RS.

MANDAYA Outstanding Corporate AR

Jl. Arteri Tol Karawang Barat, Teluk Jambe
Suka Makmur, Jawa Barat Accrual
Karawang Indonesia M01.03.934
Telephone : (0267) 8643000 Site RS. MANDAYA
Fax : (0267) 8643003, (0267) 414306 Doc. No Rev
Date Page 1 of 16

Bill To Corporate BPJS Kesehatan

:
Accident and Emergency
No. Date MRN Registration No Patient Name Registration Payer Amount
1 27-Apr- 00-25-99-78 MREG/AE/2023041400 NIA CHAIRUNNISA BPJS Kesehatan 3,151,900
2023 07
2 27-Jun- 00-18-36-15 MREG/AE/2023061800 NURHAYATI BPJS Kesehatan 212,520
2023 21
3 04-Aug- 00-16-45-57 MREG/AE/2023080200 MOHAMMAD LUTFI BPJS Kesehatan 164,100
2023 20
4 04-Aug- 00-13-24-54 MREG/AE/2023080200 NAZWA SALBIAH BPJS Kesehatan 164,100
2023 33
5 04-Aug- 00-26-11-71 MREG/AE/2023080300 NUR RAHMAWATI KODRIAH BPJS Kesehatan 164,100
2023 17
6 21-Aug- 00-26-52-13 MREG/AE/2023080800 PRADHANA AL RAFFASYA BPJS Kesehatan 198,700
2023 03
7 21-Aug- 00-26-52-10 MREG/AE/2023080700 TAN KEYSHA BPJS Kesehatan 198,700
2023 36
8 21-Aug- 00-06-21-88 MREG/AE/2023080700 WAHYU PURNOMO BPJS Kesehatan 198,700
2023 39
9 21-Aug- 00-20-91-18 MREG/AE/2023080900 RIKA RATNA SARI BPJS Kesehatan 164,100
2023 10
10 21-Aug- 00-17-39-98 MREG/AE/2023081000 ERIKA ANGGRAINI BPJS Kesehatan 164,100
2023 06
11 21-Aug- 00-07-65-01 MREG/AE/2023081000 SUGIYARTI BPJS Kesehatan 196,100
2023 22
12 22-Aug- 00-26-53-03 MREG/AE/2023081100 ALYA SAFITRI BPJS Kesehatan 301,400
2023 17
13 22-Aug- 00-26-53-88 MREG/AE/2023081500 RR. GOUDENTIA NINA BPJS Kesehatan 164,100
2023 07 SUHASTUTI

TOTAL 5,442,620

Inpatient
No. Date MRN Registration No Patient Name Registration Payer Amount
1 15-May- 00-26-19-14 MREG/IP/20230508001 IRWAN KELIAT BPJS Kesehatan 2,174,700
2023 1
2 15-May- 00-26-21-29 MREG/IP/20230508000 MUHAMMAD AL FATIH SYAWAL BPJS Kesehatan 1,086,151
2023 3
3 17-May- 00-26-22-58 MREG/IP/20230512001 JACOB PRATAMA BPJS Kesehatan 1,536,511
2023 4
4 22-May- 00-26-22-84 MREG/IP/20230513001 SYAHDAN NAJWAN ALI BPJS Kesehatan 1,757,313
2023 2
5 29-May- 00-26-25-55 MREG/IP/20230525000 BY NY RAFIKA NOVIA NINGSIH BPJS Kesehatan 1,957,509
2023 1
6 06-Jun- 00-00-35-23 MREG/IP/20230531001 NINA JUWITA BPJS Kesehatan 3,330,600
2023 2
7 07-Jun- 00-26-28-16 MREG/IP/20230601000 YASMINA SAFITRI BPJS Kesehatan 4,429,700
2023 4
8 09-Jun- 00-26-28-41 MREG/IP/20230602000 Muhamad Apip BPJS Kesehatan 4,429,700
2023 8
9 09-Jun- 00-03-93-12 MREG/IP/20230605001 TEGUH PAMUJI BPJS Kesehatan 5,127,600
2023 1
10 21-Jun- 00-26-31-94 MREG/IP/20230615000 BY NY LENNY TRIYANTI BPJS Kesehatan 5,743,800
2023 9
11 21-Jun- 00-11-65-61 MREG/IP/20230616001 RADITIA FATAHILLAH BPJS Kesehatan 3,268,500
2023 2

Copyright © 2023 PT. QPRO Sukses Mandiri | Printed Date: 23-Aug-2023 14:39 | Printed By: Tsaabit Ahnaf
 RS. MANDAYA Outstanding Corporate AR
Jl. Arteri Tol Karawang Barat, Teluk Jambe
Suka Makmur, Jawa Barat Accrual
Karawang Indonesia M01.03.934
Telephone : (0267) 8643000 Site RS. MANDAYA
Fax : (0267) 8643003, (0267) 414306 Doc. No Rev
Date Page 2 of 16

12 21-Jun- 00-26-31-67 MREG/IP/20230614000 SITI HUMAIRO BPJS Kesehatan 3,330,600

2023 5
13 22-Jun- 00-26-32-35 MREG/IP/20230617000 CETAA ALFILA KEENANTI BPJS Kesehatan 1,993,099
2023 3
14 26-Jun- 00-26-33-56 MREG/IP/20230621000 BY NY AI WIDIA BPJS Kesehatan 1,259,033
2023 5
15 04-Jul-2023 00-26-35-10 MREG/IP/20230627001 EDI SUPRIADI BPJS Kesehatan 4,429,700
1
16 04-Jul-2023 00-26-34-72 MREG/IP/20230626000 AGUS SAHDIANA BPJS Kesehatan 4,429,700
6
17 04-Jul-2023 00-26-28-91 MREG/IP/20230628000 NANI HANDRIANI BPJS Kesehatan 4,429,700
7
18 04-Jul-2023 00-26-31-94 MREG/IP/20230623001 BY NY LENNY TRIYANTI BPJS Kesehatan 3,385,000
4
19 04-Jul-2023 00-11-82-53 MREG/IP/20230628000 JOSUA SETIAWAN BPJS Kesehatan 3,330,600
2
20 04-Jul-2023 00-13-22-08 MREG/IP/20230628000 FAIZAL HERMAWAN BPJS Kesehatan 4,429,700
6
21 05-Jul-2023 00-26-35-89 MREG/IP/20230701000 BY NY SITI NURLAELA BPJS Kesehatan 1,162,113
4
22 11-Jul-2023 00-26-37-90 MREG/IP/20230707000 RIZKA DEWI SABILUNA BPJS Kesehatan 3,880,200
6
23 14-Jul-2023 00-26-38-49 MREG/IP/20230710000 ACIH BPJS Kesehatan 4,429,700
4
24 14-Jul-2023 00-25-52-30 MREG/IP/20230709001 ALDA ASTUTI BPJS Kesehatan 4,429,700
0
25 18-Jul-2023 00-26-38-81 MREG/IP/20230711000 BY NY MAYA ULFAHSARI BPJS Kesehatan 1,655,487
4
26 18-Jul-2023 00-26-39-72 MREG/IP/20230714000 BY NY SAENI NIRWANTI BPJS Kesehatan 1,083,225
2
27 20-Jul-2023 00-26-40-18 MREG/IP/20230715001 INDRIA CAROLINA USADA BPJS Kesehatan 4,429,700
3
28 20-Jul-2023 00-25-81-36 MREG/IP/20230714001 YUSYUS SUPRIYADI BPJS Kesehatan 5,852,900
5
29 20-Jul-2023 00-26-40-48 MREG/IP/20230717000 BY NY MINDO HERDINO BPJS Kesehatan 1,487,042
8 ARITONANG
30 21-Jul-2023 00-26-40-61 MREG/IP/20230717001 MUTIARA SARI BPJS Kesehatan 4,429,700
8
31 25-Jul-2023 00-26-39-84 MREG/IP/20230714000 BY NY AJENG SUKESI BPJS Kesehatan 4,814,258
7
32 27-Jul-2023 00-26-42-82 MREG/IP/20230725000 ITA BIN KASMIN BPJS Kesehatan 4,429,700
7
33 31-Jul-2023 00-24-62-28 MREG/IP/20230723000 FAIZATULHAQ FUZI BPJS Kesehatan 4,429,700
4
34 31-Jul-2023 00-24-55-64 MREG/IP/20230724000 BAYU WICAKSONO BPJS Kesehatan 4,429,700
6
35 01-Aug- 00-26-47-78 MREG/IP/20230727000 ALANA HAYVA NURANDI, BY BPJS Kesehatan 1,422,475
2023 6
36 03-Aug- 00-26-48-72 MREG/IP/20230729000 FUMIKO ANAYA KESHWARI BPJS Kesehatan 1,770,374
2023 2
37 04-Aug- 00-17-04-59 MREG/IP/20230730001 SUCI APRILIA, AN BPJS Kesehatan 3,017,700
2023 5
38 04-Aug- 00-25-54-84 MREG/IP/20230731000 CACIH BPJS Kesehatan 5,046,400
2023 7
39 04-Aug- 00-16-25-96 MREG/IP/20230731000 DEDE ANITA, NY BPJS Kesehatan 6,967,500
2023 8
40 04-Aug- 00-26-49-84 MREG/IP/20230731001 BY NY DEDE ANITA BPJS Kesehatan 1,557,508
2023 0

