH IVA 25,000
    10021701L1708195756 24/08/201 YUYU SOPIAH IVA 25,000
    10021701L1708195758 24/08/201 NURLAELA IVA 25,000
    10021701L1708195760 24/08/201 ETI IVA 25,000
    10021701L1708195762 24/08/201 NIA KURNIA IVA 25,000
    10021701L1708195765 24/08/201 SILVIA RESTIVIANI A IVA 25,000
    Tanggal,
    Pengaju Klaim,

    30/10/2017 09.09.32

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