REKAPITULASI TAGIHAN KLAIM RITP

PUSKESMAS PROPPO
KABUPATEN PAMEKASAN

No. ID BPJS ∑ Hari

No. Nama Alamat, No. Telp Diagnosa Tgl. Masuk Tgl. Pulang
Kesehatan Rawat
1 INTAN NUR AINI [0001863353643] GRO'OM THYPOID 3/29/2019 4/2/2019 4
2 SULIMAH [0000116892009] BILLA'AN GEA 3/30/2019 4/1/2019 2
3 REGINA SAPUTRI [0002258434236] SAMATAN GEA 3/30/2019 4/2/2019 3
4 SOFIYATI [0000775970908] JAMBRINGIN DHF 3/30/2019 4/4/2019 5
5 SINNA [0000774976601] PANGURAYAN HYPERTENSI 3/31/2019 4/1/2019 1
6 HABIBAH [0002164921198] BANYUPELLE VERTIGO 3/31/2019 4/1/2019 1
7 SUBAIRI [0000775364297] GRO'OM GEA 3/31/2019 4/4/2019 4
8 RINA [0000775038104] TOKET THYPOID 4/1/2019 4/2/2019 1
9 HOTIMAH [0000775708661] RP DAYA THYPOID 4/2/2019 4/4/2019 2
10 AHSANOL WIAM [0002491576536] JAMBRINGIN THYPOID 4/4/2019 4/6/2019 2
11 MOHAMMAD ZAINOL [0000776094006] RP DAYA DHF 4/6/2019 4/8/2019 2
12 SATTIYEH [0000775990697] JAMBRINGIN TENSION-TYPE HEADHACE 4/6/2019 4/10/2019 4
13 TAUFIK KURRAHMAN [0000776236476] RP DAYA DHF 4/8/2019 4/13/2019 5
14 MOH. KHOIRUL AKMAL [0002739743425] CAMPOR GEA 4/8/2019 4/10/2019 2
15 KAMILAH [0000775600942] RP DAYA HYPEREMESIS 4/10/2019 4/12/2019 2
16 PARHATUN [0001048595185] KLAMPAR DM 4/11/2019 4/12/2019 1
17 HAKMAH [0000775352801] PANAGUAN HYPERTENSI 4/11/2019 4/12/2019 1
18 HALIYEH [0000775975781] PANAGUAN THYPOID 4/12/2019 4/15/2019 3
19 SAMAD [0000776111501] BANYUBULU THYPOID 4/13/2019 4/15/2019 2
20 MUSTHOFA [0000775076038] TATTANGOH VERTIGO 4/14/2019 4/16/2019 2
21 ACHMAD UBAIDILLAH [0002494797287] SAMATAN THYPOID 4/14/2019 4/17/2019 3
22 MUTMA'INNAH [0000776384471] TLANGOH THYPOID 4/14/2019 4/17/2019 3
23 SITI MAISAROH [0000775757002] CAMPOR THYPOID 4/14/2019 4/17/2019 3
24 IQBAL NAZAR [0001048587164] JAMBRINGIN THYPOID 4/14/2019 4/17/2019 3
25 RADIMAN [0000774412211] MAPPER ASBRO 4/16/2019 4/18/2019 2
26 PU'AH [0000775941355] CAMPOR THYPOID 4/16/2019 4/20/2019 4
27 ASBIA [0002236759277] JAMBRINGIN THYPOID 4/17/2019 4/18/2019 1
28 BUNIMAH [0000774412931] MAPPER THYPOID 4/18/2019 4/20/2019 2
29 ALI MAKKI [0000776338222] TLANGOH EPILEPSY 4/18/2019 4/21/2019 3
30 MUNIYAH [0002490266867] PASURUAN DM 4/19/2019 4/21/2019 2
31 SAIDAH [0000775024481] JAMBRINGIN VERTIGO 4/20/2019 4/22/2019 2
32 MOH TARIB [0000774416654] RP DAYA GEA 4/20/2019 4/22/2019 2
33 MOH KHOIRUL ANAM [0002743736771] RP DAYA THYPOID 4/20/2019 4/22/2019 2
34 UMAMAH [0000775246342] PANGTONGGAL HYPEREMESIS 4/20/2019 4/22/2019 2
35 RESKI ADUTIYA [0002164930525] RP DAYA FEBRILE CONFULSION 4/20/2019 4/23/2019 3
36 TAUFIKUR RAHMAN [0001048600765] RP DAYA THYPOID 4/21/2019 4/23/2019 2
37 WAFI [0000775352777] TATTANGOH THYPOID 4/22/2019 4/23/2019 1
38 MAISURAH [0000774784901] PANGTONGGAL HYPERTENSI 4/22/2019 4/24/2019 2
39 ATMANI [0000776227195] JAMBRINGIN DM 4/22/2019 4/24/2019 2
40 SUMI [0000775535488] RP DAYA GEA 4/22/2019 4/27/2019 5
41 SUHARTATIK FATIMAH [0000774808323] PROPPO THYPOID 4/23/2019 4/24/2019 1
42 ROMADON [0000775757687] TATTANGOH DHF 4/23/2019 4/25/2019 2
43 MOH SALEH [0000775434914] PANGURAYAN HYPERTENSI 4/26/2019 4/27/2019 1
44 IMAM [0000775242494] PANAGUAN THYPOID 4/27/2019 4/28/2019 1
JUMLAH 103

