BPJS Kesehatan Cab.

CIMAHI
FORMULIR PENGAJUAN KLAIM

Nomor FPK : L1711000005637

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

Total Data : 19

Total Tagihan : 475,000

NO TRANSAKSI TANGGAL NAMA PESERTA JENIS KLAIM Biaya

10021701L1711196147 08/11/2017 MAESAROH IVA 25,000
10021701L1711196148 04/11/2017 WARTIKA IVA 25,000
10021701L1711196149 01/11/2017 jujan padliah IVA 25,000
10021701L1711196150 20/11/2017 ARIYANTI IVA 25,000
10021701L1711196151 22/11/2017 YOYOK SUMARTINI IVA 25,000
10021701L1711196152 01/11/2017 SANTI DEWI RAHAYU IVA 25,000
10021701L1711196153 22/11/2017 DEA MAWARNI IVA 25,000
10021701L1711196154 22/11/2017 TITIM SOLIHATI FATIMA IVA 25,000
10021701L1711196155 22/11/2017 SUMIYATI IVA 25,000
10021701L1711196156 22/11/2017 SUSI SUSILAWATI IVA 25,000
10021701L1711196158 27/11/2017 ARI SUWARI IVA 25,000
10021701L1711196159 27/11/2017 NIA HANDAYANI IVA 25,000
10021701L1711196160 27/11/2017 NADDIA OCTAVIANI IVA 25,000
10021701L1711196161 29/11/2017 DESSY PUSVITASARI IVA 25,000
10021701L1711196162 27/11/2017 AISAH IVA 25,000
10021701L1711196163 22/11/2017 ENTIN KARTINI IVA 25,000
10021701L1711196164 22/11/2017 AI KARWATI IVA 25,000
10021701L1711196165 27/11/2017 NINING IVA 25,000
10021701L1711196166 27/11/2017 RATNA SETIAWATI IVA 25,000
 Tanggal,
Pengaju Klaim,

05/06/2018 11.03.59