Mei 23

BPJS Kesehatan Cab.
TEGAL
FORMULIR PENGAJUAN KLAIM TINGKAT PERTAMA
Nomor FPK : P2305000012271
Provider : Jatirokeh
Bulan Pelayanan : May 2023

Pelayanan : RITP
Total Data : 50
Total Tagihan : Rp. 34.750.000
NO KUNJUNGAN NAMA PESERTA TGL MASUK TGL PULANG TINDAKAN TENAGA MEDIS BIAYA
110917010423P001447 SUTRISNO (0002096417586) 30/04/2023 02/05/2023 Rawat Inap di R. Perawatan Biasa EDVAND DANI EKA SATRIA Rp. 500.000
110917010423P001447 SUTRISNO (0002096417586) 30/04/2023 02/05/2023 Rawat Inap di R. Perawatan Biasa EDVAND DANI EKA SATRIA Rp. 500.000
110917010423P001448 ZAENAL ABIDIN (0000636701433) 29/04/2023 02/05/2023 Rawat Inap di R. Perawatan Biasa EDVAND DANI EKA SATRIA Rp. 750.000
110917010423P001448 ZAENAL ABIDIN (0000636701433) 29/04/2023 02/05/2023 Rawat Inap di R. Perawatan Biasa EDVAND DANI EKA SATRIA Rp. 750.000
110917010423P001449 SIFA FAUZIA (0000638516283) 29/04/2023 02/05/2023 Rawat Inap di R. Perawatan Biasa EDVAND DANI EKA SATRIA Rp. 750.000
110917010423P001449 SIFA FAUZIA (0000638516283) 29/04/2023 02/05/2023 Rawat Inap di R. Perawatan Biasa EDVAND DANI EKA SATRIA Rp. 750.000
110917010423P001450 SOPIYAH (0000638173923) 27/04/2023 02/05/2023 Rawat Inap di R. Perawatan Biasa EDVAND DANI EKA SATRIA Rp. 1.250.000
110917010423P001450 SOPIYAH (0000638173923) 27/04/2023 02/05/2023 Rawat Inap di R. Perawatan Biasa EDVAND DANI EKA SATRIA Rp. 1.250.000
110917010423P001451 WANISAH (0000637954547) 29/04/2023 02/05/2023 Rawat Inap di R. Perawatan Biasa EDVAND DANI EKA SATRIA Rp. 750.000
110917010423P001451 WANISAH (0000637954547) 29/04/2023 02/05/2023 Rawat Inap di R. Perawatan Biasa EDVAND DANI EKA SATRIA Rp. 750.000
110917010423P001452 SURATMI (0000639189494) 28/04/2023 02/05/2023 Rawat Inap di R. Perawatan Biasa EDVAND DANI EKA SATRIA Rp. 1.000.000
110917010423P001452 SURATMI (0000639189494) 28/04/2023 02/05/2023 Rawat Inap di R. Perawatan Biasa EDVAND DANI EKA SATRIA Rp. 1.000.000
GILANG PUTRA RAMADAN