Copyright © 2023 PT. QPRO Sukses Mandiri | Printed Date: 23-Aug-2023 14:39 | Printed By: Tsaabit Ahnaf
 RS. MANDAYA Outstanding Corporate AR
Jl. Arteri Tol Karawang Barat, Teluk Jambe
Suka Makmur, Jawa Barat Accrual
Karawang Indonesia M01.03.934
Telephone : (0267) 8643000 Site RS. MANDAYA
Fax : (0267) 8643003, (0267) 414306 Doc. No Rev
Date Page 3 of 16

41 07-Aug- 00-14-01-53 MREG/IP/20230801000 SUMARNI. NY BPJS Kesehatan 6,967,500

2023 9
42 07-Aug- 00-26-50-32 MREG/IP/20230802000 ASTIN BPJS Kesehatan 5,368,100
2023 2
43 08-Aug- 00-23-22-47 MREG/IP/20230805001 TRI HANDOYO BPJS Kesehatan 2,633,800
2023 1
44 08-Aug- 00-26-51-14 MREG/IP/20230805000 SITI UNAYAH BPJS Kesehatan 6,967,500
2023 1
45 08-Aug- 00-25-46-24 MREG/IP/20230801001 DIDI KUSNADI BPJS Kesehatan 2,174,700
2023 1
46 08-Aug- 00-26-50-34 MREG/IP/20230802000 MUHAMMAD IDRIS SALIM BPJS Kesehatan 2,960,800
2023 3
47 08-Aug- 00-26-50-48 MREG/IP/20230802000 MARWAN SETIAWAN BPJS Kesehatan 2,174,700
2023 9
48 08-Aug- 00-26-50-49 MREG/IP/20230802001 UTI SUSILAWATI BPJS Kesehatan 3,611,500
2023 2
49 08-Aug- 00-16-34-23 MREG/IP/20230802001 ABIZARD RAFFASYA ALFARIZI BPJS Kesehatan 1,939,100
2023 7
50 08-Aug- 00-12-07-77 MREG/IP/20230802001 NURVITA ALVINA RAHMA BPJS Kesehatan 2,174,700
2023 8 SUYATNO
51 08-Aug- 00-26-50-44 MREG/IP/20230803000 ARRAHMAN FIRDAUS BPJS Kesehatan 6,091,600
2023 4
52 08-Aug- 00-26-33-69 MREG/IP/20230803000 YUNARTI BPJS Kesehatan 5,262,600
2023 2
53 08-Aug- 00-26-16-52 MREG/IP/20230803001 RAFANDRA GHIFARI EMRAN BPJS Kesehatan 1,635,100
2023 1
54 08-Aug- 00-26-50-89 MREG/IP/20230803001 NURCAHYA BPJS Kesehatan 2,174,700
2023 6
55 08-Aug- 00-24-73-95 MREG/IP/20230804000 RIZKI FAJAR PRATAMA BPJS Kesehatan 3,017,700
2023 7
56 08-Aug- 00-26-51-07 MREG/IP/20230804000 ESTER PARAPAT BPJS Kesehatan 2,269,000
2023 9
57 08-Aug- 00-26-49-57 MREG/IP/20230730001 ARETHA ASHILA PUTRI AHMAD BPJS Kesehatan 5,437,100
2023 3
58 08-Aug- 00-18-40-86 MREG/IP/20230430000 H. RUSMIDI, DRS, TN BPJS Kesehatan 23,255,400
2023 6
59 08-Aug- 00-26-19-14 MREG/IP/20230502000 IRWAN KELIAT BPJS Kesehatan 2,579,000
2023 9
60 09-Aug- 00-15-62-20 MREG/IP/20230803000 ALDEBARAN FAUZI, AN BPJS Kesehatan 7,180,800
2023 8
61 09-Aug- 00-16-94-97 MREG/IP/20230805001 INAWATI BPJS Kesehatan 5,458,700
2023 5
62 09-Aug- 00-26-36-81 MREG/IP/20230805000 DIAN WATY BPJS Kesehatan 4,580,200
2023 5
63 09-Aug- 00-26-51-26 MREG/IP/20230805000 SOLEHA BPJS Kesehatan 2,269,000
2023 6
64 09-Aug- 00-26-50-87 MREG/IP/20230803001 MUHAMMAD ERZHAN IBRAHIM BPJS Kesehatan 3,613,600
2023 4
65 09-Aug- 00-04-03-90 MREG/IP/20230804000 KUS RAHMADONA NY. BPJS Kesehatan 4,429,700
2023 2
66 10-Aug- 00-19-43-48 MREG/IP/20230805000 RIKI SUBAGJA BPJS Kesehatan 2,335,600
2023 9
67 10-Aug- 00-26-49-55 MREG/IP/20230730001 BY NY SITI NURLAELASARI BPJS Kesehatan 4,318,700
2023 1
68 10-Aug- 00-26-51-12 MREG/IP/20230804001 TEGAR SETIAWAN BPJS Kesehatan 9,550,400
2023 0
69 11-Aug- 00-18-83-29 MREG/IP/20230809001 UGI ASIH BT SUHADI SUMBER CIPTA MULTINIAGA, PT 2,184,700
2023 4

Copyright © 2023 PT. QPRO Sukses Mandiri | Printed Date: 23-Aug-2023 14:39 | Printed By: Tsaabit Ahnaf
 RS. MANDAYA Outstanding Corporate AR
Jl. Arteri Tol Karawang Barat, Teluk Jambe
Suka Makmur, Jawa Barat Accrual
Karawang Indonesia M01.03.934
Telephone : (0267) 8643000 Site RS. MANDAYA
Fax : (0267) 8643003, (0267) 414306 Doc. No Rev
Date Page 4 of 16

70 11-Aug- 00-26-01-66 MREG/IP/20230805000 ERNI WIDIAWATI BPJS Kesehatan 6,967,500

2023 8
71 11-Aug- 00-26-51-49 MREG/IP/20230805001 SULIS SETIOWATI BPJS Kesehatan 1,635,100
2023 7
72 11-Aug- 00-08-57-71 MREG/IP/20230806000 HJ IMAS NUNU BPJS Kesehatan 1,904,900
2023 6
73 11-Aug- 00-15-53-71 MREG/IP/20230806001 SUSI ANDAYANI, NY BPJS Kesehatan 4,429,700
2023 1
74 11-Aug- 00-02-08-69 MREG/IP/20230807000 SATA BPJS Kesehatan 6,310,500
2023 3
75 11-Aug- 00-26-51-53 MREG/IP/20230806000 BY NY ERNI WIDIAWATI BPJS Kesehatan 1,634,659
2023 4
76 11-Aug- 00-26-51-59 MREG/IP/20230807000 BY NY NATALIA DELVIA BPJS Kesehatan 2,633,800
2023 1
77 11-Aug- 00-26-51-56 MREG/IP/20230806000 RISKIANIS KURLILAH BPJS Kesehatan 3,017,700
2023 8
78 11-Aug- 00-26-51-64 MREG/IP/20230807000 MUHAMAD SARIP BPJS Kesehatan 2,174,700
2023 2
79 11-Aug- 00-26-27-60 MREG/IP/20230807001 MUHAMAD RAYSHA NABIHA BPJS Kesehatan 1,635,100
2023 8 MAHESWARA
80 12-Aug- 00-20-85-58 MREG/IP/20230808001 ABIYA SHAULA MECCA SUMBER CIPTA MULTINIAGA, PT 4,806,100
2023 8
81 14-Aug- 00-26-51-44 MREG/IP/20230805001 H. NUNUNG SUMARSANA, BPJS Kesehatan 4,192,000
2023 2 DRS,MM
82 14-Aug- 00-26-28-91 MREG/IP/20230807001 NANI HANDRIANI BPJS Kesehatan 4,806,100
2023 2
83 14-Aug- 00-26-21-13 MREG/IP/20230807001 MUHAMAMAD FATIH BPJS Kesehatan 6,753,800
2023 4 ARGANTARA
84 14-Aug- 00-26-52-05 MREG/IP/20230807001 DIAN SRIHARTATI BPJS Kesehatan 4,829,200
2023 7 SIMANJORANG
85 14-Aug- 00-26-52-15 MREG/IP/20230808000 KUSWARA KRIFALGI BPJS Kesehatan 2,633,800
2023 5
86 14-Aug- 00-13-21-39 MREG/IP/20230808001 RAMDHAN RAKA NUGRAHA, TN BPJS Kesehatan 3,759,600
2023 1
87 14-Aug- 00-11-50-13 MREG/IP/20230808000 WINDHA LORENT BPJS Kesehatan 2,957,000
2023 8
88 14-Aug- 00-07-42-62 MREG/IP/20230808002 DINAL MUSTAQIN BASRI BPJS Kesehatan 1,635,100
2023 4
89 14-Aug- 00-26-52-60 MREG/IP/20230809001 DEVI PRATIWI BPJS Kesehatan 2,174,700
2023 7
90 14-Aug- 00-26-51-85 MREG/IP/20230809001 ANGLINA ESTHER CAROLINE BPJS Kesehatan 3,631,000
2023 2
91 14-Aug- 00-13-12-78 MREG/IP/20230809000 HILDA PERMATA SARI BPJS Kesehatan 4,429,700
2023 1
92 14-Aug- 00-17-29-54 MREG/IP/20230809001 LEO REGINA LAVENIA BPJS Kesehatan 3,739,000
2023 0
93 14-Aug- 00-26-35-81 MREG/IP/20230811000 ADE PUDIN BPJS Kesehatan 3,949,400
2023 2
94 14-Aug- 00-26-50-54 MREG/IP/20230811001 AINUN NAIM BPJS Kesehatan 6,091,600
2023 8
95 14-Aug- 00-26-52-18 MREG/IP/20230810000 FAZRIANSYAH BPJS Kesehatan 4,580,200
2023 5
96 15-Aug- 00-26-13-70 MREG/IP/20230811000 TITIN CASTINI BPJS Kesehatan 1,792,000
2023 1
97 15-Aug- 00-06-21-88 MREG/IP/20230809001 WAHYU PURNOMO BPJS Kesehatan 4,715,300
2023 5
98 16-Aug- 00-05-44-86 MREG/IP/20230813000 SHILVIA DEWI PRAMULYANA BPJS Kesehatan 2,891,300
2023 9

