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    Khutbah Idul Adha 1438 H DPP Hidayatullah

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    harin aulia
    This document is a claim form from BPJS Kesehatan Cab. Tegal for reimbursement of medical services provided in December 2017. It details 4 medical transactions totaling 100,000 involving prenatal care services by Dr. Suraji Adi Purwo for 4 patients. The form includes patient names, dates of service, procedures, attending physicians, and costs for each transaction. It requests verification and submission on January 19, 2018.

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    Khutbah Idul Adha 1438 H DPP Hidayatullah

    Uploaded by

    harin aulia
    2 views1 page
    This document is a claim form from BPJS Kesehatan Cab. Tegal for reimbursement of medical services provided in December 2017. It details 4 medical transactions totaling 100,000 involving prenatal care services by Dr. Suraji Adi Purwo for 4 patients. The form includes patient names, dates of service, procedures, attending physicians, and costs for each transaction. It requests verification and submission on January 19, 2018.

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    GHHGJHGUHKJKLKOK

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    This document is a claim form from BPJS Kesehatan Cab. Tegal for reimbursement of medical services provided in December 2017. It details 4 medical transactions totaling 100,000 involving prenatal care services by Dr. Suraji Adi Purwo for 4 patients. The form includes patient names, dates of service, procedures, attending physicians, and costs for each transaction. It requests verification and submission on January 19, 2018.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    2 views1 page

    Khutbah Idul Adha 1438 H DPP Hidayatullah

    Uploaded by

    harin aulia
    This document is a claim form from BPJS Kesehatan Cab. Tegal for reimbursement of medical services provided in December 2017. It details 4 medical transactions totaling 100,000 involving prenatal care services by Dr. Suraji Adi Purwo for 4 patients. The form includes patient names, dates of service, procedures, attending physicians, and costs for each transaction. It requests verification and submission on January 19, 2018.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
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    of 1

    BPJS Kesehatan Cab.

    TEGAL
    FORMULIR PENGAJUAN KLAIM TINGKAT PERTAMA

    Nomor FPK : P1712000038285


    Provider : Luwunggede
    Bulan Pelayanan : December, 2017
    Pelayanan : RJTP

    Total Data : 4

    Total Tagihan : 100,000

    NO TRANSAKSI NAMA PESERTA TANGGAL TINDAKAN TENAGA MEDIS Biaya


    110912031217Y000765 ENDANG SULYASIH 06/12/201 Pelayanan PNC 1 (Satu) dr Suraji Adi Purwo 25,000
    110912031217Y000768 TO'ASIH 09/12/201 Pelayanan PNC 1 (Satu) dr Suraji Adi Purwo 25,000
    110912031217Y000776 DASTI BT DASIWAD 14/12/201 Pelayanan PNC 1 (Satu) dr Suraji Adi Purwo 25,000
    110912031217Y000802 LIA RISTIANTI 31/12/201 Pelayanan PNC 1 (Satu) dr Suraji Adi Purwo 25,000

    Tanggal terima Tanggal, 19 January 2018


    Verifikator, Pengaju Klaim,

    19/01/2018 14.48.34

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