110917010423P001453 28/04/2023 01/05/2023 Rawat Inap di R. Perawatan Biasa EDVAND DANI EKA SATRIA Rp. 750.000
(0002842100166)
GILANG PUTRA RAMADAN
(0002842100166)
110917010423P001454 SILVIA AULINA ROHMAN (0003275168117) 30/04/2023 03/05/2023 Rawat Inap di R. Perawatan Biasa EDVAND DANI EKA SATRIA Rp. 750.000
110917010423P001454 SILVIA AULINA ROHMAN (0003275168117) 30/04/2023 03/05/2023 Rawat Inap di R. Perawatan Biasa EDVAND DANI EKA SATRIA Rp. 750.000
110917010423P001476 NURHALIMAH (0002294515664) 30/04/2023 04/05/2023 Rawat Inap di R. Perawatan Biasa dr. RITA Rp. 1.000.000
110917010423P001476 NURHALIMAH (0002294515664) 30/04/2023 04/05/2023 Rawat Inap di R. Perawatan Biasa dr. RITA Rp. 1.000.000
110917010523P000177 MIPTAPUL HIKMAH (0002080214021) 02/05/2023 03/05/2023 Rawat Inap di R. Perawatan Biasa EDVAND DANI EKA SATRIA Rp. 250.000
110917010523P000177 MIPTAPUL HIKMAH (0002080214021) 02/05/2023 03/05/2023 Rawat Inap di R. Perawatan Biasa EDVAND DANI EKA SATRIA Rp. 250.000
110917010523P000310 KHALDA NABILA ULFA (0001032368117) 03/05/2023 06/05/2023 Rawat Inap di R. Perawatan Biasa dr. RITA Rp. 750.000
110917010523P000310 KHALDA NABILA ULFA (0001032368117) 03/05/2023 06/05/2023 Rawat Inap di R. Perawatan Biasa dr. RITA Rp. 750.000
110917010523P000313 INDAH NURHIDAYAH (0002099046723) 03/05/2023 06/05/2023 Rawat Inap di R. Perawatan Biasa dr. RITA Rp. 750.000
110917010523P000313 INDAH NURHIDAYAH (0002099046723) 03/05/2023 06/05/2023 Rawat Inap di R. Perawatan Biasa dr. RITA Rp. 750.000
110917010523P000315 PUTRI PEPRIYANI (0002770463968) 03/05/2023 06/05/2023 Rawat Inap di R. Perawatan Biasa dr. RITA Rp. 750.000
110917010523P000315 PUTRI PEPRIYANI (0002770463968) 03/05/2023 06/05/2023 Rawat Inap di R. Perawatan Biasa dr. RITA Rp. 750.000
ANGGI OKA LEVIANA DEWI

110917010523P000435 05/05/2023 08/05/2023 Rawat Inap di R. Perawatan Biasa dr. NUR DIAN AFIDAH Rp. 750.000
(0002802036317)
110917010523P000441 KHUMESIH (0000637755524) 06/05/2023 08/05/2023 Rawat Inap di R. Perawatan Biasa dr. NUR DIAN AFIDAH Rp. 500.000
110917010523P000525 TASLIAH (0000637618994) 06/05/2023 09/05/2023 Rawat Inap di R. Perawatan Biasa dr. NUR DIAN AFIDAH Rp. 750.000
AYU KARTIKA NOPITA SARI

110917010523P000531 06/05/2023 09/05/2023 Rawat Inap di R. Perawatan Biasa dr. NUR DIAN AFIDAH Rp. 750.000
(0000638129924)
110917010523P000539 ENY RAHAYU (0000637624001) 05/05/2023 09/05/2023 Rawat Inap di R. Perawatan Biasa dr. NUR DIAN AFIDAH Rp. 1.000.000
110917010523P000700 M.HUSNI AL FAQIH (0002928351442) 07/05/2023 09/05/2023 Rawat Inap di R. Perawatan Biasa dr. NUR DIAN AFIDAH Rp. 500.000
110917010523P000701 PATIKHO (0002802036712) 08/05/2023 10/05/2023 Rawat Inap di R. Perawatan Biasa dr. NUR DIAN AFIDAH Rp. 500.000
110917010523P000702 ULFA PURNA NINGSIH (0000637316291) 08/05/2023 10/05/2023 Rawat Inap di R. Perawatan Biasa dr. NUR DIAN AFIDAH Rp. 500.000
110917010523P000854 A. FURQON SOBARUDIN (0002579172939) 11/05/2023 12/05/2023 Rawat Inap di R. Perawatan Biasa EVY AWALINA SHOFIA Rp. 250.000
110917010523P000855 HABISAH (0000637784324) 10/05/2023 12/05/2023 Rawat Inap di R. Perawatan Biasa EVY AWALINA SHOFIA Rp. 500.000
ARAZQA GHAISAN SHABIRUNNAFI

