Scribd Logo
Upload

Welcome to Scribd!

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

    Uploaded by

    ahmad
    14 views2 pages
    This document is a claim form from BPJS Kesehatan Cab. PAMEKASAN for promotional services provided in October 2017. It includes 17 transactions totaling 170,000 in costs. All transactions were for glucose level tests performed on various patients by Dr. Susilo on October 28th, 2017 as part of a promotional or prevention program. The claim form is dated November 20th, 2017.

    Original Description:

    fpk gda

    Original Title

    fpk gda 10

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    Report this Document
    This document is a claim form from BPJS Kesehatan Cab. PAMEKASAN for promotional services provided in October 2017. It includes 17 transactions totaling 170,000 in costs. All transactions were for glucose level tests performed on various patients by Dr. Susilo on October 28th, 2017 as part of a promotional or prevention program. The claim form is dated November 20th, 2017.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    14 views2 pages

    Formulir Pengajuan Klaim Tingkat Pertama: BPJS Kesehatan Cab. PAMEKASAN

    Uploaded by

    ahmad
    This document is a claim form from BPJS Kesehatan Cab. PAMEKASAN for promotional services provided in October 2017. It includes 17 transactions totaling 170,000 in costs. All transactions were for glucose level tests performed on various patients by Dr. Susilo on October 28th, 2017 as part of a promotional or prevention program. The claim form is dated November 20th, 2017.

    Copyright:

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

    BPJS Kesehatan Cab.

    PAMEKASAN
    FORMULIR PENGAJUAN KLAIM TINGKAT PERTAMA

    Nomor FPK : P1710000037839


    Provider : PRAGAAN
    Bulan Pelayanan : October, 2017
    Pelayanan : Promotif

    Total Data : 17

    Total Tagihan : 170,000

    NO TRANSAKSI NAMA PESERTA TANGGAL TINDAKAN TENAGA MEDIS Biaya


    133618011017Y004081 MASJHURI .H 28/10/201 Gula Darah Sewaktu (GDS) - PRB/Prolanis DR. SUSILO 10,000
    133618011017Y004082 SULAIHAH 28/10/201 Gula Darah Sewaktu (GDS) - PRB/Prolanis DR. SUSILO 10,000
    133618011017Y004083 BAIDAI 28/10/201 Gula Darah Sewaktu (GDS) - PRB/Prolanis DR. SUSILO 10,000
    133618011017Y004084 K. SYAMSURI SY 28/10/201 Gula Darah Sewaktu (GDS) - PRB/Prolanis DR. SUSILO 10,000
    133618011017Y004085 BANANI 28/10/201 Gula Darah Sewaktu (GDS) - PRB/Prolanis DR. SUSILO 10,000
    133618011017Y004086 RADIYADI 28/10/201 Gula Darah Sewaktu (GDS) - PRB/Prolanis DR. SUSILO 10,000
    133618011017Y004087 HADIYAH 28/10/201 Gula Darah Puasa (GDP) - PRB/Prolanis DR. SUSILO 10,000
    133618011017Y004088 SAPPANI 28/10/201 Gula Darah Puasa (GDP) - PRB/Prolanis DR. SUSILO 10,000
    133618011017Y004089 SURAKNA 28/10/201 Gula Darah Sewaktu (GDS) - PRB/Prolanis DR. SUSILO 10,000
    133618011017Y004090 SUNARYA. 28/10/201 Gula Darah Puasa (GDP) - PRB/Prolanis DR. SUSILO 10,000
    133618011017Y004092 MUJIB 28/10/201 Gula Darah Sewaktu (GDS) - PRB/Prolanis DR. SUSILO 10,000
    133618011017Y004093 JUMARIN 28/10/201 Gula Darah Sewaktu (GDS) - PRB/Prolanis DR. SUSILO 10,000
    133618011017Y004094 BUSINI 28/10/201 Gula Darah Puasa (GDP) - PRB/Prolanis DR. SUSILO 10,000
    133618011017Y004095 SHADIR 28/10/201 Gula Darah Sewaktu (GDS) - PRB/Prolanis DR. SUSILO 10,000

    Tanggal terima Tanggal, 20 November 2017


    Verifikator, Pengaju Klaim,

    20/11/2017 11.15.28
    BPJS Kesehatan Cab. PAMEKASAN
    FORMULIR PENGAJUAN KLAIM TINGKAT PERTAMA

    Nomor FPK : P1710000037839


    Provider : PRAGAAN
    Bulan Pelayanan : October, 2017
    Pelayanan : Promotif

    Total Data : 17

    Total Tagihan : 170,000

    NO TRANSAKSI NAMA PESERTA TANGGAL TINDAKAN TENAGA MEDIS Biaya


    133618011017Y004096 ROHANA. 28/10/201 Gula Darah Sewaktu (GDS) - PRB/Prolanis DR. SUSILO 10,000
    133618011017Y004097 MOH SADIK 28/10/201 Gula Darah Sewaktu (GDS) - PRB/Prolanis DR. SUSILO 10,000
    133618011017Y004098 SUHERAH 28/10/201 Gula Darah Sewaktu (GDS) - PRB/Prolanis DR. SUSILO 10,000

    Tanggal terima Tanggal, 20 November 2017


    Verifikator, Pengaju Klaim,

    20/11/2017 11.15.28

    You might also like