Pamekasan,

Kepala puskesmas

Hj. ZAITUN ERNAWATI, S.ST, M.M

NIP. 19680501 199003 2 009
ULASI TAGIHAN KLAIM RITP
PUSKESMAS PROPPO
BUPATEN PAMEKASAN

Biaya/hari Total

180,000 720,000
180,000 360,000
180,000 540,000
180,000 900,000
180,000 180,000
180,000 180,000
180,000 720,000
180,000 180,000
180,000 360,000
180,000 360,000
180,000 360,000
180,000 720,000
180,000 900,000
180,000 360,000
180,000 360,000
180,000 180,000
180,000 180,000
180,000 540,000
180,000 360,000
180,000 360,000
180,000 540,000
180,000 540,000
180,000 540,000
180,000 540,000
180,000 360,000
180,000 720,000
180,000 180,000
180,000 360,000
180,000 540,000
180,000 360,000
180,000 360,000
180,000 360,000
180,000 360,000
180,000 360,000
180,000 540,000
180,000 360,000
180,000 180,000
180,000 360,000
180,000 360,000
 180,000 900,000
180,000 180,000
180,000 360,000
180,000 180,000
180,000 180,000
180,000 18,540,000

Kepala puskesmas

Hj. ZAITUN ERNAWATI, S.ST, M.Mkes

NIP. 19680501 199003 2 009
 Kode Rekening : 1.02.01.07.5
Kwitansi : / 1.02.01.07.54.5.2.2.03.15/2019
Sudah terima dari : KEPALA DINAS KESEHATAN KABUPATEN PAMEKASAN
Jumlah Uang : Tiga Juta Delapan Ratus Delapan Puluh Delapan Ribu Rupiah
Untuk Pembayaran : Pelayanan Rawat Inap pada Kegiatan Pendukung Pelayanan Kesehatan
Puskesmas Proppo dan Jaringannya ( Non Kapitasi ) sebanyak 54 Hari
Bagian Bulan September 2018
Dengan rincian sbb :

∑
No. ID BPJS Alamat, No.
No. Nama Diagnosa Tgl. Masuk Tgl. Pulang Hari
Kesehatan Telp
Rawat

1 MARBUAH [0001048586185] JAMBRINGIN HIPERTENSI 8/30/2018 9/2/2018 3

2 FATIMA [0000774433359] MAPPER THYPOID 8/31/2018 9/1/2018 1
3 SUMINA [0000775845718] PANAGUAN THYPOID 9/1/2018 9/2/2018 1
4 HORIYAH [0000776039859] RP DAYA THYPOID 9/2/2018 9/3/2018 1
5 SATROYAN [0000775526782] REK KERREK GEA 9/2/2018 9/4/2018 2
6 IBNO HAJER [0000775762108] CAMPOR DHF 9/4/2018 9/7/2018 3
7 KERTO [0000775602112] JAMBRINGIN VERTIGO 9/5/2018 9/6/2018 1
8 SITI SULIHA [0000775010845] SAMIRAN DM 9/6/2018 9/7/2018 1
9 MOH WAPUR [0000776338018] REK KERREK THYPOID 9/6/2018 9/8/2018 2
10 HARIFUL RIJAL [0000775512494] PANGURAYAN THYPOID 9/6/2018 9/10/2018 4
11 FARMI [0000775967859] CANDI BURUNG GEA 9/7/2018 9/10/2018 3
12 RUSYATI [0000775031477] BILLA'AN GEA 9/9/2018 9/12/2018 3
13 SURIYEH [0000775556706] BADUNG THYPOID 9/13/2018 9/15/2018 2
14 HASYIM [0000776198889] BADUNG DM 9/13/2018 9/15/2018 2
15 SOHIBUL LIWEK [0000776552646] PANGBATOK THYPOID 9/13/2018 9/15/2018 2
16 ROHIM [0000776192106] PANAGUAN THYPOID 9/14/2018 9/16/2018 2
17 LUTVI YUDHA [0000776132482] BADUNG THYPOID 9/15/2018 9/17/2018 2
18 SOVIMADANI ASID M [0000775566022] RP LAOK THYPOID 9/16/2018 9/19/2018 3
19 HABIBULLAH [0002468176029] SAMATAN DHF 9/16/2018 9/17/2018 1
20 MUKTADIR [0000770310911] KAMONDUNG DHF 9/20/2018 9/22/2018 2
21 SITTINA [0000775003847] JAMBRINGIN GEA 9/20/2018 9/22/2018 2
22 MOH. HASAN [0000776285098] CAMPOR THYPOID 9/20/2018 9/22/2018 2
23 RIZKI [0000771218379] KAMONDUNG DHF 9/21/2018 9/23/2018 2
24 SAMOLAH [0000776274039] PANGTONGGAL GEA 9/21/2018 9/24/2018 3
25 SRI SUHARTATIK [0000117097187] SAMATAN DM 9/23/2018 9/24/2018 1
26 PAKYAN [0000775548029] RP DAYA THYPOID 9/23/2018 9/25/2018 2
27 ZAINAP [0000775839587] LENTENG APPENDICITIS 9/27/2018 9/28/2018 1
54

Terbilang : 3,888,000,-
Pamekasan,
Mengetahui
Pejabat Pelaksana Teknis Kegiatan Yang menerima
HJ. ZAITUN ERNAWATI, S.ST, M.Mkes NURUL FAJARIYAH, Amd. Kep
NIP. 19680501 199003 2 009 NIP. 19860601 201704 200 7

Setutju dibayar Lunas dibayar

Kuasa Pengguna Anggaran Bendahara Pengeluaran

Dr. H. ACHMAD MARSUKI, MM FITRI SABTIANA. SE

NIP.19641024 199703 1 002 NIP. 19761218 201101 2 007
 Kode Rekening : 1.02.01.07.5
Kwitansi : / 1.02.01.07.54.5.2.2.03.15/ 2019
Sudah terima dari : KEPALA DINAS KESEHATAN KABUPATEN PAMEKASAN
Jumlah Uang : Enam Juta Empat Ratus Delapan Puluh Ribu Rupiah
Untuk Pembayaran : Pelayanan Rawat Inap pada Kegiatan Pendukung Pelayanan Kesehatan
Puskesmas Proppo dan Jaringannya ( Non Kapitasi ) sebanyak 90 Hari
Bagian Bulan Oktober 2018
Dengan rincian sbb :

