RUMAH SAKIT Dr.

OEN KANDANG SAPI SOLO

INVOICE
Jl. Brigjend Katamso No.55
(Summary)
Surakarta 57128

Phone : (0271)
Billing No : IPB/20210214/00074

643139

Fax : (0271)
642026

Yayasan Kesehatan Panti Kosala ( NPWP : )

Patient Name : HERU SUNARDI,IR. MM Medical No : 00-41-86-30

Date of Birth : 22-May-1964 Service Unit / Class : LT 7 UTARA | VIP

Registration No Room / Bed No
: IPR/20210211/00033 : LT7 UTARA VIP6 | 7U-VIP-766
Registration
: 11-Feb-2021 19:44 Corporate : (376*) AIA FINACIAL
Date
: dr. Isbianto Sutedjo, M.Sc.SpPD, FINASIM Discharge Date : 17-Feb-2021 19:02
Registered
: dr. Wangi Niko Yuandika Notes :-
Physician Referrer

Physician

TRANSACTION
Item Group Total Amount Personal Amount Corporate Amount

INPATIENT | LT 7 UTARA
KAMAR PERAWATAN 3,262,500.00 2,528,757.00 733,743.00

OBAT-OBATAN 3,196,814.47 0.00 3,196,814.47

APOTIK UTAMA 3,196,814.47 0.00 3,196,814.47

PEMERIKSAAN LABORATORIUM 1,177,000.00 0.00 1,177,000.00
dr. Catherine Halim,M.Sc., Sp.PK 725,000.00 0.00 725,000.00
ELECTRO CARDIOGRAFI 33,000.00 0.00 33,000.00
dr. Isbianto Sutedjo, M.Sc.SpPD, FINASIM 33,000.00 0.00 33,000.00
ULTRASONOGRAFI 726,000.00 0.00 726,000.00
dr. Hardyanto Eko Prahoro 726,000.00 0.00 726,000.00
PASANG INFUS 55,500.00 0.00 55,500.00

JASA KEPERAWATAN 600,000.00 0.00 600,000.00

PERALATAN DAN BAHAN MEDIS 194,480.00 0.00 194,480.00

LT 5 SELATAN 192,142.50 0.00 192,142.50

RADIOLOGI 2,337.50 0.00 2,337.50
KLINIK GIZI 128,000.00 0.00 128,000.00

ADMINISTRASI 420,000.00 0.00 420,000.00

BAHAN PENUNJANG - NON MEDIS 240,000.00 0.00 240,000.00

VISITE 450,000.00 0.00 450,000.00

dr. Isbianto Sutedjo, M.Sc.SpPD, FINASIM 450,000.00 0.00 450,000.00
JASA DOKTER 175,000.00 0.00 175,000.00
dr. Erlangga Eka Gautama, M.Kes, Sp.THT 175,000.00 0.00 175,000.00
KONSULTASI 187,500.00 0.00 187,500.00
dr. Anung Noto Nugroho, Sp.B KBD 187,500.00 0.00 187,500.00
Sub Total INPATIENT 10,845,794.47 2,528,757.00 8,317,037.47

MEDINFRAS - PM-00634 | INVOICE, Print Date/Time:18-Feb-2021/13:38:32, User Page 1 of

EMERGENCY | INSTALASI GAWAT DARURAT | EMR/20210211/00053

OBAT-OBATAN 29,480.34 0.00 29,480.34

INSTALASI GAWAT DARURAT 29,480.3 0.00 29,480.34

4
PEMERIKSAAN LABORATORIUM 335,000.00 0.00 335,000.00

RONTGEN 227,000.00 0.00 227,000.00

dr. Murti Wigati , Sp.Rad 227,000.00 0.00 227,000.00
LAIN-LAIN (OTHERS) 11,264.00 0.00 11,264.00

INSTALASI GAWAT DARURAT 11,264.0 0.00 11,264.00

0
PERALATAN DAN BAHAN MEDIS 219,490.25 0.00 219,490.25

INSTALASI GAWAT DARURAT 214,815.25 0.00 214,815.25

RADIOLOGI 4,675.00 0.00 4,675.00
IGD 282,000.00 0.00 282,000.00
dr. Fendy Suyanto 123,000.00 0.00 123,000.00
Sub Total EMERGENCY 1,104,234.59 0.00 1,104,234.59

MEDINFRAS - PM-00634 | INVOICE, Print Date/Time:18-Feb-2021/13:38:32, User Page 2 of

HERU SUNARDI,IR. MM | Male | 56 yr 8 mnth 20 day Registration IPR/20210211/00033 Medical 00-41-86-30
No No

TOTAL TRANSACTION 11,950,029.06 2,528,757.00 9,421,272.06

Cash : 14,000.00 Personal Corporate

Credit Card : 0.00 Total Transaction 2,528,757.00 9,421,272.06
Debit Card : 0.00 Total Admin 0.00 0.00
Transfer Bank : 0.00 Total Coverage 2,528,757.00 9,421,272.06
Voucher / PB : 0.00 Total Rounding 43.00 0.00
2,528,800.00 9,421,272.06
Down Payment : 0.00
Refund : 0.00 Grand Total Transaction 2,528,800.00 9,421,272.06
Account Receivable : 17,406,340.45 Total Payment 14,000.00 0.00
Balance Total 2,514,800.00 9,421,272.06

Payment
Deposit No / Payment No Payment Date Patient Name Refund
Amount
IPS/20210217/00041 | 17-Feb-2021 HERU SUNARDI,IR. 0.00 14,000.00

PELUNASAN IPY/20210217/00044 17-Feb-2021 0.00 17,406,340.45

MM HERU SUNARDI,IR.
| PIUTANG - INSTANSI
MM

KEMENTERIAN KESEHATAN 17,406,340.45

TOTAL PAYMENT RECEIVE 17,420,340.45

Surakarta, Thursday, 18 February 2021

13:38:32

YULIUS AGUS

MEDINFRAS - PM-00634 | INVOICE, Print Date/Time:18-Feb-2021/13:38:32, User Page 3 of