Copyright © 2023 PT. QPRO Sukses Mandiri | Printed Date: 23-Aug-2023 14:39 | Printed By: Tsaabit Ahnaf
 RS. MANDAYA Outstanding Corporate AR
Jl. Arteri Tol Karawang Barat, Teluk Jambe
Suka Makmur, Jawa Barat Accrual
Karawang Indonesia M01.03.934
Telephone : (0267) 8643000 Site RS. MANDAYA
Fax : (0267) 8643003, (0267) 414306 Doc. No Rev
Date Page 5 of 16

99 16-Aug- 00-26-53-42 MREG/IP/20230813001 BY NY SHILVIA DEWI BPJS Kesehatan 949,746

2023 0 PRAMULYANA
100 18-Aug- 00-26-38-17 MREG/IP/20230809000 DEWI LESTARI BPJS Kesehatan 2,838,100
2023 4
101 18-Aug- 00-26-52-81 MREG/IP/20230810001 MAISHAKA ADNAN YAHYA BPJS Kesehatan 2,633,800
2023 9
102 18-Aug- 00-26-51-53 MREG/IP/20230811002 BY NY ERNI WIDIAWATI BPJS Kesehatan 3,606,600
2023 0
103 18-Aug- 00-26-52-64 MREG/IP/20230810000 MAGHIRA IDZQIYYA AKHMAD BPJS Kesehatan 2,579,000
2023 1
104 18-Aug- 00-19-20-33 MREG/IP/20230811002 EFA EFRIDA YENI BPJS Kesehatan 2,885,400
2023 2
105 18-Aug- 00-26-53-35 MREG/IP/20230812000 SEPTIANTO ALFARIZ BPJS Kesehatan 2,633,800
2023 8
106 18-Aug- 00-25-58-53 MREG/IP/20230810000 ZENOBIA ZEINA SYAHRAZAQ BPJS Kesehatan 4,806,100
2023 7
107 21-Aug- 00-15-68-18 MREG/IP/20230808001 ENDI HERMAWAN ,TN BPJS Kesehatan 5,638,000
2023 3
108 21-Aug- 00-22-07-24 MREG/IP/20230811002 KASMIN, TN BPJS Kesehatan 3,151,900
2023 3
109 21-Aug- 00-22-04-92 MREG/IP/20230813001 CASTINAH BPJS Kesehatan 2,174,700
2023 2
110 21-Aug- 00-26-38-49 MREG/IP/20230813001 ACIH BPJS Kesehatan 1,635,100
2023 3
111 21-Aug- 00-26-53-56 MREG/IP/20230814000 SANIA SEPTIANI BPJS Kesehatan 4,829,200
2023 8
112 21-Aug- 00-25-38-50 MREG/IP/20230814000 GIENKA ADELINE EL MECCA BPJS Kesehatan 2,174,700
2023 1
113 21-Aug- 00-26-53-82 MREG/IP/20230814001 YUNI RAHMAWATI BPJS Kesehatan 3,154,300
2023 9
114 21-Aug- 00-09-37-13 MREG/IP/20230815000 BRAM ARI PURWANTO BPJS Kesehatan 6,091,600
2023 3
115 21-Aug- 00-26-21-37 MREG/IP/20230815001 SUHADA BPJS Kesehatan 3,611,500
2023 5
116 21-Aug- 00-23-44-26 MREG/IP/20230815001 HENI NURAENI, NY BPJS Kesehatan 5,289,100
2023 1
117 21-Aug- 00-23-34-57 MREG/IP/20230815000 HJ ENUNG HARTINI BPJS Kesehatan 5,127,600
2023 8
118 21-Aug- 00-09-88-32 MREG/IP/20230815000 NINING PUSPITASARI, NY BPJS Kesehatan 2,957,000
2023 6
119 21-Aug- 00-15-17-73 MREG/IP/20230816001 AGUS SURWADI BPJS Kesehatan 3,562,000
2023 2
120 21-Aug- 00-14-29-06 MREG/IP/20230816001 YUNI SULISTIAWATI BPJS Kesehatan 2,891,300
2023 7
121 21-Aug- 00-26-54-69 MREG/IP/20230816001 BY NY YUNI SULISTIAWATI BPJS Kesehatan 2,292,172
2023 8
122 21-Aug- 00-23-68-04 MREG/IP/20230817000 HJ SITI ROMLAH BPJS Kesehatan 4,803,200
2023 7
123 22-Aug- 00-26-54-15 MREG/IP/20230816002 MUAMMAR RIZKY ABDILLAH BPJS Kesehatan 2,174,700
2023 1
124 22-Aug- 00-11-06-76 MREG/IP/20230816000 PIPIT INDRIATI BPJS Kesehatan 2,633,800
2023 5
125 22-Aug- 00-26-54-72 MREG/IP/20230817000 DHELIA SRI LISKA PUTRI BPJS Kesehatan 2,269,000
2023 5
126 22-Aug- 00-26-54-74 MREG/IP/20230817001 NETRIDA BPJS Kesehatan 2,097,400
2023 2
127 22-Aug- 00-26-53-74 MREG/IP/20230818000 YULIA DEFRIANTI BPJS Kesehatan 6,091,600
2023 6

Copyright © 2023 PT. QPRO Sukses Mandiri | Printed Date: 23-Aug-2023 14:39 | Printed By: Tsaabit Ahnaf
 RS. MANDAYA Outstanding Corporate AR
Jl. Arteri Tol Karawang Barat, Teluk Jambe
Suka Makmur, Jawa Barat Accrual
Karawang Indonesia M01.03.934
Telephone : (0267) 8643000 Site RS. MANDAYA
Fax : (0267) 8643003, (0267) 414306 Doc. No Rev
Date Page 6 of 16

128 22-Aug- 00-26-32-21 MREG/IP/20230818000 TETI WILLIYANTI BPJS Kesehatan 6,999,300

2023 4
129 23-Aug- 00-14-28-02 MREG/IP/20230816000 AHNAF SIDQI ARYASUTA S BPJS Kesehatan 2,633,800
2023 1
130 23-Aug- 00-26-54-82 MREG/IP/20230818000 KIRANA ASHEEQA ALBIRRU BPJS Kesehatan 4,806,100
2023 1
131 23-Aug- 00-16-39-77 MREG/IP/20230818000 LEO REVINA NATALIA BPJS Kesehatan 3,017,700
2023 2
132 23-Aug- 00-24-24-80 MREG/IP/20230817001 REZA IBNU JAENUDIN BPJS Kesehatan 2,174,700
2023 0
133 23-Aug- 00-16-94-97 MREG/IP/20230818002 INAWATI BPJS Kesehatan 5,458,700
2023 0
134 23-Aug- 00-26-29-52 MREG/IP/20230819001 SITI FARIDA BPJS Kesehatan 3,330,600
2023 1
135 23-Aug- 00-12-91-28 MREG/IP/20230819000 YANTI SUPRIYANTI NY. BPJS Kesehatan 1,891,500
2023 3

TOTAL 498,814,875

Outpatient
No. Date MRN Registration No Patient Name Registration Payer Amount
1 17-Apr- 00-15-60-45 MREG/OP/2023041300 YOGHA SETIAWAN TN BPJS Kesehatan 196,100
2023 31
2 28-Apr- 00-26-15-20 MREG/OP/2023041900 KEYZA CASSANDRA PUTRI BPJS Kesehatan 196,100
2023 50
3 28-Apr- 00-15-60-45 MREG/OP/2023042000 YOGHA SETIAWAN TN BPJS Kesehatan 196,100
2023 38
4 28-Apr- 00-16-86-70 MREG/OP/2023042500 ACHMAD DEDE BPJS Kesehatan 196,100
2023 12
5 28-Apr- 00-26-18-01 MREG/OP/2023042500 KYOVAN LEON GUNAWAN BPJS Kesehatan 196,100
2023 33
6 02-May- 00-26-15-20 MREG/OP/2023042600 KEYZA CASSANDRA PUTRI BPJS Kesehatan 196,100
2023 47
7 03-May- 00-26-18-01 MREG/OP/2023042800 KYOVAN LEON GUNAWAN BPJS Kesehatan 709,000
2023 61
8 11-May- 00-25-30-18 MREG/OP/2023050900 ERIS JAYA SANTIKA BPJS Kesehatan 196,100
2023 73
9 15-May- 00-26-18-74 MREG/OP/2023051000 NURLITA KIRANA PUTRI BPJS Kesehatan 196,100
2023 74 ANDESLAB
10 15-May- 00-26-20-17 MREG/OP/2023051100 HJ. WARIYAH BPJS Kesehatan 196,100
2023 06
11 20-May- 00-25-30-18 MREG/OP/2023051300 ERIS JAYA SANTIKA BPJS Kesehatan 150,900
2023 56
12 22-May- 00-25-30-18 MREG/OP/2023051700 ERIS JAYA SANTIKA BPJS Kesehatan 196,100
2023 88
13 24-May- 00-05-86-29 MREG/OP/2023051900 SAI MULYADI BPJS Kesehatan 196,100
2023 23
14 25-May- 00-26-23-27 MREG/OP/2023052000 TUTIK MULYANI BPJS Kesehatan 150,900
2023 40
15 25-May- 00-17-70-77 MREG/OP/2023052300 YULIANA,NY BPJS Kesehatan 196,100
2023 08
16 25-May- 00-25-30-18 MREG/OP/2023052401 ERIS JAYA SANTIKA BPJS Kesehatan 196,100
2023 01
17 26-May- 00-26-23-27 MREG/OP/2023052400 TUTIK MULYANI BPJS Kesehatan 196,100
2023 97
18 31-May- 00-17-70-77 MREG/OP/2023053000 YULIANA,NY BPJS Kesehatan 196,100
2023 13
19 02-Jun- 00-26-18-74 MREG/OP/2023053100 NURLITA KIRANA PUTRI BPJS Kesehatan 150,900
2023 54 ANDESLAB