∑
No. ID BPJS Alamat, No.
No. Nama Diagnosa Tgl. Masuk Tgl. Pulang Hari
Kesehatan Telp
Rawat

1 LINA [0000776274772] PANGTONGGAL THYPOID 10/2/2018 10/5/2018 3

2 MANIA [0001048599584] BANYUBULU THYPOID 10/2/2018 10/4/2018 2
3 FERA FITRIAWATI NINGSIH [0000775590197] JAMBRINGIN THYPOID 10/3/2018 10/6/2018 3
4 HASANAH [0000775598422] BANYUPELLE GEA 10/4/2018 10/6/2018 2
5 SUMAIYAH [0000777090126] RP DAYA VERTIGO 10/6/2018 10/7/2018 1
6 SANI [0000775396866] BANYUBULU VERTIGO 10/6/2018 10/8/2018 2
7 JAMSURI [0000774841972] CAMPOR THYPOID 10/7/2018 10/9/2018 2
8 NUR NAYADI [0000775550533] BANYUBULU DHF 10/7/2018 10/11/2018 4
9 HOLIPAH [0000775752669] RP DAYA THYPOID 10/8/2018 10/10/2018 2
10 ASMARAH [0000774714205] PANGTONGGAL THYPOID 10/8/2018 10/11/2018 3
11 ISBAH [0000777003041] RP DAYA VERTIGO 10/9/2018 10/11/2018 2
12 MOH. AFFAN FIRDAUS [0002308607032] SAMIRAN GEA 10/10/2018 10/12/2018 2
13 HOMSIYAH [0000775868005] JAMBRINGIN THYPOID 10/10/2018 10/13/2018 3
14 SATRIA [0000777143621] RP DAYA GEA 10/11/2018 10/13/2018 2
15 HOSNI [0000776133472] PANGLEMAH THYPOID 10/12/2018 10/13/2018 1
16 AMNA [0000776157682] JAMBRINGIN THYPOID 10/12/2018 10/13/2018 1
17 SINDYATUL KHOIR F P [0002246188599] LENTENG THYPOID 10/12/2018 10/15/2018 3
18 ADRIYA [0000775092879] TOKET HT 10/13/2018 10/15/2018 2
19 FADILAH [0000775021871] JAMBRINGIN THYPOID 10/14/2018 10/16/2018 2
20 FARIDATUS SOLIHAH [0001296094882] RP LAOK GEA 10/15/2018 10/17/2018 2
21 NUR HAMI [0000770428787] KAMONDUNG THYPOID 10/15/2018 10/17/2018 2
22 LINDA SULISTIANI NINGSIH [0000775843187] JAMBRINGIN GEA 10/16/2018 10/19/2018 3
23 WERDEH [0000775225293] PANAGUAN DHF 10/16/2018 10/19/2018 3
24 MOH FAIRUS [0000775900585] RP LAOK THYPOID 10/17/2018 10/19/2018 2
25 MOH KAMIL [0000775125235] RP LAOK GEA 10/18/2018 10/20/2018 2
26 SANINGRAT [0000774996704] JAMBRINGIN GEA 10/20/2018 10/22/2018 2
27 MIFTAHUL QOMARIYAH [0000775755955] SAMIRAN THYPOID 10/20/2018 10/23/2018 3
28 JUMLIYAH [0000774365657] MAPPER THYPOID 10/20/2018 10/23/2018 3
29 SUPYAN [0000776021499] RP DAYA THYPOID 10/22/2018 10/24/2018 2
30 MUHAMMAD BUSTOMI [0000776485585] REK KERREK DHF 10/24/2018 10/26/2018 2
31 MARYAM [0000776025909] RP DAYA ESSENTIAL THROMBOCYTOSIS 10/26/2018 10/27/2018 1
32 ACH RIDO'I [0000775647549] PANGLEMAH GEA 10/27/2018 10/29/2018 2
33 SALIMUN [0000776274017] MAPPER THYPOID 10/27/2018 10/29/2018 2
34 RUKMIYATI [0000775907199] JAMBRINGIN THYPOID 10/27/2018 10/30/2018 3
35 JAMILA [0000776279935] JAMBRINGIN HIPEREMESIS 10/27/2018 10/30/2018 3
36 SULAIMAN [0000776018125] PANAGUAN GEA 10/27/2018 10/31/2018 4
37 NOR HOLIS [0000772377388] ROBATAL THYPOID 10/28/2018 10/30/2018 2
38 YANI [0000776050389] PANAGUAN THYPOID 10/28/2018 10/30/2018 2
39 ASMA [0000776090654] REK KERREK HIPEREMESIS 10/28/2018 10/30/2018 2
40 TALIH [0000776346197] BILLA'AN GEA 10/29/2018 10/30/2018 1
90

Terbilang : 6,480,000,-
Pamekasan,
Mengetahui
Pejabat Pelaksana Teknis Kegiatan Yang menerima

