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

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    lalu salman
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    This document is a claim form from BPJS Kesehatan Cab. SELONG for inpatient care provided in February 2018 by BONJERUK hospital. It includes details of 25 patient admissions, with patient names, admission and discharge dates, procedures, attending physicians, and individual costs. The total claim amount is Rp10,800,000.

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    fpk ri feb

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    This document is a claim form from BPJS Kesehatan Cab. SELONG for inpatient care provided in February 2018 by BONJERUK hospital. It includes details of 25 patient admissions, with patient names, admission and discharge dates, procedures, attending physicians, and individual costs. The total claim amount is Rp10,800,000.

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    © All Rights Reserved
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    10 views2 pages

    Formulir Pengajuan Klaim Tingkat Pertama: BPJS Kesehatan Cab. SELONG

    Uploaded by

    lalu salman
    This document is a claim form from BPJS Kesehatan Cab. SELONG for inpatient care provided in February 2018 by BONJERUK hospital. It includes details of 25 patient admissions, with patient names, admission and discharge dates, procedures, attending physicians, and individual costs. The total claim amount is Rp10,800,000.

    Copyright:

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

    BPJS Kesehatan Cab.

    SELONG
    FORMULIR PENGAJUAN KLAIM TINGKAT PERTAMA

    Nomor FPK : P1802000042089


    Provider : BONJERUK
    Bulan Pelayanan : February, 2018

    Pelayanan : RITP
    Total Data : 25

    Total Tagihan : 10,800,000

    NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG TINDAKAN TENAGA MEDIS Biaya
    230201020118Y000548 INDRIANI 30/01/201 02/02/2018 Rawat Inap di R. Perawatan Biasa dr. Wiwin Ita Arofah 540,000
    230201020118Y000549 M. HATTAN GHIFARI 31/01/201 03/02/2018 Rawat Inap di R. Perawatan Biasa dr. Wiwin Ita Arofah 540,000
    230201020118Y000550 SANI 31/01/201 05/02/2018 Rawat Inap di R. Perawatan Biasa dr. Wiwin Ita Arofah 900,000
    230201020218Y000380 DIAN 03/02/201 06/02/2018 Rawat Inap di R. Perawatan Biasa dr. Wiwin Ita Arofah 540,000
    230201020218Y000381 SARIANI 07/02/201 09/02/2018 Rawat Inap di R. Perawatan Biasa dr. Wiwin Ita Arofah 360,000
    230201020218Y000382 SATRAH 07/02/201 09/02/2018 Rawat Inap di R. Perawatan Biasa dr. Wiwin Ita Arofah 360,000
    230201020218Y000383 SUSANTI 08/02/201 09/02/2018 Rawat Inap di R. Perawatan Biasa dr. Wiwin Ita Arofah 180,000
    230201020218Y000384 JOHAN ASTAGINA 08/02/201 10/02/2018 Rawat Inap di R. Perawatan Biasa dr. Wiwin Ita Arofah 360,000
    230201020218Y000385 MISAH 10/02/201 13/02/2018 Rawat Inap di R. Perawatan Biasa dr. Wiwin Ita Arofah 540,000
    230201020218Y000386 UMAR 10/02/201 12/02/2018 Rawat Inap di R. Perawatan Biasa dr. Wiwin Ita Arofah 360,000
    230201020218Y000387 SITI NAZIRA 11/02/201 14/02/2018 Rawat Inap di R. Perawatan Biasa dr. Wiwin Ita Arofah 540,000
    230201020218Y000388 RAUHUN 10/02/201 11/02/2018 Rawat Inap di R. Perawatan Biasa dr. Wiwin Ita Arofah 180,000
    230201020218Y000389 HENDRAWAN 09/02/201 10/02/2018 Rawat Inap di R. Perawatan Biasa dr. Wiwin Ita Arofah 180,000
    230201020218Y000390 SRIK HARMILIH WATI 13/02/201 16/02/2018 Rawat Inap di R. Perawatan Biasa dr. Wiwin Ita Arofah 540,000

    Tanggal terima Tanggal, 17 April 2018


    Verifikator, Pengaju Klaim,

    17/04/2018 07.55.28
    BPJS Kesehatan Cab. SELONG
    FORMULIR PENGAJUAN KLAIM TINGKAT PERTAMA

    Nomor FPK : P1802000042089


    Provider : BONJERUK
    Bulan Pelayanan : February, 2018

    Pelayanan : RITP
    Total Data : 25

    Total Tagihan : 10,800,000

    NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG TINDAKAN TENAGA MEDIS Biaya
    230201020218Y000391 MUHAMMAD MINADI 13/02/201 14/02/2018 Rawat Inap di R. Perawatan Biasa dr. Wiwin Ita Arofah 180,000
    230201020218Y000392 SAEBAH 18/02/201 19/02/2018 Rawat Inap di R. Perawatan Biasa dr. Wiwin Ita Arofah 180,000
    230201020218Y000393 JUMITRI 18/02/201 20/02/2018 Rawat Inap di R. Perawatan Biasa dr. Wiwin Ita Arofah 360,000
    230201020218Y000394 SALMI 19/02/201 22/02/2018 Rawat Inap di R. Perawatan Biasa dr. Wiwin Ita Arofah 540,000
    230201020218Y000395 NURUL FADILA 20/02/201 22/02/2018 Rawat Inap di R. Perawatan Biasa dr. Wiwin Ita Arofah 360,000
    230201020218Y000396 RAISAH 20/02/201 23/02/2018 Rawat Inap di R. Perawatan Biasa dr. Wiwin Ita Arofah 540,000
    230201020218Y000397 MAESUN 23/02/201 26/02/2018 Rawat Inap di R. Perawatan Biasa dr. Wiwin Ita Arofah 540,000
    230201020218Y000398 NURMIN 23/02/201 26/02/2018 Rawat Inap di R. Perawatan Biasa dr. Wiwin Ita Arofah 540,000
    230201020218Y000399 AHMAD ZAMHARIR 23/02/201 27/02/2018 Rawat Inap di R. Perawatan Biasa dr. Wiwin Ita Arofah 720,000
    230201020218Y000400 ROSIDI 24/02/201 27/02/2018 Rawat Inap di R. Perawatan Biasa dr. Wiwin Ita Arofah 540,000
    230201020218Y000401 ZURRIATI 27/02/201 28/02/2018 Rawat Inap di R. Perawatan Biasa dr. Wiwin Ita Arofah 180,000

    Tanggal terima Tanggal, 17 April 2018


    Verifikator, Pengaju Klaim,

    17/04/2018 07.55.28

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