Copyright © 2023 PT. QPRO Sukses Mandiri | Printed Date: 23-Aug-2023 14:39 | Printed By: Tsaabit Ahnaf
 RS. MANDAYA Outstanding Corporate AR
Jl. Arteri Tol Karawang Barat, Teluk Jambe
Suka Makmur, Jawa Barat Accrual
Karawang Indonesia M01.03.934
Telephone : (0267) 8643000 Site RS. MANDAYA
Fax : (0267) 8643003, (0267) 414306 Doc. No Rev
Date Page 7 of 16

20 02-Jun- 00-25-30-18 MREG/OP/2023053100 ERIS JAYA SANTIKA BPJS Kesehatan 196,100

2023 77
21 07-Jun- 00-00-42-96 MREG/OP/2023060200 IMELDA BPJS Kesehatan 1,129,300
2023 94
22 07-Jun- 00-26-23-51 MREG/OP/2023060501 SARWENDAH BPJS Kesehatan 150,900
2023 17
23 09-Jun- 00-25-77-43 MREG/OP/2023060600 EUIS NY BPJS Kesehatan 198,700
2023 95
24 09-Jun- 00-18-39-17 MREG/OP/2023060700 DADAN MEDIANA BPJS Kesehatan 196,100
2023 57
25 09-Jun- 00-17-53-18 MREG/OP/2023060600 HANA SHAIMA IZZATUNISA BPJS Kesehatan 198,700
2023 54
26 09-Jun- 00-26-28-15 MREG/OP/2023060600 DONY RICHARD BPJS Kesehatan 201,000
2023 19
27 09-Jun- 00-26-23-51 MREG/OP/2023060700 SARWENDAH BPJS Kesehatan 196,100
2023 75
28 09-Jun- 00-26-29-71 MREG/OP/2023060700 ARTHUR ALVARENDRA BPJS Kesehatan 196,100
2023 64 KHALEED MAULANA
29 09-Jun- 00-26-30-07 MREG/OP/2023060800 MARYA DEWI SAPUTRI BPJS Kesehatan 198,700
2023 63
30 12-Jun- 00-26-28-15 MREG/OP/2023060900 DONY RICHARD BPJS Kesehatan 196,100
2023 01
31 12-Jun- 00-11-72-51 MREG/OP/2023060900 MAMUN NAWAWI, TN BPJS Kesehatan 196,100
2023 71
32 12-Jun- 00-00-42-96 MREG/OP/2023060900 IMELDA BPJS Kesehatan 196,100
2023 19
33 13-Jun- 00-15-59-43 MREG/OP/2023061000 AMUK BPJS Kesehatan 196,100
2023 77
34 13-Jun- 00-18-12-61 MREG/OP/2023061000 HENDRI DARMAWAN BPJS Kesehatan 196,100
2023 80
35 14-Jun- 00-26-26-86 MREG/OP/2023061301 yoyoh BPJS Kesehatan 196,100
2023 18
36 14-Jun- 00-15-59-43 MREG/OP/2023061200 AMUK BPJS Kesehatan 196,100
2023 82
37 14-Jun- 00-11-72-51 MREG/OP/2023061200 MAMUN NAWAWI, TN BPJS Kesehatan 254,300
2023 01
38 15-Jun- 00-17-53-18 MREG/OP/2023061300 HANA SHAIMA IZZATUNISA BPJS Kesehatan 196,100
2023 19
39 15-Jun- 00-25-77-43 MREG/OP/2023061301 EUIS NY BPJS Kesehatan 196,100
2023 16
40 15-Jun- 00-26-16-20 MREG/OP/2023061401 WARTI BPJS Kesehatan 196,100
2023 08
41 15-Jun- 00-26-16-20 MREG/OP/2023061300 WARTI BPJS Kesehatan 196,100
2023 63
42 16-Jun- 00-26-31-73 MREG/OP/2023061600 NADIH GUNAWAN BPJS Kesehatan 151,800
2023 19
43 19-Jun- 00-26-26-86 MREG/OP/2023061200 yoyoh BPJS Kesehatan 179,800
2023 44
44 19-Jun- 00-00-42-96 MREG/OP/2023061600 IMELDA BPJS Kesehatan 196,100
2023 39
45 19-Jun- 00-26-29-42 MREG/OP/2023061600 AQILA AYUDIA KIRANI BPJS Kesehatan 196,100
2023 09
46 19-Jun- 00-26-30-07 MREG/OP/2023061500 MARYA DEWI SAPUTRI BPJS Kesehatan 196,100
2023 99
47 21-Jun- 00-26-23-51 MREG/OP/2023061901 SARWENDAH BPJS Kesehatan 150,900
2023 05
48 21-Jun- 00-25-77-43 MREG/OP/2023062000 EUIS NY BPJS Kesehatan 196,100
2023 80

Copyright © 2023 PT. QPRO Sukses Mandiri | Printed Date: 23-Aug-2023 14:39 | Printed By: Tsaabit Ahnaf
 RS. MANDAYA Outstanding Corporate AR
Jl. Arteri Tol Karawang Barat, Teluk Jambe
Suka Makmur, Jawa Barat Accrual
Karawang Indonesia M01.03.934
Telephone : (0267) 8643000 Site RS. MANDAYA
Fax : (0267) 8643003, (0267) 414306 Doc. No Rev
Date Page 8 of 16

49 21-Jun- 00-17-53-18 MREG/OP/2023062000 HANA SHAIMA IZZATUNISA BPJS Kesehatan 196,100

2023 35
50 22-Jun- 00-26-28-15 MREG/OP/2023061900 DONY RICHARD BPJS Kesehatan 196,100
2023 04
51 22-Jun- 00-18-12-61 MREG/OP/2023061900 HENDRI DARMAWAN BPJS Kesehatan 198,700
2023 24
52 23-Jun- 00-26-28-15 MREG/OP/2023062100 DONY RICHARD BPJS Kesehatan 201,000
2023 74
53 28-Jun- 00-26-30-07 MREG/OP/2023062700 MARYA DEWI SAPUTRI BPJS Kesehatan 196,100
2023 89
54 28-Jun- 00-25-77-43 MREG/OP/2023062700 EUIS NY BPJS Kesehatan 196,100
2023 90
55 30-Jun- 00-18-12-61 MREG/OP/2023062800 HENDRI DARMAWAN BPJS Kesehatan 196,100
2023 44
56 03-Jul-2023 00-13-06-98 MREG/OP/2023070200 RONI MUSTARI TN. BPJS Kesehatan 977,900
01
57 04-Jul-2023 00-11-89-78 MREG/OP/2023051501 ARJAN BPJS Kesehatan 150,900
34
58 04-Jul-2023 00-11-89-78 MREG/OP/2023051700 ARJAN BPJS Kesehatan 134,300
29
59 05-Jul-2023 00-17-70-77 MREG/OP/2023070300 YULIANA,NY BPJS Kesehatan 196,100
14
60 05-Jul-2023 00-26-28-15 MREG/OP/2023070400 DONY RICHARD BPJS Kesehatan 201,000
80
61 06-Jul-2023 00-26-32-11 MREG/OP/2023070500 NAFISATUZ ZAHRO BPJS Kesehatan 196,100
01
62 10-Jul-2023 00-15-87-02 MREG/OP/2023070700 HENI OKTAVIANI BPJS Kesehatan 196,100
11
63 11-Jul-2023 00-26-34-22 MREG/OP/2023070800 HARIATI KURNIADI BPJS Kesehatan 196,100
27
64 11-Jul-2023 00-26-38-45 MREG/OP/2023071000 JOHARI BPJS Kesehatan 254,300
13
65 12-Jul-2023 00-26-38-64 MREG/OP/2023071001 UJANG AHMAD DARUSSALAM BPJS Kesehatan 347,100
11
66 12-Jul-2023 00-26-24-79 MREG/OP/2023071000 SAENI NIRWANTI BPJS Kesehatan 150,900
35
67 12-Jul-2023 00-26-28-15 MREG/OP/2023071100 DONY RICHARD BPJS Kesehatan 201,000
70
68 14-Jul-2023 00-26-39-14 MREG/OP/2023071200 HOTIB BPJS Kesehatan 151,800
82
69 15-Jul-2023 00-15-87-02 MREG/OP/2023071400 HENI OKTAVIANI BPJS Kesehatan 196,100
49
70 20-Jul-2023 00-26-28-15 MREG/OP/2023071700 DONY RICHARD BPJS Kesehatan 196,100
09
71 20-Jul-2023 00-26-40-02 MREG/OP/2023071701 EMAY BPJS Kesehatan 196,800
10
72 20-Jul-2023 00-26-40-57 MREG/OP/2023071700 HERI SISWOYO BPJS Kesehatan 196,100
92
73 20-Jul-2023 00-26-38-45 MREG/OP/2023071700 JOHARI BPJS Kesehatan 196,100
12
74 22-Jul-2023 00-26-32-11 MREG/OP/2023072100 NAFISATUZ ZAHRO BPJS Kesehatan 196,100
05
75 24-Jul-2023 00-15-87-02 MREG/OP/2023072200 HENI OKTAVIANI BPJS Kesehatan 150,900
32
76 24-Jul-2023 00-26-38-64 MREG/OP/2023072100 UJANG AHMAD DARUSSALAM BPJS Kesehatan 201,000
20
77 25-Jul-2023 00-26-38-45 MREG/OP/2023072400 JOHARI BPJS Kesehatan 196,100
11