HJ. ZAITUN ERNAWATI, S.ST, M.Mkes NURUL FAJARIYAH, Amd. Kep

NIP. 19680501 199003 2 009 NIP. 19860601 201704 200 7

Setutju dibayar Lunas dibayar

Kuasa Pengguna Anggaran Bendahara Pengeluaran

Dr. H. ACHMAD MARSUKI, MM FITRI SABTIANA. SE

NIP.19641024 199703 1 002 NIP. 19761218 201101 2 007
 Kode Rekening : 1.02.01.07.5
Kwitansi : / 1.02.01.07.54.5.2.2.03.15/ 2019
Sudah terima dari : KEPALA DINAS KESEHATAN KABUPATEN PAMEKASAN
Jumlah Uang : Lima Juta Sembilan Ratus Empat Ribu Rupiah
Untuk Pembayaran : Pelayanan Rawat Inap pada Kegiatan Pendukung Pelayanan Kesehatan
Puskesmas Proppo dan Jaringannya ( Non Kapitasi ) sebanyak 82 Hari
Bagian Bulan November 2018
Dengan rincian sbb :

∑
No. ID BPJS Alamat, No.
No. Nama Diagnosa Tgl. Masuk Tgl. Pulang Hari
Kesehatan Telp
Rawat

1 RAUDATUL MINRIYATIH J [0000776089631] RP DAYA THYPOID 11/1/2018 11/3/2018 2

2 FIFI MOKARROMATUS S [0000776180709] TLANGOH PERITONITIS 11/2/2018 11/3/2018 1
3 MUHAMMAD MUKSIN [0000775505338] PANGURAYAN GEA 11/2/2018 11/5/2018 3
4 MUHAMMAD HARI [0001048592981] LENTENG GEA 11/2/2018 11/5/2018 3
5 MISNORI [0000775808954] JAMBRINGIN THYPOID 11/3/2018 11/4/2018 1
6 MISEH [0000776068896] BANYUPELLE HYPERTENSI 11/3/2018 11/6/2018 3
7 M RIZAL [0000776153823] RP LAOK THYPOID 11/3/2018 11/6/2018 3
8 FARIDATUS SHOLIHA [0001296094882] RP LAOK VERTIGO 11/5/2018 11/7/2018 2
9 NORUL [0002121604986] JAMBRINGIN VERTIGO 11/7/2018 11/8/2018 1
10 ALI ROZIN RAHMAN [0002256620253] LENTENG THYPOID 11/7/2018 11/8/2018 1
11 ATTRAP [0000775880561] KLAMPAR THYPOID 11/7/2018 11/9/2018 2
12 NIMA [0002324458258] RP DAYA HYPEREMESIS 11/7/2018 11/9/2018 2
13 M. HASAN [0000775933378] JAMBRINGIN DHF 11/7/2018 11/11/2018 4
14 SAIDAH [0000775024481] JAMBRINGIN THYPOID 11/9/2018 11/12/2018 3
15 SUNAMI [0000775181248] JAMBRINGIN DM 11/10/2018 11/12/2018 2
16 MARGI [0000776309861] CAMPOR THYPOID 11/11/2018 11/13/2018 2
17 AS'ARI [0000775865924] PANGTONGGAL GEA 11/11/2018 11/13/2018 2
18 SULASTRI [0000775167906] JAMBRINGIN DHF 11/11/2018 11/14/2018 3
19 MISKATI [0000775486978] BANYUBULU HYPERTENSI 11/12/2018 11/14/2018 2
20 NUR HAMI [0000770428787] KAMONDUNG THYPOID 11/14/2018 11/15/2018 1
21 FAJARIYA [0000776305708] JAMBRINGIN DHF 11/14/2018 11/17/2018 3
22 ACH ZEHID R [0000770828793] OMBEN THYPOID 11/15/2018 11/16/2018 1
23 UMMI KULSUM [0000775825582] PANAGUAN THYPOID 11/16/2018 11/17/2018 1
24 LIYAH [0000774753581] CAMPOR THYPOID 11/16/2018 11/19/2018 3
25 SULIMAN [0000775987773] JAMBRINGIN GEA 11/17/2018 11/19/2018 2
26 SITI SULIHA [0000775010845] SAMIRAN DM 11/18/2018 11/21/2018 3
27 SADIYAH [0000776026056] PANGLEMAH HYPERTENSI 11/19/2018 11/20/2018 1
28 MOH ALI [0000775884947] PANAGUAN THYPOID 11/19/2018 11/21/2018 2
29 ROUDATUL JANNAH [0000776089631] RP DAYA THYPOID 11/19/2018 11/21/2018 2
30 MOH . ROFI'UDDIN [0000775104164] PANGTONGGAL THYPOID 11/19/2018 11/22/2018 3
31 SA'RANI [0000775879672] LENTENG HYPERTENSI 11/22/2018 11/23/2018 1
32 REHAN [0000774072303] JAMBRINGIN GEA 11/22/2018 11/23/2018 1
33 SATROMO [0000775284232] JAMBRINGIN THYPOID 11/23/2018 11/24/2018 1
34 MOHAMMAD WASIK [0000776001587] PANGURAYAN THYPOID 11/23/2018 11/26/2018 3
35 DENI LUKMAN HAKIM [0000775476573] PANGURAYAN THYPOID 11/24/2018 11/26/2018 2
36 MATBAHRI [0000775599794] RP DAYA THYPOID 11/24/2018 11/27/2018 3
37 UKI [0000773674738] BANDARAN THYPOID 11/25/2018 11/27/2018 2
38 SAMUDIN [0000774839709] PROPPO GEA 11/26/2018 11/27/2018 1
39 KAMILAH [0000776121232] PANGTONGGAL THYPOID 11/26/2018 11/28/2018 2
40 ABDUL RAZEK [0000775123479] PANGTONGGAL ASBRO 11/28/2018 11/30/2018 2
82

Terbilang : 5,904,000,-
Pamekasan,
Mengetahui
Pejabat Pelaksana Teknis Kegiatan Yang menerima

