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

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    Edy Pramana
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    This document is a claim form submitted by Klinik Aisyiyah Sragen to BPJS Kesehatan for reimbursement of medical services provided in September 2018. It includes details of 18 patients who received glucose blood tests (GDP) for a total cost of 360,000. All tests were performed on September 7th by Dr. Virani Rizatama. The claim form was submitted on September 19th.

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    September Klaim

    Original Title

    September Klaim

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    This document is a claim form submitted by Klinik Aisyiyah Sragen to BPJS Kesehatan for reimbursement of medical services provided in September 2018. It includes details of 18 patients who received glucose blood tests (GDP) for a total cost of 360,000. All tests were performed on September 7th by Dr. Virani Rizatama. The claim form was submitted on September 19th.

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    © All Rights Reserved
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    9 views2 pages

    Formulir Pengajuan Klaim Tingkat Pertama: BPJS Kesehatan Cab. SURAKARTA

    Uploaded by

    Edy Pramana
    This document is a claim form submitted by Klinik Aisyiyah Sragen to BPJS Kesehatan for reimbursement of medical services provided in September 2018. It includes details of 18 patients who received glucose blood tests (GDP) for a total cost of 360,000. All tests were performed on September 7th by Dr. Virani Rizatama. The claim form was submitted on September 19th.

    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.

    SURAKARTA
    FORMULIR PENGAJUAN KLAIM TINGKAT PERTAMA

    Nomor FPK : P1809000002485


    Provider : Klinik Aisyiyah Sragen
    Bulan Pelayanan : September, 2018
    Pelayanan : Promotif

    Total Data : 18

    Total Tagihan : 360,000

    NO TRANSAKSI NAMA PESERTA TANGGAL TINDAKAN TENAGA MEDIS Biaya


    0154B0120918Y000244 SRI SUDARTI 07/09/201 Gula Darah Puasa (GDP) - PRB/Prolanis dr.Virani Rizatama 20,000
    0154B0120918Y000245 dyah haryani herlina iriani 07/09/201 Gula Darah Puasa (GDP) - PRB/Prolanis dr.Virani Rizatama 20,000
    0154B0120918Y000246 BENEDICTA SUMIATUN 07/09/201 Gula Darah Puasa (GDP) - PRB/Prolanis dr.Virani Rizatama 20,000
    0154B0120918Y000247 MULYONO RAHARJO,S.PD 07/09/201 Gula Darah Puasa (GDP) - PRB/Prolanis dr.Virani Rizatama 20,000
    0154B0120918Y000248 SUTAYA 07/09/201 Gula Darah Puasa (GDP) - PRB/Prolanis dr.Virani Rizatama 20,000
    0154B0120918Y000249 SUPARNO 07/09/201 Gula Darah Puasa (GDP) - PRB/Prolanis dr.Virani Rizatama 20,000
    0154B0120918Y000250 TRI NURSITO 07/09/201 Gula Darah Puasa (GDP) - PRB/Prolanis dr.Virani Rizatama 20,000
    0154B0120918Y000251 BAGUS SUWANTO 07/09/201 Gula Darah Puasa (GDP) - PRB/Prolanis dr.Virani Rizatama 20,000
    0154B0120918Y000252 MARYANTI 07/09/201 Gula Darah Puasa (GDP) - PRB/Prolanis dr.Virani Rizatama 20,000
    0154B0120918Y000253 RETNO CAHYANI 07/09/201 Gula Darah Puasa (GDP) - PRB/Prolanis dr.Virani Rizatama 20,000
    0154B0120918Y000254 W. KRISNANTO 07/09/201 Gula Darah Puasa (GDP) - PRB/Prolanis dr.Virani Rizatama 20,000
    0154B0120918Y000255 AGUS SETIYANTO 07/09/201 Gula Darah Puasa (GDP) - PRB/Prolanis dr.Virani Rizatama 20,000
    0154B0120918Y000256 MUJIATI 07/09/201 Gula Darah Puasa (GDP) - PRB/Prolanis dr.Virani Rizatama 20,000
    0154B0120918Y000257 SRI WAHYUNI 07/09/201 Gula Darah Puasa (GDP) - PRB/Prolanis dr.Virani Rizatama 20,000

    Tanggal terima Tanggal, 19 September 2018


    Verifikator, Pengaju Klaim,

    19/09/2018 15.31.49
    BPJS Kesehatan Cab. SURAKARTA
    FORMULIR PENGAJUAN KLAIM TINGKAT PERTAMA

    Nomor FPK : P1809000002485


    Provider : Klinik Aisyiyah Sragen
    Bulan Pelayanan : September, 2018
    Pelayanan : Promotif

    Total Data : 18

    Total Tagihan : 360,000

    NO TRANSAKSI NAMA PESERTA TANGGAL TINDAKAN TENAGA MEDIS Biaya


    0154B0120918Y000258 UMI MUYASAROH 07/09/201 Gula Darah Puasa (GDP) - PRB/Prolanis dr.Virani Rizatama 20,000
    0154B0120918Y000259 suparjo 07/09/201 Gula Darah Puasa (GDP) - PRB/Prolanis dr.Virani Rizatama 20,000
    0154B0120918Y000260 SUHERLAN BUDI PRAYITNO 07/09/201 Gula Darah Puasa (GDP) - PRB/Prolanis dr.Virani Rizatama 20,000
    0154B0120918Y000427 sudarno 07/09/201 Gula Darah Puasa (GDP) - PRB/Prolanis dr.Virani Rizatama 20,000

    Tanggal terima Tanggal, 19 September 2018


    Verifikator, Pengaju Klaim,

    19/09/2018 15.31.49

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