REKAP PENGAJUAN KLAIM RIT REKAP PENGAJUAN KLAIM RITP PUSKESMAS BANTUR

BULAN JANUARI 2023

RAWAT INAP
NO NAMA NO KARTU ALAMAT NO TLPN DIAGNOSA JUMLAH JUMLAH
TGL MASUK TGL KELUAR TARIF PAKET
HARI

1 AISYAH HUMAIROH 0003142984173 SRIGONCO 085748052287 DIARE 1/3/2023 1/6/2023 3 Rp 540,000 Rp 540,000
2 AINUR FIDHA RAHMADANI 0003142984184 SRIGONCO 085748052287 OF 1/3/2023 1/6/2023 3 Rp 540,000 Rp 540,000
3 IMAM AGUS FAIZAL 0000678746766 BANTUR 081233566788 THYPOID 1/2/2023 1/5/2023 3 Rp 540,000 Rp 540,000
4 ANDIKA AVIV 0002774550947 BANTUR 082230357563 OF 1/2/2023 1/5/2023 3 Rp 540,000 Rp 540,000
5 SYAFIATUN M. WALI 0000108770218 SRIGONCO 081233200737 DHF 1/3/2023 1/4/2023 1 Rp 180,000 Rp 180,000
6 SAID 0000679251262 SRIGONCO 085955251114 HT 1/4/2023 1/7/2023 3 Rp 540,000 Rp 540,000
7 YULIUS ADI 0000677412843 WONOREJO 085733490325 OF 1/3/2023 1/8/2023 5 Rp 900,000 Rp 900,000
8 MUSTAKIM 0000678481108 BANTUR 085716164116 ABDOMINAL PAIN 1/9/2023 1/11/2023 2 Rp 360,000 Rp 360,000
9 ANGGI JULIANA 0000678520855 SUMBEREJO 085730581874 OF 1/7/2023 1/11/2023 4 Rp 720,000 Rp 720,000
10 SALSABILA IRDINA 0002454178803 BANDUNGREJO 081217456046 OF 1/7/2023 1/10/2023 3 Rp 540,000 Rp 540,000
11 PIANI 0002876376835 BANTUR 085252525595 OF 1/7/2023 1/10/2023 3 Rp 540,000 Rp 540,000
12 SUYANTO 0002077261604 BANTUR 085889170119 K29 1/8/2023 1/11/2023 3 Rp 540,000 Rp 540,000
13 SUMIATI 0002004769574 REJOSARI 08214132471 OF 1/8/2023 1/12/2023 4 Rp 720,000 Rp 720,000
14 TRIMURNI 0003130891029 TUMPAKREJO 085100611878 VOMITING 1/5/2023 1/8/2023 3 Rp 540,000 Rp 540,000
15 AHMAD NUR FAIZIN 0000207961896 BANTUR 085706805181 DHF 1/11/2023 1/14/2023 3 Rp 540,000 Rp 540,000
16 ZAFLAN 0003131847268 BANTUR 081333768749 DIARE 1/12/2023 1/15/2023 3 Rp 540,000 Rp 540,000
17 MISELIN 0003137423859 BANDUNGREJO 082111982789 CHD 1/9/2023 1/10/2023 1 Rp 180,000 Rp 180,000
18 MATYADI 0000679496984 SRIGONCO ABDOMINAL PAIN 1/4/2023 1/7/2023 3 Rp 540,000 Rp 540,000
19 ANITASARI 0002134055327 PRINGGONDANI 085895432004 OF 1/12/2023 1/16/2023 4 Rp 720,000 Rp 720,000
20 FITRIATUL KHASANAH 0001314703427 BANTUR 082140791124 DHF 1/10/2023 1/12/2023 2 Rp 360,000 Rp 360,000
21 MAULIDI AHMAD SAMAKO 0000110226925 BANTUR 085210806119 OF 1/11/2023 1/14/2023 3 Rp 540,000 Rp 540,000
22 IIS ROHMAN SARIFATUL 0000679561738 SRIGONCO OF 1/10/2023 1/13/2023 3 Rp 540,000 Rp 540,000
23 AURA PUSPA DEWI 0000678251518 BANDUNGREJO R06 1/7/2023 1/8/2023 1 Rp 180,000 Rp 180,000
24 IDA ASTUTI 0001477444893 BANTUR 085815555491 ABDOMINAL PAIN 1/13/2023 1/16/2023 3 Rp 540,000 Rp 540,000
25 AULIZA FEBRINA 0001839014425 BANTUR 085231648893 THYPOID 1/18/2023 1/21/2023 3 Rp 540,000 Rp 540,000
26 HARTONO 0000100242009 SRIGONCO 085731651472 OF 1/17/2023 1/20/2023 3 Rp 540,000 Rp 540,000
27 PUDYANING TRIFENA 0002730018622 WONOREJO 085806446199 R06 1/16/2023 1/20/2023 4 Rp 720,000 Rp 720,000
28 SRI MULYANI 0000678296564 TUMPAKREJO DIARE 1/15/2023 1/19/2023 4 Rp 720,000 Rp 720,000
29 ACHMAD DZAWIN 0003067488617 BANTUR OF 1/16/2023 1/19/2023 3 Rp 540,000 Rp 540,000
30 FIKRY HUSNI 0001834220316 BANTUR 081231656313 OF 1/16/2023 1/19/2023 3 Rp 540,000 Rp 540,000
31 ARIF PRASETYO 0003149801291 BANTUR 081333478046 THYPOID 1/20/2023 1/23/2023 3 Rp 540,000 Rp 540,000
32 MESTI 0002004767493 BANTUR 082245653914 HT 1/16/2023 1/19/2023 3 Rp 540,000 Rp 540,000
33 SATIRA 0003005459482 PRINGGONDANI 081289524917 DIARE 1/16/2023 1/19/2023 3 Rp 540,000 Rp 540,000
34 WINDI RINDAWATI 0002609131184 SRIGONCO 085855083856 DHF 1/20/2023 1/21/2023 1 Rp 180,000 Rp 180,000
35 ERMIA SARI 0000677439213 WONOREJO O90 1/10/2023 1/12/2023 2 Rp 360,000 Rp 360,000
36 AJENG ANGGELINA 0002004877787 BANTUR 082257183110 OF 1/23/2023 1/26/2023 3 Rp 540,000 Rp 540,000
37 SUPINI 0000678894401 REJOSARI DIARE 1/23/2023 1/26/2023 3 Rp 540,000 Rp 540,000
38 TUMINEM 0000678687074 BANTUR 081252303650 ABDOMINAL PAIN 1/28/2023 1/31/2023 3 Rp 900,000 Rp 900,000
39 RUMANI 0000678202053 BANDUNGREJO 085895421511 HT 1/27/2023 1/30/2023 3 Rp 900,000 Rp 900,000
40 SUNADI 0001038169912 BANTUR DYSPEPSIA 1/25/2023 1/28/2023 3 Rp 900,000 Rp 900,000
41 ARJUNA RASYA 0003313904264 SRIGONCO 085608798639 OF 1/21/2023 1/24/2023 3 Rp 540,000 Rp 540,000
42 RANTIYEM 0002680659865 BANTUR R10 1/25/2023 1/26/2023 1 Rp 300,000 Rp 300,000
43 SULASTRI 0000679868201 BANTUR 0858553355636 I10 12/29/2023 1/3/2023 5 Rp 900,000 Rp 900,000
44 INDRA NUR INDAHSARI 0001083871271 BANTUR 081249598322 OF 12/30/2022 1/3/2023 4 Rp 720,000 Rp 720,000