HJ. ZAITUN ERNAWATI, S.ST, M.Mkes NURUL FAJARIYAH, Amd. Kep

NIP. 19680501 199003 2 009 NIP. 19860601 201704 200 7

Setutju dibayar Lunas dibayar

Kuasa Pengguna Anggaran Bendahara Pengeluaran

Dr. H. ACHMAD MARSUKI, MM FITRI SABTIANA. SE

NIP.19641024 199703 1 002 NIP. 19761218 201101 2 007
 Kode Rekening : 1.02.01.07.5
Kwitansi : / 1.02.01.07.54.5.2.2.03.15/ 2019
Sudah terima dari : KEPALA DINAS KESEHATAN KABUPATEN PAMEKASAN
Jumlah Uang : Delapan Juta Tujuh Ratus Delapan Puluh Empat Ribu Rupiah
Untuk Pembayaran : Pelayanan Rawat Inap pada Kegiatan Pendukung Pelayanan Kesehatan
Puskesmas Proppo dan Jaringannya ( Non Kapitasi ) sebanyak 122 Hari
Bagian Bulan Desember 2018
Dengan rincian sbb :

∑
No. ID BPJS Alamat, No.
No. Nama Diagnosa Tgl. Masuk Tgl. Pulang Hari
Kesehatan Telp
Rawat

1 MOH. ROFIUDDIN [0000774920013] JAMBRINGIN THYPOID 11/30/2018 12/1/2018 1

2 SA'EN [0000775554851] BILLAAN DHF 11/30/2018 12/3/2018 3
3 PINGKAN LESTARI [0001410186881] LENTENG GEA 12/2/2018 12/3/2018 1
4 HOSNIYAH [0000776058985] PANGLEMAH THYPOID 12/2/2018 12/4/2018 2
5 SITI AMINA [0000776050503] SAMIRAN THYPOID 12/2/2018 12/4/2018 2
6 BUNAMIN [0001048599009] BANYUBULU THYPOID 12/4/2018 12/6/2018 2
7 HOSNOL HOTIMAH [0000775572524] TOKET THYPOID 12/4/2018 12/6/2018 2
8 ADNI [0000775806006] JAMBRINGIN VERTIGO 12/5/2018 12/8/2018 3
9 SUPRIYADI [0000775403673] BANYUBULU THYPOID 12/6/2018 12/7/2018 1
10 JUMANI [0000775752647] RP DAYA DM 12/8/2018 12/10/2018 2
11 RUBA'I [0000776284312] RP DAYA GEA 12/9/2018 12/11/2018 2
12 NUFITA ANDRIANAI [0000774930284] JAMBRINGIN THYPOID 12/9/2018 12/11/2018 2
13 ERNA SARI [0000776620113] REK KERREK DHF 12/10/2018 12/13/2018 3
14 MUHAMMAD JATIM [0000776057556] PANGORAYAN GEA 12/11/2018 12/13/2018 2
15 ATIK KRISNAWATI NINGSIH [0000775674483] SAMIRAN THYPOID 12/11/2018 12/14/2018 3
16 HAYYAH [0001048582427] PANGBATOK VERTIGO 12/12/2018 12/14/2018 2
17 SRI ROSIDAH [0000775545164] SAMIRAN THYPOID 12/12/2018 12/14/2018 2
18 FATLA [0000774606058] JAMBRINGIN ISK 12/12/2018 12/14/2018 2
19 SUNAYYAH [0000775491063] RP DAYA THYPOID 12/13/2018 12/15/2018 2
20 IHLAS [0000775023186] MAPPER THYPOID 12/13/2018 12/15/2018 2
21 HAMIDEH [0001048585342] CAMPOR THYPOID 12/16/2018 12/18/2018 2
22 SITI AISYATUR ROHMAH R [0000775637752] KODIK THYPOID 12/16/2018 12/18/2018 2
23 MUHAMMAD ZAMRONI [0000776222267] PANGTONGGAL THYPOID 12/16/2018 12/19/2018 3
24 HATIMAH [0000775713936] REK KERREK GEA 12/16/2018 12/19/2018 3
25 UMAR [0000770175562] KAMONDUNG GEA 12/18/2018 12/22/2018 4
26 FAHRULLAH [0000776963226] SAMIRAN THYPOID 12/19/2018 12/20/2018 1
27 SUMINA [0000775845718] PANAGUAN THYPOID 12/19/2018 12/20/2018 1
28 SITTI ROMLAH [0000776156016] RP LAOK GEA 12/19/2018 12/20/2018 1
29 MISDIN [0000776137364] MAPPER GEA 12/19/2018 12/21/2018 2
30 MUZENNI [0000775210588] PANAGUAN GEA 12/19/2018 12/21/2018 2
31 YUYUN SUKAWATI [0002458529177] PANGURAYAN DHF 12/20/2018 12/24/2018 4
32 JALAL [0000775630146] PANGBATOK THYPOID 12/21/2018 12/22/2018 1
33 ST. SULAIHA [0001048587153] JAMBRINGIN DHF 12/21/2018 12/22/2018 1
34 NAKAH [0001410187893] KLAMPAR GEA 12/21/2018 12/22/2018 1
35 SURATMO [0000775898199] RP LAOK THYPOID 12/21/2018 12/23/2018 2
36 SAMARI [0000775325103] JAMBRINGIN GEA 12/21/2018 12/24/2018 3
37 PADYA [0001048599033] BANYUBULU GEA 12/21/2018 12/25/2018 4
38 MARTIA [0000774874574] RP DAYA DM 12/21/2018 12/26/2018 5
39 JUNAIDI [0000776079246] LENTENG GEA 12/22/2018 12/23/2018 1
40 ARLIYAN [0000774685844] PANGTONGGAL GEA 12/22/2018 12/24/2018 2
41 SAKBAN [0000776719811] REK KERREK THYPOID 12/22/2018 12/25/2018 3
42 SATROMO [0000775284232] JAMBRINGIN GASTRITIS 12/23/2018 12/24/2018 1
43 NURPATILAH [0000776007325] JAMBRINGIN THYPOID 12/23/2018 12/25/2018 2
44 ACH BAIDAWI [0000776352519] LENTENG THYPOID 12/24/2018 12/26/2018 2
45 DEWI WULANDARI [0000776066951] BADUNG THYPOID 12/24/2018 12/29/2018 5
46 RIZKI MOHAMMAD A [0002491329486] BANYUBULU GEA 12/25/2018 12/26/2018 1
47 ALI MAKKI [0000775524363] SAMIRAN THYPOID 12/25/2018 12/27/2018 2
48 LUCKY MAULANA [0002420370347] MALANG THYPOID 12/27/2018 12/30/2018 3
49 AMILATUN [0000775513642] PANGURAYAN THYPOID 12/28/2018 12/30/2018 2
50 ABD MUNIR [0001048590538] BILLAAN THYPOID 12/28/2018 12/30/2018 2
51 ZAINUN NIAM [0000776850107] CAMPOR THYPOID 12/28/2018 12/30/2018 2
52 HUSNOL HOTIMAH [0000775278764] PANGLEMAH THYPOID 12/28/2018 12/30/2018 2
53 PUTRI ALKAROMI [0002164929783] BANYUBULU THYPOID 12/28/2018 12/30/2018 2
54 MURSALIM [0000775208349] PROPPO THYPOID 12/28/2018 12/30/2018 2
55 SUPAH [0000776304674] PANGTONGGAL GEA 12/28/2018 12/31/2018 3
56 JUHAYRIYAH [0000775532924] RP DAYA VERTIGO 12/29/2018 12/30/2018 1
57 NIYATUS SOLIHAH [0000776289846] TOKET THYPOID 12/29/2018 12/30/2018 1
122