Copyright © 2023 PT. QPRO Sukses Mandiri | Printed Date: 23-Aug-2023 14:39 | Printed By: Tsaabit Ahnaf
 RS. MANDAYA Outstanding Corporate AR
Jl. Arteri Tol Karawang Barat, Teluk Jambe
Suka Makmur, Jawa Barat Accrual
Karawang Indonesia M01.03.934
Telephone : (0267) 8643000 Site RS. MANDAYA
Fax : (0267) 8643003, (0267) 414306 Doc. No Rev
Date Page 9 of 16

78 25-Jul-2023 00-26-34-22 MREG/OP/2023072400 HARIATI KURNIADI BPJS Kesehatan 196,100

19
79 26-Jul-2023 00-26-40-57 MREG/OP/2023072401 HERI SISWOYO BPJS Kesehatan 196,100
03
80 27-Jul-2023 00-26-24-79 MREG/OP/2023072600 SAENI NIRWANTI BPJS Kesehatan 201,000
38
81 27-Jul-2023 00-17-70-77 MREG/OP/2023072600 YULIANA,NY BPJS Kesehatan 196,100
05
82 29-Jul-2023 00-26-28-15 MREG/OP/2023072701 DONY RICHARD BPJS Kesehatan 196,100
00
83 29-Jul-2023 00-26-32-11 MREG/OP/2023072800 NAFISATUZ ZAHRO BPJS Kesehatan 196,100
04
84 31-Jul-2023 00-26-38-64 MREG/OP/2023072800 UJANG AHMAD DARUSSALAM BPJS Kesehatan 201,000
16
85 31-Jul-2023 00-15-87-02 MREG/OP/2023072900 HENI OKTAVIANI BPJS Kesehatan 196,100
55
86 01-Aug- 00-26-34-22 MREG/OP/2023073100 HARIATI KURNIADI BPJS Kesehatan 196,100
2023 18
87 02-Aug- 00-26-40-57 MREG/OP/2023073101 HERI SISWOYO BPJS Kesehatan 196,100
2023 00
88 03-Aug- 00-26-42-67 MREG/OP/2023080200 SYIFA KHOERUNISA BPJS Kesehatan 196,100
2023 01
89 03-Aug- 00-12-75-01 MREG/OP/2023080200 IIS YUNITAWATI BPJS Kesehatan 196,100
2023 03
90 03-Aug- 00-14-91-40 MREG/OP/2023080200 SIRNAYANTI, NY. BPJS Kesehatan 254,300
2023 13
91 03-Aug- 00-26-40-97 MREG/OP/2023080100 MUHAMAD NUR BPJS Kesehatan 578,700
2023 69
92 03-Aug- 00-12-53-86 MREG/OP/2023080100 STEPHANIE LYDIA SENA BPJS Kesehatan 134,300
2023 28
93 03-Aug- 00-04-66-28 MREG/OP/2023080100 TITIK HANDAYANI BPJS Kesehatan 134,300
2023 30
94 03-Aug- 00-26-33-67 MREG/OP/2023080100 NUR AHMAD ZAELANI BPJS Kesehatan 134,300
2023 32
95 03-Aug- 00-26-23-51 MREG/OP/2023080100 SARWENDAH BPJS Kesehatan 134,300
2023 39
96 03-Aug- 00-15-28-91 MREG/OP/2023080100 BENNY BUDIMAN TN BPJS Kesehatan 134,300
2023 44
97 03-Aug- 00-16-25-49 MREG/OP/2023080100 JONRY HIBSON SIMATUPANG BPJS Kesehatan 134,300
2023 50
98 03-Aug- 00-26-33-69 MREG/OP/2023080100 YUNARTI BPJS Kesehatan 196,100
2023 89
99 03-Aug- 00-06-65-07 MREG/OP/2023080100 H. UJANG JUHADIRTA.SPD BPJS Kesehatan 169,100
2023 91
100 03-Aug- 00-26-39-87 MREG/OP/2023080100 RAZETA BENING BPJS Kesehatan 196,100
2023 79 ALFATHUNNISA
101 03-Aug- 00-26-37-65 MREG/OP/2023080100 TATI HARYATI BPJS Kesehatan 196,100
2023 85
102 03-Aug- 00-25-13-57 MREG/OP/2023080100 TASYA AZZAHRO AERIL BPJS Kesehatan 134,300
2023 86
103 03-Aug- 00-13-36-96 MREG/OP/2023080200 DEVI YULIUS ARMAN BPJS Kesehatan 196,100
2023 02
104 03-Aug- 00-21-99-37 MREG/OP/2023080200 AKHMAD JAMA AH FIRDAUS BPJS Kesehatan 134,300
2023 77
105 03-Aug- 00-25-80-68 MREG/OP/2023080200 NIA SEFTI MUHROM BPJS Kesehatan 196,100
2023 19
106 03-Aug- 00-26-26-92 MREG/OP/2023080200 RINAWATI BPJS Kesehatan 134,300
2023 42

Copyright © 2023 PT. QPRO Sukses Mandiri | Printed Date: 23-Aug-2023 14:39 | Printed By: Tsaabit Ahnaf
 RS. MANDAYA Outstanding Corporate AR
Jl. Arteri Tol Karawang Barat, Teluk Jambe
Suka Makmur, Jawa Barat Accrual
Karawang Indonesia M01.03.934
Telephone : (0267) 8643000 Site RS. MANDAYA
Fax : (0267) 8643003, (0267) 414306 Doc. No Rev
Date Page 10 of 1

107 03-Aug- 00-00-16-60 MREG/OP/2023080200 MATTHEW CHRISTIAN BPJS Kesehatan 134,300

2023 43 DARMAWAN
108 03-Aug- 00-26-35-23 MREG/OP/2023080200 HAYU WIDORETNO, S.PD BPJS Kesehatan 198,700
2023 54
109 03-Aug- 00-26-50-44 MREG/OP/2023080200 ARRAHMAN FIRDAUS BPJS Kesehatan 196,100
2023 56
110 03-Aug- 00-13-35-92 MREG/OP/2023080200 ZIPORA MARBUN BPJS Kesehatan 263,600
2023 57
111 03-Aug- 00-26-50-40 MREG/OP/2023080200 ANGELY PUTRI WIBOWO BPJS Kesehatan 201,000
2023 29
112 03-Aug- 00-26-50-50 MREG/OP/2023080200 ROMIYANI BPJS Kesehatan 198,700
2023 83
113 03-Aug- 00-11-86-68 MREG/OP/2023080200 RATNA DEWI BPJS Kesehatan 196,100
2023 85
114 03-Aug- 00-21-91-11 MREG/OP/2023080200 DAMAH BPJS Kesehatan 134,300
2023 90
115 03-Aug- 00-07-95-60 MREG/OP/2023080200 AJENG LILI DHAMITA BPJS Kesehatan 134,300
2023 94
116 03-Aug- 00-26-50-54 MREG/OP/2023080200 AINUN NAIM BPJS Kesehatan 196,100
2023 99
117 03-Aug- 00-19-74-67 MREG/OP/2023080200 ANGEL NATALIA BPJS Kesehatan 198,700
2023 65
118 03-Aug- 00-15-53-14 MREG/OP/2023080200 VALLERIE DANIEL BPJS Kesehatan 198,700
2023 66
119 03-Aug- 00-26-45-60 MREG/OP/2023080201 AHMAD FARHAN BPJS Kesehatan 254,300
2023 05
120 04-Aug- 00-16-27-53 MREG/OP/2023080300 HERWANTO ,TN BPJS Kesehatan 134,300
2023 10
121 04-Aug- 00-16-25-49 MREG/OP/2023080300 JONRY HIBSON SIMATUPANG BPJS Kesehatan 134,300
2023 38
122 04-Aug- 00-21-40-46 MREG/OP/2023080300 ANISVA INDIRA BPJS Kesehatan 201,000
2023 22
123 04-Aug- 00-26-37-94 MREG/OP/2023080300 SYAPRI S BPJS Kesehatan 134,300
2023 87
124 04-Aug- 00-03-32-58 MREG/OP/2023080301 UMI KULSUM BPJS Kesehatan 323,800
2023 01
125 10-Aug- 00-12-50-35 MREG/OP/2023080400 RETNO WAHYU A NY. BPJS Kesehatan 474,300
2023 71
126 10-Aug- 00-00-35-23 MREG/OP/2023080400 NINA JUWITA BPJS Kesehatan 196,100
2023 29
127 10-Aug- 00-26-38-89 MREG/OP/2023080400 ENDAS BPJS Kesehatan 134,300
2023 62
128 10-Aug- 00-04-66-28 MREG/OP/2023080400 TITIK HANDAYANI BPJS Kesehatan 134,300
2023 27
129 10-Aug- 00-26-36-37 MREG/OP/2023080400 BUDI HERMANTO BPJS Kesehatan 196,100
2023 26
130 10-Aug- 00-26-33-67 MREG/OP/2023080400 NUR AHMAD ZAELANI BPJS Kesehatan 134,300
2023 25
131 10-Aug- 00-10-01-87 MREG/OP/2023080400 AGUS SOPIYAN BPJS Kesehatan 196,100
2023 02
132 10-Aug- 00-26-49-74 MREG/OP/2023080400 SARWI BPJS Kesehatan 254,300
2023 16
133 10-Aug- 00-26-30-38 MREG/OP/2023080400 BAYI NYONYA HANA SHOFARIA BPJS Kesehatan 338,300
2023 78
134 10-Aug- 00-18-01-05 MREG/OP/2023080400 ATIH, NY BPJS Kesehatan 150,900
2023 80
135 10-Aug- 00-26-39-84 MREG/OP/2023080400 BY NY AJENG SUKESI BPJS Kesehatan 196,100
2023 89