(0003300577435)
ARAZQA GHAISAN SHABIRUNNAFI
(0003300577435)
110917010523P000966 DAMANHURI (0001844353203) 13/05/2023 16/05/2023 Rawat Inap di R. Perawatan Biasa EDVAND DANI EKA SATRIA Rp. 750.000
110917010523P000966 DAMANHURI (0001844353203) 13/05/2023 16/05/2023 Rawat Inap di R. Perawatan Biasa EDVAND DANI EKA SATRIA Rp. 750.000
110917010523P000968 NADIA NAZAFARIN (0002889209013) 14/05/2023 16/05/2023 Rawat Inap di R. Perawatan Biasa EDVAND DANI EKA SATRIA Rp. 500.000
110917010523P000968 NADIA NAZAFARIN (0002889209013) 14/05/2023 16/05/2023 Rawat Inap di R. Perawatan Biasa EDVAND DANI EKA SATRIA Rp. 500.000
110917010523P001094 CASMI (0000636898544) 14/05/2023 17/05/2023 Rawat Inap di R. Perawatan Biasa dr. RITA Rp. 750.000
110917010523P001094 CASMI (0000636898544) 14/05/2023 17/05/2023 Rawat Inap di R. Perawatan Biasa dr. RITA Rp. 750.000
110917010523P001101 DEWI SRIFANI (0002842095723) 15/05/2023 18/05/2023 Rawat Inap di R. Perawatan Biasa dr. RITA Rp. 750.000
110917010523P001101 DEWI SRIFANI (0002842095723) 15/05/2023 18/05/2023 Rawat Inap di R. Perawatan Biasa dr. RITA Rp. 750.000
110917010523P001102 WARNIASIH (0000637648593) 15/05/2023 18/05/2023 Rawat Inap di R. Perawatan Biasa dr. RITA Rp. 750.000
110917010523P001102 WARNIASIH (0000637648593) 15/05/2023 18/05/2023 Rawat Inap di R. Perawatan Biasa dr. RITA Rp. 750.000
110917010523P001103 NOKTUROH (0002127914133) 15/05/2023 18/05/2023 Rawat Inap di R. Perawatan Biasa dr. RITA Rp. 750.000
110917010523P001103 NOKTUROH (0002127914133) 15/05/2023 18/05/2023 Rawat Inap di R. Perawatan Biasa dr. RITA Rp. 750.000
110917010523P001232 WARPI (0002256175135) 17/05/2023 20/05/2023 Rawat Inap di R. Perawatan Biasa EDVAND DANI EKA SATRIA Rp. 750.000
110917010523P001232 WARPI (0002256175135) 17/05/2023 20/05/2023 Rawat Inap di R. Perawatan Biasa EDVAND DANI EKA SATRIA Rp. 750.000
110917010523P001234 SUKMAWATI (0000638069962) 17/05/2023 20/05/2023 Rawat Inap di R. Perawatan Biasa EDVAND DANI EKA SATRIA Rp. 750.000
110917010523P001234 SUKMAWATI (0000638069962) 17/05/2023 20/05/2023 Rawat Inap di R. Perawatan Biasa EDVAND DANI EKA SATRIA Rp. 750.000
110917010523P001308 SUPARJO (0000637997387) 18/05/2023 22/05/2023 Rawat Inap di R. Perawatan Biasa EVY AWALINA SHOFIA Rp. 1.000.000
110917010523P001313 SAENI (0000637842058) 20/05/2023 22/05/2023 Rawat Inap di R. Perawatan Biasa EVY AWALINA SHOFIA Rp. 500.000
110917010523P001415 M. DEDI PRIYANTO (0000638039856) 18/05/2023 22/05/2023 Rawat Inap di R. Perawatan Biasa EVY AWALINA SHOFIA Rp. 1.000.000
110917010523P001604 WARSONI (0002638448965) 21/05/2023 25/05/2023 Rawat Inap di R. Perawatan Biasa EDVAND DANI EKA SATRIA Rp. 1.000.000
110917010523P001604 WARSONI (0002638448965) 21/05/2023 25/05/2023 Rawat Inap di R. Perawatan Biasa EDVAND DANI EKA SATRIA Rp. 1.000.000
110917010523P001620 UMYATI (0000637685008) 22/05/2023 25/05/2023 Rawat Inap di R. Perawatan Biasa dr. NUR DIAN AFIDAH Rp. 750.000
110917010523P001691 AHMAD NURSIDIK (0002600655028) 23/05/2023 26/05/2023 Rawat Inap di R. Perawatan Biasa EVY AWALINA SHOFIA Rp. 750.000
110917010523P001697 PUTIKHA (0000638198504) 23/05/2023 26/05/2023 Rawat Inap di R. Perawatan Biasa dr. NUR DIAN AFIDAH Rp. 750.000
110917010523P001766 KURNIAWAN ARI S (0000637784829) 24/05/2023 27/05/2023 Rawat Inap di R. Perawatan Biasa dr. NUR DIAN AFIDAH Rp. 750.000
110917010523P001767 SOLIKHA (0002600863863) 25/05/2023 28/05/2023 Rawat Inap di R. Perawatan Biasa EDVAND DANI EKA SATRIA Rp. 750.000
110917010523P001767 SOLIKHA (0002600863863) 25/05/2023 28/05/2023 Rawat Inap di R. Perawatan Biasa EDVAND DANI EKA SATRIA Rp. 750.000
110917010523P001857 VIRDA OKVIANA (0002099803601) 27/05/2023 29/05/2023 Rawat Inap di R. Perawatan Biasa dr. RITA Rp. 500.000
110917010523P001869 RAIYAH (0000638198831) 26/05/2023 29/05/2023 Rawat Inap di R. Perawatan Biasa dr. RITA Rp. 750.000
110917010523P001869 RAIYAH (0000638198831) 26/05/2023 29/05/2023 Rawat Inap di R. Perawatan Biasa dr. RITA Rp. 750.000
110917010523P001875 WARSEM (0000637884911) 26/05/2023 29/05/2023 Rawat Inap di R. Perawatan Biasa dr. RITA Rp. 750.000
110917010523P001875 WARSEM (0000637884911) 26/05/2023 29/05/2023 Rawat Inap di R. Perawatan Biasa dr. RITA Rp. 750.000
110917010523P001894 SUNITAH (0003524792152) 25/05/2023 28/05/2023 Rawat Inap di R. Perawatan Biasa dr. NUR DIAN AFIDAH Rp. 750.000
MUHAMMAD AFIF FAHREZI