Terbilang : 8,784,000,-
Pamekasan,
Mengetahui
Pejabat Pelaksana Teknis Kegiatan Yang menerima

HJ. ZAITUN ERNAWATI, S.ST, M.Mkes NURUL FAJARIYAH, Amd. Kep

NIP. 19680501 199003 2 009 NIP. 19860601 201704 200 7

Setutju dibayar Lunas dibayar

Kuasa Pengguna Anggaran Bendahara Pengeluaran

Dr. H. ACHMAD MARSUKI, MM FITRI SABTIANA. SE

NIP.19641024 199703 1 002 NIP. 19761218 201101 2 007
 Kode Rekening : 1.02.01.07.54.5.2.2.03.15
4.5.2.2.03.15/2019

Biaya/ha
Total
ri

72,000 216,000
72,000 72,000
72,000 72,000
72,000 72,000
72,000 144,000
72,000 216,000
72,000 72,000
72,000 72,000
72,000 144,000
72,000 288,000
72,000 216,000
72,000 216,000
72,000 144,000
72,000 144,000
72,000 144,000
72,000 144,000
72,000 144,000
72,000 216,000
72,000 72,000
72,000 144,000
72,000 144,000
72,000 144,000
72,000 144,000
72,000 216,000
72,000 72,000
72,000 144,000
72,000 72,000
72,000 3,888,000

Yang menerima
NURUL FAJARIYAH, Amd. Kep
NIP. 19860601 201704 200 7

Lunas dibayar
Bendahara Pengeluaran

FITRI SABTIANA. SE
NIP. 19761218 201101 2 007
 Kode Rekening : 1.02.01.07.54.5.2.2.03.15
4.5.2.2.03.15/ 2019

Biaya/ha
Total
ri

72,000 216,000
72,000 144,000
72,000 216,000
72,000 144,000
72,000 72,000
72,000 144,000
72,000 144,000
72,000 288,000
72,000 144,000
72,000 216,000
72,000 144,000
72,000 144,000
72,000 216,000
72,000 144,000
72,000 72,000
72,000 72,000
72,000 216,000
72,000 144,000
72,000 144,000
72,000 144,000
72,000 144,000
72,000 216,000
72,000 216,000
72,000 144,000
72,000 144,000
72,000 144,000
72,000 216,000
72,000 216,000
72,000 144,000
72,000 144,000
72,000 72,000
72,000 144,000
72,000 144,000
72,000 216,000
72,000 216,000
 72,000 288,000
72,000 144,000
72,000 144,000
72,000 144,000
72,000 72,000
72,000 6,480,000

Yang menerima

NURUL FAJARIYAH, Amd. Kep

NIP. 19860601 201704 200 7

Lunas dibayar
Bendahara Pengeluaran

FITRI SABTIANA. SE
NIP. 19761218 201101 2 007
 Kode Rekening : 1.02.01.07.54.5.2.2.03.15
4.5.2.2.03.15/ 2019

Biaya/ha
Total
ri

72,000 144,000
72,000 72,000
72,000 216,000
72,000 216,000
72,000 72,000
72,000 216,000
72,000 216,000
72,000 144,000
72,000 72,000
72,000 72,000
72,000 144,000
72,000 144,000
72,000 288,000
72,000 216,000
72,000 144,000
72,000 144,000
72,000 144,000
72,000 216,000
72,000 144,000
72,000 72,000
72,000 216,000
72,000 72,000
72,000 72,000
72,000 216,000
72,000 144,000
72,000 216,000
72,000 72,000
72,000 144,000
72,000 144,000
72,000 216,000
72,000 72,000
72,000 72,000
72,000 72,000
72,000 216,000
72,000 144,000
 72,000 216,000
72,000 144,000
72,000 72,000
72,000 144,000
72,000 144,000
72,000 5,904,000