Copyright © 2023 PT. QPRO Sukses Mandiri | Printed Date: 23-Aug-2023 14:39 | Printed By: Tsaabit Ahnaf
 RS. MANDAYA Outstanding Corporate AR
Jl. Arteri Tol Karawang Barat, Teluk Jambe
Suka Makmur, Jawa Barat Accrual
Karawang Indonesia M01.03.934
Telephone : (0267) 8643000 Site RS. MANDAYA
Fax : (0267) 8643003, (0267) 414306 Doc. No Rev
Date Page 11 of 1

136 10-Aug- 00-03-77-45 MREG/OP/2023080400 LUSSI LISMAWATI BPJS Kesehatan 323,800

2023 46
137 10-Aug- 00-26-42-34 MREG/OP/2023080400 MUHAMMAD RAIHAN AL BPJS Kesehatan 196,100
2023 47 MUMTADZ
138 10-Aug- 00-26-41-75 MREG/OP/2023080500 CUCUN GUNARSIH BPJS Kesehatan 254,300
2023 54
139 10-Aug- 00-12-53-86 MREG/OP/2023080500 STEPHANIE LYDIA SENA BPJS Kesehatan 134,300
2023 28
140 10-Aug- 00-08-90-18 MREG/OP/2023080500 ENTIN SUPRIATIN BPJS Kesehatan 196,100
2023 13
141 10-Aug- 00-05-72-35 MREG/OP/2023080500 RATNA CHRISTINA BPJS Kesehatan 578,700
2023 16
142 10-Aug- 00-25-83-29 MREG/OP/2023080500 YOSEFA BPJS Kesehatan 277,700
2023 32
143 10-Aug- 00-26-30-31 MREG/OP/2023080500 OMSIH BPJS Kesehatan 196,100
2023 37
144 10-Aug- 00-16-94-97 MREG/OP/2023080500 INAWATI BPJS Kesehatan 578,700
2023 02
145 10-Aug- 00-26-35-55 MREG/OP/2023080500 MIRAH BPJS Kesehatan 196,100
2023 06
146 10-Aug- 00-26-23-51 MREG/OP/2023080500 SARWENDAH BPJS Kesehatan 134,300
2023 39
147 10-Aug- 00-07-95-60 MREG/OP/2023080500 AJENG LILI DHAMITA BPJS Kesehatan 134,300
2023 40
148 10-Aug- 00-26-26-92 MREG/OP/2023080500 RINAWATI BPJS Kesehatan 134,300
2023 43
149 10-Aug- 00-15-87-02 MREG/OP/2023080500 HENI OKTAVIANI BPJS Kesehatan 196,100
2023 47
150 12-Aug- 00-14-47-87 MREG/OP/2023081001 WATI BPJS Kesehatan 608,834
2023 16
151 12-Aug- 00-16-25-49 MREG/OP/2023081000 JONRY HIBSON SIMATUPANG BPJS Kesehatan 232,000
2023 36
152 12-Aug- 00-26-33-67 MREG/OP/2023081000 NUR AHMAD ZAELANI BPJS Kesehatan 232,000
2023 40
153 12-Aug- 00-16-25-96 MREG/OP/2023081000 DEDE ANITA, NY BPJS Kesehatan 403,400
2023 42
154 12-Aug- 00-06-65-07 MREG/OP/2023081000 H. UJANG JUHADIRTA.SPD BPJS Kesehatan 237,500
2023 93
155 12-Aug- 00-26-38-89 MREG/OP/2023081000 ENDAS BPJS Kesehatan 232,000
2023 45
156 12-Aug- 00-15-62-72 MREG/OP/2023081001 KUSNANTO, TN BPJS Kesehatan 255,480
2023 20
157 16-Aug- 00-15-53-36 MREG/OP/2023080501 AZIZAH SUKMIATI SASMITA BPJS Kesehatan 198,700
2023 05
158 16-Aug- 00-26-20-32 MREG/OP/2023080500 AMELIA AYUMI PUTRI BPJS Kesehatan 198,700
2023 99
159 16-Aug- 00-26-20-40 MREG/OP/2023080501 ETIN SUPRIHATIN BPJS Kesehatan 196,100
2023 02
160 16-Aug- 00-07-58-95 MREG/OP/2023080501 ATTILA NARENDRA PUTRA BPJS Kesehatan 201,000
2023 13
161 16-Aug- 00-26-33-67 MREG/OP/2023080701 NUR AHMAD ZAELANI BPJS Kesehatan 134,300
2023 18
162 16-Aug- 00-26-37-81 MREG/OP/2023080700 DJOHAN TAN BPJS Kesehatan 196,100
2023 08
163 16-Aug- 00-00-86-74 MREG/OP/2023080700 ETI SUGIHARTI BPJS Kesehatan 196,100
2023 37
164 16-Aug- 00-13-20-00 MREG/OP/2023080701 YOHANES IRPAN BPJS Kesehatan 196,100
2023 32

Copyright © 2023 PT. QPRO Sukses Mandiri | Printed Date: 23-Aug-2023 14:39 | Printed By: Tsaabit Ahnaf
 RS. MANDAYA Outstanding Corporate AR
Jl. Arteri Tol Karawang Barat, Teluk Jambe
Suka Makmur, Jawa Barat Accrual
Karawang Indonesia M01.03.934
Telephone : (0267) 8643000 Site RS. MANDAYA
Fax : (0267) 8643003, (0267) 414306 Doc. No Rev
Date Page 12 of 1

165 16-Aug- 00-16-25-49 MREG/OP/2023080701 JONRY HIBSON SIMATUPANG BPJS Kesehatan 134,300
2023 31
166 16-Aug- 00-16-27-53 MREG/OP/2023080700 HERWANTO ,TN BPJS Kesehatan 134,300
2023 31
167 16-Aug- 00-26-49-58 MREG/OP/2023080700 JAJA DJAENUDIN BPJS Kesehatan 196,100
2023 13
168 16-Aug- 00-26-49-01 MREG/OP/2023080700 ELLEN BPJS Kesehatan 196,100
2023 02
169 16-Aug- 00-26-42-84 MREG/OP/2023080700 DADANG BPJS Kesehatan 196,100
2023 21
170 16-Aug- 00-26-51-67 MREG/OP/2023080700 FATHAAN ATHARRAZKA BPJS Kesehatan 150,900
2023 17 MALIQUE
171 16-Aug- 00-26-51-91 MREG/OP/2023080701 IWAN BPJS Kesehatan 196,100
2023 00
172 16-Aug- 00-25-13-57 MREG/OP/2023080701 TASYA AZZAHRO AERIL BPJS Kesehatan 134,300
2023 29
173 16-Aug- 00-26-27-51 MREG/OP/2023080500 AHMAD JUNAEDI HARYONO BPJS Kesehatan 245,600
2023 96
174 16-Aug- 00-26-29-01 MREG/OP/2023080700 HATI BPJS Kesehatan 196,100
2023 19
175 16-Aug- 00-26-38-89 MREG/OP/2023080800 ENDAS BPJS Kesehatan 134,300
2023 55
176 16-Aug- 00-26-40-57 MREG/OP/2023080800 HERI SISWOYO BPJS Kesehatan 134,300
2023 06
177 16-Aug- 00-26-52-18 MREG/OP/2023080800 FAZRIANSYAH BPJS Kesehatan 196,100
2023 25
178 16-Aug- 00-26-52-20 MREG/OP/2023080800 TONO HANDY BPJS Kesehatan 254,300
2023 33
179 16-Aug- 00-26-52-27 MREG/OP/2023080800 TARSINAH BPJS Kesehatan 198,700
2023 83
180 16-Aug- 00-12-53-86 MREG/OP/2023080800 STEPHANIE LYDIA SENA BPJS Kesehatan 134,300
2023 26
181 16-Aug- 00-15-28-91 MREG/OP/2023080800 BENNY BUDIMAN TN BPJS Kesehatan 134,300
2023 43
182 16-Aug- 00-06-65-07 MREG/OP/2023080800 H. UJANG JUHADIRTA.SPD BPJS Kesehatan 134,300
2023 11
183 16-Aug- 00-26-52-44 MREG/OP/2023080900 AMINAH BPJS Kesehatan 196,100
2023 53
184 16-Aug- 00-26-26-92 MREG/OP/2023080900 RINAWATI BPJS Kesehatan 134,300
2023 32
185 16-Aug- 00-09-03-21 MREG/OP/2023080900 DEDEH KURNIA NINGSIH BPJS Kesehatan 412,900
2023 37
186 16-Aug- 00-04-66-28 MREG/OP/2023080701 TITIK HANDAYANI BPJS Kesehatan 134,300
2023 13
187 16-Aug- 00-00-16-60 MREG/OP/2023080900 MATTHEW CHRISTIAN BPJS Kesehatan 134,300
2023 36 DARMAWAN
188 16-Aug- 00-18-00-35 MREG/OP/2023080900 LIM LI HA BPJS Kesehatan 196,100
2023 01
189 16-Aug- 00-19-53-49 MREG/OP/2023080900 ARZACHEL ATHARIZ CALIEF. BPJS Kesehatan 198,700
2023 38 AN
190 16-Aug- 00-07-95-60 MREG/OP/2023080900 AJENG LILI DHAMITA BPJS Kesehatan 134,300
2023 41
191 16-Aug- 00-11-86-68 MREG/OP/2023080900 RATNA DEWI BPJS Kesehatan 196,100
2023 76
192 16-Aug- 00-26-23-51 MREG/OP/2023080900 SARWENDAH BPJS Kesehatan 134,300
2023 72
193 16-Aug- 00-26-37-94 MREG/OP/2023080900 SYAPRI S BPJS Kesehatan 134,300
2023 69

