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    Formulir Pengajuan Klaim: BPJS Kesehatan Cab. CIMAHI

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    pkm cikalongwetan
    This document is a claim form from BPJS Kesehatan Cimahi for November 2017. It includes 19 individual claims totaling 475,000. Each claim is for 25,000 and is for promotional healthcare services provided by CIKALONG WETAN to patients between November 1-29, 2017.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Formulir Pengajuan Klaim: BPJS Kesehatan Cab. CIMAHI

    Uploaded by

    pkm cikalongwetan
    8 views2 pages
    This document is a claim form from BPJS Kesehatan Cimahi for November 2017. It includes 19 individual claims totaling 475,000. Each claim is for 25,000 and is for promotional healthcare services provided by CIKALONG WETAN to patients between November 1-29, 2017.

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    This document is a claim form from BPJS Kesehatan Cimahi for November 2017. It includes 19 individual claims totaling 475,000. Each claim is for 25,000 and is for promotional healthcare services provided by CIKALONG WETAN to patients between November 1-29, 2017.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    8 views2 pages

    Formulir Pengajuan Klaim: BPJS Kesehatan Cab. CIMAHI

    Uploaded by

    pkm cikalongwetan
    This document is a claim form from BPJS Kesehatan Cimahi for November 2017. It includes 19 individual claims totaling 475,000. Each claim is for 25,000 and is for promotional healthcare services provided by CIKALONG WETAN to patients between November 1-29, 2017.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    BPJS Kesehatan Cab.

    CIMAHI
    FORMULIR PENGAJUAN KLAIM

    Nomor FPK : L1711000005637


    Provider : CIKALONG WETAN
    Bulan Pelayanan : November, 2017
    Pelayanan : Promotif

    Total Data : 19

    Total Tagihan : 475,000

    NO TRANSAKSI TANGGAL NAMA PESERTA JENIS KLAIM Biaya


    10021701L1711196147 08/11/2017 MAESAROH IVA 25,000
    10021701L1711196148 04/11/2017 WARTIKA IVA 25,000
    10021701L1711196149 01/11/2017 jujan padliah IVA 25,000
    10021701L1711196150 20/11/2017 ARIYANTI IVA 25,000
    10021701L1711196151 22/11/2017 YOYOK SUMARTINI IVA 25,000
    10021701L1711196152 01/11/2017 SANTI DEWI RAHAYU IVA 25,000
    10021701L1711196153 22/11/2017 DEA MAWARNI IVA 25,000
    10021701L1711196154 22/11/2017 TITIM SOLIHATI FATIMA IVA 25,000
    10021701L1711196155 22/11/2017 SUMIYATI IVA 25,000
    10021701L1711196156 22/11/2017 SUSI SUSILAWATI IVA 25,000
    10021701L1711196158 27/11/2017 ARI SUWARI IVA 25,000
    10021701L1711196159 27/11/2017 NIA HANDAYANI IVA 25,000
    10021701L1711196160 27/11/2017 NADDIA OCTAVIANI IVA 25,000
    10021701L1711196161 29/11/2017 DESSY PUSVITASARI IVA 25,000
    10021701L1711196162 27/11/2017 AISAH IVA 25,000
    10021701L1711196163 22/11/2017 ENTIN KARTINI IVA 25,000
    10021701L1711196164 22/11/2017 AI KARWATI IVA 25,000
    10021701L1711196165 27/11/2017 NINING IVA 25,000
    10021701L1711196166 27/11/2017 RATNA SETIAWATI IVA 25,000
    Tanggal,
    Pengaju Klaim,

    05/06/2018 11.03.59

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