Yang menerima

NURUL FAJARIYAH, Amd. Kep

NIP. 19860601 201704 200 7

Lunas dibayar
Bendahara Pengeluaran

FITRI SABTIANA. SE
NIP. 19761218 201101 2 007
 Kode Rekening : 1.02.01.07.54.5.2.2.03.15
4.5.2.2.03.15/ 2019

Biaya/ha
Total
ri

72,000 72,000
72,000 216,000
72,000 72,000
72,000 144,000
72,000 144,000
72,000 144,000
72,000 144,000
72,000 216,000
72,000 72,000
72,000 144,000
72,000 144,000
72,000 144,000
72,000 216,000
72,000 144,000
72,000 216,000
72,000 144,000
72,000 144,000
72,000 144,000
72,000 144,000
72,000 144,000
72,000 144,000
72,000 144,000
72,000 216,000
72,000 216,000
72,000 288,000
72,000 72,000
72,000 72,000
72,000 72,000
72,000 144,000
72,000 144,000
72,000 288,000
72,000 72,000
72,000 72,000
72,000 72,000
72,000 144,000
72,000 216,000
72,000 288,000
72,000 360,000
72,000 72,000
72,000 144,000
72,000 216,000
72,000 72,000
72,000 144,000
72,000 144,000
72,000 360,000
 72,000 72,000
72,000 144,000
72,000 216,000
72,000 144,000
72,000 144,000
72,000 144,000
72,000 144,000
72,000 144,000
72,000 144,000
72,000 216,000
72,000 72,000
72,000 72,000
72,000 8,784,000

Yang menerima

NURUL FAJARIYAH, Amd. Kep

NIP. 19860601 201704 200 7

Lunas dibayar
Bendahara Pengeluaran

FITRI SABTIANA. SE
NIP. 19761218 201101 2 007
 REKAPITULASI TAGIHAN KLAIM RUJUKAN
PUSKESMAS PROPPO
KABUPATEN PAMEKASAN

TGL JARAK
NO NAMA UMUR NO. BPJS DIAGNOSA TUJUAN TRANSPORTASI
RUJUKAN (KM)

1 SATTIYEH 48 [0000775990697] TENSION-TYPE HEADHACE 4/10/2019 RS LARASATI Ambulance 12

2 ALI MAKKI 23 [0000776338222] EPILEPSY 4/21/2019 RSUD Ambulance 12

Pamekasan,
Kepala Puskesmas Proppo

Hj. ZAITUN ERNAWATI, S.ST, M.Mkes

NIP. 19680501 199003 2 009
TAGIHAN KLAIM RUJUKAN
ESMAS PROPPO
ATEN PAMEKASAN

BIAYA
PP
HARI TOTAL
(KM)
(Rp)

24 156,000 156,000
24 156,000 156,000
312,000

Kepala Puskesmas Proppo

Hj. ZAITUN ERNAWATI, S.ST, M.Mkes

NIP. 19680501 199003 2 009

Kwitansi
Sudah terima dari
Jumlah Uang
Untuk Pembayaran
Dengan rincian sbb
Kode Rekening : 1.02.01.0
: /1.02.01.07.54.5.2.2.03.15/2019
: KEPALA DINAS KESEHATAN KABUPATEN PAMEKASAN
: Seratus Dua Puluh Empat Ribu Delapan Ratus Rupiah
: Pelayanan Transport Rujukan Umum pada Kegiatan Pendukung Pelayanan Kesehatan
Puskesmas Proppo dan Jaringannya ( Non Kapitasi ) sebanyak 2 Orang
Bagian Bulan September 2018
:

TGL TRANSP JARAK

NO NAMA UMUR NO. BPJS DIAGNOSA TUJUAN
RUJUKAN ORTASI (KM)

1 ALIYAH 54 [0000776028802] HYPOVOLAEMIC SHOCK 9/4/2018 RSUD Ambulance 12

2 ZAINAP 34 [0000775839587] APPENDICITIS 9/28/2018 RSUD Ambulance 12

Terbilang : 124,800,-

Pamekasan,
Mengetahui
Pejabat Pelaksana Teknis Kegiatan Yang menerima

HJ. ZAITUN ERNAWATI, S.ST, M.Mkes NURUL FAJARIYAH, Amd. Kep

NIP. 19680501 199003 2 009 NIP. 19860601 201704 200 7

Setuju dibayar Lunas dibayar

Kuasa Pengguna Anggaran Bendahara Pengeluaran

Dr. H. ACHMAD MARSUKI, MM FITRI SABTIANA. SE

NIP.19641024 199703 1 002 NIP. 19761218 201101 2 007
 Kode Rekening : 1.02.01.07.54.5.2.2.03.15
019
BUPATEN PAMEKASAN