Copyright © 2023 PT. QPRO Sukses Mandiri | Printed Date: 23-Aug-2023 14:39 | Printed By: Tsaabit Ahnaf
 RS. MANDAYA Outstanding Corporate AR
Jl. Arteri Tol Karawang Barat, Teluk Jambe
Suka Makmur, Jawa Barat Accrual
Karawang Indonesia M01.03.934
Telephone : (0267) 8643000 Site RS. MANDAYA
Fax : (0267) 8643003, (0267) 414306 Doc. No Rev
Date Page 13 of 1

194 16-Aug- 00-26-37-94 MREG/OP/2023080701 SYAPRI S BPJS Kesehatan 150,900

2023 07
195 16-Aug- 00-21-91-11 MREG/OP/2023080900 DAMAH BPJS Kesehatan 134,300
2023 84
196 21-Aug- 00-26-36-81 MREG/OP/2023080901 DIAN WATY BPJS Kesehatan 201,000
2023 04
197 21-Aug- 00-16-27-53 MREG/OP/2023081000 HERWANTO ,TN BPJS Kesehatan 134,300
2023 25
198 21-Aug- 00-26-40-57 MREG/OP/2023081000 HERI SISWOYO BPJS Kesehatan 134,300
2023 09
199 21-Aug- 00-04-66-28 MREG/OP/2023081100 TITIK HANDAYANI BPJS Kesehatan 134,300
2023 17
200 21-Aug- 00-15-28-91 MREG/OP/2023081100 BENNY BUDIMAN TN BPJS Kesehatan 134,300
2023 36
201 21-Aug- 00-16-42-21 MREG/OP/2023081100 H. HENDRIK SANUSI BPJS Kesehatan 198,700
2023 26
202 21-Aug- 00-26-33-69 MREG/OP/2023081100 YUNARTI BPJS Kesehatan 201,000
2023 04
203 21-Aug- 00-26-32-21 MREG/OP/2023081100 TETI WILLIYANTI BPJS Kesehatan 196,100
2023 05
204 21-Aug- 00-26-50-50 MREG/OP/2023081100 ROMIYANI BPJS Kesehatan 150,900
2023 60
205 21-Aug- 00-26-52-97 MREG/OP/2023081100 SADI BPJS Kesehatan 164,100
2023 14
206 21-Aug- 00-26-30-38 MREG/OP/2023081100 BAYI NYONYA HANA SHOFARIA BPJS Kesehatan 338,300
2023 72
207 21-Aug- 00-25-13-57 MREG/OP/2023081100 TASYA AZZAHRO AERIL BPJS Kesehatan 134,300
2023 62
208 21-Aug- 00-26-51-12 MREG/OP/2023081100 TEGAR SETIAWAN BPJS Kesehatan 201,000
2023 79
209 21-Aug- 00-06-65-07 MREG/OP/2023081200 H. UJANG JUHADIRTA.SPD BPJS Kesehatan 245,600
2023 95
210 21-Aug- 00-26-49-22 MREG/OP/2023081200 INTAN KHUDAEPI BPJS Kesehatan 198,700
2023 96
211 21-Aug- 00-26-20-40 MREG/OP/2023081200 ETIN SUPRIHATIN BPJS Kesehatan 245,600
2023 41
212 21-Aug- 00-21-91-11 MREG/OP/2023081201 DAMAH BPJS Kesehatan 134,300
2023 00
213 21-Aug- 00-12-53-86 MREG/OP/2023081200 STEPHANIE LYDIA SENA BPJS Kesehatan 134,300
2023 31
214 21-Aug- 00-26-26-92 MREG/OP/2023081200 RINAWATI BPJS Kesehatan 134,300
2023 46
215 21-Aug- 00-15-59-43 MREG/OP/2023081200 AMUK BPJS Kesehatan 198,700
2023 51
216 21-Aug- 00-00-16-60 MREG/OP/2023081200 MATTHEW CHRISTIAN BPJS Kesehatan 134,300
2023 52 DARMAWAN
217 21-Aug- 00-09-33-83 MREG/OP/2023081200 LIA TAMALA BPJS Kesehatan 245,600
2023 53
218 21-Aug- 00-26-53-25 MREG/OP/2023081201 ERMYE AMOLO BPJS Kesehatan 196,100
2023 08
219 22-Aug- 00-26-38-89 MREG/OP/2023081400 ENDAS BPJS Kesehatan 134,300
2023 91
220 22-Aug- 00-16-27-36 MREG/OP/2023081400 LANI HERAWATI AKHYAR BPJS Kesehatan 323,800
2023 94
221 22-Aug- 00-26-53-63 MREG/OP/2023081401 YUNI WIJAYANTI, SH BPJS Kesehatan 578,700
2023 00
222 22-Aug- 00-26-29-01 MREG/OP/2023081400 HATI BPJS Kesehatan 196,100
2023 13

Copyright © 2023 PT. QPRO Sukses Mandiri | Printed Date: 23-Aug-2023 14:39 | Printed By: Tsaabit Ahnaf
 RS. MANDAYA Outstanding Corporate AR
Jl. Arteri Tol Karawang Barat, Teluk Jambe
Suka Makmur, Jawa Barat Accrual
Karawang Indonesia M01.03.934
Telephone : (0267) 8643000 Site RS. MANDAYA
Fax : (0267) 8643003, (0267) 414306 Doc. No Rev
Date Page 14 of 1