110917010523P001955 26/05/2023 30/05/2023 Rawat Inap di R. Perawatan Biasa EVY AWALINA SHOFIA Rp. 1.000.000
(0000638358221)
110917010523P001988 TUYEM BT TARYA (0000637879656) 27/05/2023 28/05/2023 Rawat Inap di R. Perawatan Biasa EVY AWALINA SHOFIA Rp. 250.000
110917010523P002025 MUHAMMAD DAWUD (0003061859736) 29/05/2023 31/05/2023 Rawat Inap di R. Perawatan Biasa EVY AWALINA SHOFIA Rp. 500.000
110917010523P002072 DAPEN (0001032362313) 22/05/2023 24/05/2023 Rawat Inap di R. Perawatan Biasa EVY AWALINA SHOFIA Rp. 500.000
Tanggal terima FPK, Tanggal, 03/06/2023

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Mei 23

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BPJS Kesehatan Cab.

Nomor FPK : P2305000012271

Bulan Pelayanan : May 2023

Total Tagihan : Rp. 34.750.000

GILANG PUTRA RAMADAN

ANGGI OKA LEVIANA DEWI

AYU KARTIKA NOPITA SARI

ARAZQA GHAISAN SHABIRUNNAFI

MUHAMMAD AFIF FAHREZI

Tanggal terima FPK, Tanggal, 03/06/2023

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