BIAYA
PP
HARI TOTAL
(KM)
(Rp)
24 62,400 62,400
24 62,400 62,400
124,800

Yang menerima

NURUL FAJARIYAH, Amd. Kep

NIP. 19860601 201704 200 7

Lunas dibayar
Bendahara Pengeluaran

FITRI SABTIANA. SE
NIP. 19761218 201101 2 007
NAFIYAH 2/26/2019 3/4/2019
SIRI 2/27/2019 3/2/2019
REHAN MAULANA 2/28/2019 3/4/2019
FITRIYAH 2/26/2019 3/1/2019
LAILI 2/28/2019 3/1/2019
SUBAIDAH 2/27/2019 3/1/2019
TIMA 2/27/2019 3/2/2019
USWATUN HASANAH 2/27/2019 3/2/2019
MOH.DA'I 3/1/2019 3/4/2019
MAHHUR 3/9/2019 3/11/2019
HUMAIROH 3/9/2019 3/12/2019
ABDUL LATIF 3/29/2019 3/30/2019
SOFIYAH 3/11/2019 3/15/2019
DESI RAHAYU LARASATI 3/12/2019 3/14/2019
RENO 3/9/2019 3/12/2019
SOFIANA DAMAYANTI 3/9/2019 3/12/2019
BUATI 3/12/2019 3/14/2019
RASID 3/1/2019 3/4/2019
IMROATUL IMAMAH 3/11/2019 3/13/2019
SAMBUNG 3/4/2019 3/7/2019
YUYUN WAHYUNI 3/7/2019 3/9/2019
KOMARUS ZAMAN 3/11/2019 3/14/2019
MOHAMMAD JUNAIDI 3/7/2019 3/9/2019
MAFTUHAH 3/2/2019 3/4/2019
BAHRIYAH 3/1/2019 3/5/2019
SRI RAHAYU 3/15/2019 3/18/2019
ROMSIYAH 3/2/2019 3/5/2019
MOH. ROMADON 3/8/2019 3/11/2019
SITI ZAINAB A 3/5/2019 3/6/2019
SATROMO 3/30/2019 3/31/2019
MOH. IWAN 3/7/2019 3/9/2019
ANDANI 3/10/2019 3/12/2019
SYAKIRA DWI AL MAHIRA 3/13/2019 3/15/2019
HALIM 3/14/2019 3/15/2019
HELMI HIDAYAT 3/11/2019 3/13/2019
SATRAJI 3/27/2019 3/28/2019
YULIANA 3/27/2019 3/28/2019
WASILAH 3/25/2019 3/28/2019
HUDI 3/20/2019 3/22/2019
MUHAMMAD ALI IBRAHIM 3/19/2019 3/22/2019
SITTI HATIJA 3/21/2019 3/22/2019
IMAM FAWAID 3/19/2019 3/21/2019
NORHEKMAH 3/20/2019 3/21/2019
YUNI SILFANA SALEH 3/17/2019 3/19/2019
ACH ROIS 3/25/2019 3/26/2019
SAMAD 3/21/2019 3/23/2019
WIRDA 3/23/2019 3/27/2019
MARBU'AH 3/26/2019 3/27/2019
NUR MAYATI 3/25/2019 3/28/2019
FAUZAH BILJANNAH 3/21/2019 3/23/2019
ITA 3/6/2019 3/9/2019
HOSEH 3/16/2019 3/19/2019
MUHAMMAD FAUZI 3/7/2019 3/8/2019
JUMLANIATUL LAILA 3/15/2019 3/16/2019
JUARI 3/5/2019 3/9/2019
BUSIKAH 3/28/2019 3/31/2019
MUHAMMAD IQBAL 3/15/2019 3/19/2019
ULFA APRILIYA WATI 3/13/2019 3/16/2019
NAILA ALFITA SYAFRIN 3/28/2019 3/30/2019
NOR HOLIS 3/7/2019 3/9/2019
MUSLIMAH 3/22/2019 3/29/2019
NOR HASIM 3/26/2019 3/29/2019
JAMALUDDIN 3/24/2019 3/28/2019
ABU NARMIN 3/14/2019 3/16/2019
AFIFUR RAHMAN 3/7/2019 3/11/2019
 774686979 PANGTONGGAL DHF
776493821 REK KERREK HYPERTENSI
775894825 JAMBRINGIN DHF
1185584949 BANYUPELLE THYPOID
776463671 BADUNG GEA
775606746 RP LAOK THYPOID
775761704 RP DAYA ASBRO
775929969 KLAMPAR HYPEREMESIS
1048592586 LENTENG THYPOID
775909629 MAPPER THYPOID
775042457 PANAGUAN DHF
775585877 CAMPOR THYPOID
775551025 BADUNG DHF
2481826228 JAMBRINGIN BRONCHOPNEUMONIA
775785993 PANAGUAN ENCHEPALITIS
775566088 RP LAOK ENCHEPALITIS
776365031 CAMPOR THYPOID
775459451 BANYUBULU THYPOID
2414713746 RP DAYA THYPOID
775861481 PANGTONGGAL THYPOID
775250392 CAMPOR THYPOID
776207158 JAMBRINGIN THYPOID
776246613 PANGTONGGAL DHF
775245791 PANGTONGGAL THYPOID
775012296 PANGTONGGAL DHF
776028745 KODIK THYPOID
776838339 REK KERREK THYPOID
774066306 JAMBRINGIN THYPOID
775797377 RP DAYA DHF
775284232 JAMBRINGIN THYPOID
776109284 PANAGUAN THYPOID
775682616 RP DAYA THYPOID
2416965579 TOKET DHF
775000416 TOKET THYPOID
2626003416 JAMBRINGIN THYPOID
1048590246 BILLAAN VERTIGO
775864168 JAMBRINGIN GASTRITIS
775053066 BANYUBULU THYPOID
776125754 PANGTONGGAL THYPOID
2286447344 LENTENG DHF
117096063 PROPPO THYPOID
2295206921 PANGURAYAN THYPOID
775849487 RP DAYA THYPOID
775435937 PANGURAYAN THYPOID
776468834 KLAMPAR THYPOID
776114627 PANGTONGGAL GEA
 776052145 MAPPER THYPOID
775593022 JAMBRINGIN THYPOID
775208024 JAMBRINGIN THYPOID
776835213 REK KERREK THYPOID
776161754 RP LAOK GEA
775413887 MAPPER DHF
1917235258 CAMPOR THYPOID
776176738 RP LAOK GEA
774481757 RP DAYA THYPOID
776329964 TOKET THYPOID
2199736315 PANAGUAN THYPOID
775634297 RP DAYA DHF
776294234 KODIK THYPOID
772377388 ROBATAL THYPOID
775703654 RP DAYA DHF
775878208 PANGTONGGAL THYPOID
775128003 KARANG ANYAR DHF
775702934 RP DAYA DHF
774049296 JAMBRINGIN THYPOID