223 22-Aug- 00-26-50-89 MREG/OP/2023081400 NURCAHYA BPJS Kesehatan 196,100

2023 14
224 22-Aug- 00-15-28-91 MREG/OP/2023081401 BENNY BUDIMAN TN BPJS Kesehatan 134,300
2023 08
225 22-Aug- 00-26-37-94 MREG/OP/2023081401 SYAPRI S BPJS Kesehatan 134,300
2023 12
226 22-Aug- 00-26-53-70 MREG/OP/2023081401 CUCU SALAMAH BPJS Kesehatan 196,100
2023 13
227 22-Aug- 00-15-32-71 MREG/OP/2023081400 UCU NURJANAH, NY BPJS Kesehatan 323,800
2023 45
228 22-Aug- 00-26-50-32 MREG/OP/2023081401 ASTIN BPJS Kesehatan 196,100
2023 18
229 22-Aug- 00-15-87-02 MREG/OP/2023081401 HENI OKTAVIANI BPJS Kesehatan 134,300
2023 20
230 22-Aug- 00-26-50-50 MREG/OP/2023081401 ROMIYANI BPJS Kesehatan 134,300
2023 37
231 22-Aug- 00-09-37-13 MREG/OP/2023081401 BRAM ARI PURWANTO BPJS Kesehatan 150,900
2023 43
232 22-Aug- 00-26-53-74 MREG/OP/2023081401 YULIA DEFRIANTI BPJS Kesehatan 196,100
2023 48
233 22-Aug- 00-26-52-05 MREG/OP/2023081401 DIAN SRIHARTATI BPJS Kesehatan 201,000
2023 60 SIMANJORANG
234 22-Aug- 00-26-33-67 MREG/OP/2023081400 NUR AHMAD ZAELANI BPJS Kesehatan 134,300
2023 52
235 22-Aug- 00-26-53-50 MREG/OP/2023081400 DESTIN KURNIAWATI BPJS Kesehatan 254,300
2023 05
236 22-Aug- 00-25-46-24 MREG/OP/2023081400 DIDI KUSNADI BPJS Kesehatan 196,100
2023 07
237 22-Aug- 00-26-49-58 MREG/OP/2023081400 JAJA DJAENUDIN BPJS Kesehatan 196,100
2023 09
238 22-Aug- 00-04-66-28 MREG/OP/2023081400 TITIK HANDAYANI BPJS Kesehatan 134,300
2023 39
239 22-Aug- 00-00-35-23 MREG/OP/2023081400 NINA JUWITA BPJS Kesehatan 196,100
2023 27
240 22-Aug- 00-26-50-48 MREG/OP/2023081400 MARWAN SETIAWAN BPJS Kesehatan 196,100
2023 02
241 22-Aug- 00-15-62-20 MREG/OP/2023081501 ALDEBARAN FAUZI, AN BPJS Kesehatan 201,000
2023 13
242 22-Aug- 00-26-52-20 MREG/OP/2023081501 TONO HANDY BPJS Kesehatan 196,100
2023 20
243 22-Aug- 00-25-13-57 MREG/OP/2023081500 TASYA AZZAHRO AERIL BPJS Kesehatan 134,300
2023 48
244 22-Aug- 00-15-64-50 MREG/OP/2023081500 UDAYATI BPJS Kesehatan 196,100
2023 78
245 22-Aug- 00-16-25-49 MREG/OP/2023081500 JONRY HIBSON SIMATUPANG BPJS Kesehatan 134,300
2023 40
246 22-Aug- 00-26-40-57 MREG/OP/2023081500 HERI SISWOYO BPJS Kesehatan 134,300
2023 05
247 22-Aug- 00-26-49-55 MREG/OP/2023081500 BY NY SITI NURLAELASARI BPJS Kesehatan 150,900
2023 96
248 22-Aug- 00-26-51-91 MREG/OP/2023081500 IWAN BPJS Kesehatan 196,100
2023 87
249 22-Aug- 00-26-54-07 MREG/OP/2023081500 NURDIN JUNAEDI BPJS Kesehatan 196,100
2023 50
250 22-Aug- 00-09-92-78 MREG/OP/2023081501 RAYYANDA MAIRA SALEH BPJS Kesehatan 196,100
2023 14
251 22-Aug- 00-26-50-54 MREG/OP/2023081501 AINUN NAIM BPJS Kesehatan 201,000
2023 15

Copyright © 2023 PT. QPRO Sukses Mandiri | Printed Date: 23-Aug-2023 14:39 | Printed By: Tsaabit Ahnaf
 RS. MANDAYA Outstanding Corporate AR
Jl. Arteri Tol Karawang Barat, Teluk Jambe
Suka Makmur, Jawa Barat Accrual
Karawang Indonesia M01.03.934
Telephone : (0267) 8643000 Site RS. MANDAYA
Fax : (0267) 8643003, (0267) 414306 Doc. No Rev
Date Page 15 of 1

252 22-Aug- 00-26-51-85 MREG/OP/2023081501 ANGLINA ESTHER CAROLINE BPJS Kesehatan 201,000
2023 32
253 22-Aug- 00-12-53-86 MREG/OP/2023081500 STEPHANIE LYDIA SENA BPJS Kesehatan 134,300
2023 19
254 22-Aug- 00-01-20-33 MREG/OP/2023081600 HERLITA SARI, NY BPJS Kesehatan 323,800
2023 01
255 22-Aug- 00-26-33-67 MREG/OP/2023081600 NUR AHMAD ZAELANI BPJS Kesehatan 134,300
2023 25
256 22-Aug- 00-15-03-31 MREG/OP/2023081600 TRI LISTYOWATI BPJS Kesehatan 196,100
2023 36
257 22-Aug- 00-26-38-46 MREG/OP/2023081600 INDRA SAPUTRA BPJS Kesehatan 196,100
2023 43
258 22-Aug- 00-26-26-92 MREG/OP/2023081600 RINAWATI BPJS Kesehatan 134,300
2023 45
259 22-Aug- 00-00-16-60 MREG/OP/2023081600 MATTHEW CHRISTIAN BPJS Kesehatan 134,300
2023 46 DARMAWAN
260 22-Aug- 00-21-91-11 MREG/OP/2023081600 DAMAH BPJS Kesehatan 134,300
2023 95
261 22-Aug- 00-26-38-89 MREG/OP/2023081601 ENDAS BPJS Kesehatan 134,300
2023 08
262 22-Aug- 00-26-37-94 MREG/OP/2023081600 SYAPRI S BPJS Kesehatan 134,300
2023 88
263 22-Aug- 00-26-50-40 MREG/OP/2023081600 ANGELY PUTRI WIBOWO BPJS Kesehatan 201,000
2023 93
264 22-Aug- 00-11-50-13 MREG/OP/2023081600 WINDHA LORENT BPJS Kesehatan 218,300
2023 04
265 22-Aug- 00-26-51-64 MREG/OP/2023081600 MUHAMAD SARIP BPJS Kesehatan 196,100
2023 06
266 22-Aug- 00-26-54-43 MREG/OP/2023081600 YULI YULIANI BPJS Kesehatan 323,800
2023 77
267 22-Aug- 00-26-36-81 MREG/OP/2023081601 DIAN WATY BPJS Kesehatan 201,000
2023 16
268 23-Aug- 00-08-03-47 MREG/OP/2023081800 IIN MULYATI BPJS Kesehatan 196,100
2023 07
269 23-Aug- 00-14-91-40 MREG/OP/2023081800 SIRNAYANTI, NY. BPJS Kesehatan 196,100
2023 12
270 23-Aug- 00-15-87-02 MREG/OP/2023081800 HENI OKTAVIANI BPJS Kesehatan 134,300
2023 48
271 23-Aug- 00-26-52-18 MREG/OP/2023081800 FAZRIANSYAH BPJS Kesehatan 201,000
2023 27
272 23-Aug- 00-25-14-16 MREG/OP/2023081800 RODRIGO NAPOLEON M LONDA BPJS Kesehatan 196,100
2023 93
273 23-Aug- 00-11-72-51 MREG/OP/2023081800 MAMUN NAWAWI, TN BPJS Kesehatan 196,100
2023 95
274 23-Aug- 00-04-66-28 MREG/OP/2023081800 TITIK HANDAYANI BPJS Kesehatan 134,300
2023 37
275 23-Aug- 00-26-51-12 MREG/OP/2023081801 TEGAR SETIAWAN BPJS Kesehatan 201,000
2023 01
276 23-Aug- 00-26-50-50 MREG/OP/2023081800 ROMIYANI BPJS Kesehatan 134,300
2023 73
277 23-Aug- 00-15-28-91 MREG/OP/2023081800 BENNY BUDIMAN TN BPJS Kesehatan 169,100
2023 78
278 23-Aug- 00-21-99-37 MREG/OP/2023081800 AKHMAD JAMA AH FIRDAUS BPJS Kesehatan 134,300
2023 79
279 23-Aug- 00-26-54-90 MREG/OP/2023081800 PAMELA OCTAVIA BPJS Kesehatan 323,800
2023 88
280 23-Aug- 00-26-40-57 MREG/OP/2023081900 HERI SISWOYO BPJS Kesehatan 134,300
2023 09

Copyright © 2023 PT. QPRO Sukses Mandiri | Printed Date: 23-Aug-2023 14:39 | Printed By: Tsaabit Ahnaf
 RS. MANDAYA Outstanding Corporate AR
Jl. Arteri Tol Karawang Barat, Teluk Jambe
Suka Makmur, Jawa Barat Accrual
Karawang Indonesia M01.03.934
Telephone : (0267) 8643000 Site RS. MANDAYA
Fax : (0267) 8643003, (0267) 414306 Doc. No Rev
Date Page 16 of 1

281 23-Aug- 00-26-55-03 MREG/OP/2023081900 TAUPIK, SAG BPJS Kesehatan 254,300

2023 13
282 23-Aug- 00-26-51-44 MREG/OP/2023081900 H. NUNUNG SUMARSANA, BPJS Kesehatan 196,100
2023 28 DRS,MM
283 23-Aug- 00-26-18-68 MREG/OP/2023081900 WAKIAH BPJS Kesehatan 277,700
2023 19
284 23-Aug- 00-21-91-11 MREG/OP/2023081900 DAMAH BPJS Kesehatan 134,300
2023 86
285 23-Aug- 00-17-05-44 MREG/OP/2023081900 SILVIANA PUTRI RAMADHANI BPJS Kesehatan 196,100
2023 88
286 23-Aug- 00-26-53-25 MREG/OP/2023081900 ERMYE AMOLO BPJS Kesehatan 245,600
2023 90
287 23-Aug- 00-26-34-26 MREG/OP/2023081900 SUNENGSIH BPJS Kesehatan 196,100
2023 04
288 23-Aug- 00-07-95-60 MREG/OP/2023081900 AJENG LILI DHAMITA BPJS Kesehatan 134,300
2023 46

TOTAL 58,781,414

Walk In
No. Date MRN Registration No Patient Name Registration Payer Amount
1 29-Jul-2023 00-26-48-52 MREG/WI/2023072900 SOPYAN TSAORI BPJS Kesehatan 977,900
03

TOTAL 977,900
GRAND
TOTAL

Copyright © 2023 PT. QPRO Sukses Mandiri | Printed Date: 23-Aug-2023 14:39 | Printed By: Tsaabit Ahnaf