Rp 24,420,000
Bantur, FEBRUARI 2023
Kepala UPT Puskesmas Bantur

SOEBAGIJONO, S.Kep, M.Mkes

NIP. 19681009 199003 1 003

REKAP PENGAJUAN KLAIM RIT REKAP PENGAJUAN KLAIM RITP PUSKESMAS BANTUR

BULAN JANUARI 2023

RAWAT INAP
NO NAMA NO KARTU ALAMAT NO TLPN DIAGNOSA JUMLAH JUMLAH
TGL MASUK TGL KELUAR TARIF PAKET
HARI

1 PAITON 0000677500569 TUMPAKREJO 0813337262 R10 1/30/2023 2/2/2023 3 Rp 900,000 Rp 900,000

2 RIRIN ROSILAWATI 0002004875188 SUMBERBENING 0881027836118 THYPOID 1/30/2023 2/2/2023 3 Rp 900,000 Rp 900,000
3 KARTILAN 0000677969469 TUMPAKREJO 085918421854 VOMITING 1/30/2023 2/1/2023 2 Rp 600,000 Rp 600,000
4 SAYYIDINA UMAR SANDI 0002622366562 SRIGONCO OF 1/30/2023 2/1/2023 2 Rp 600,000 Rp 600,000
5 DENI ARDIANTO 0002484420276 TUMPAKREJO 082141652427 DIARE 1/30/2023 2/2/2023 3 Rp 900,000 Rp 900,000
6 TRUBUS WICAKSONO 0002324934898 BANTUR 081334142108 K29 2/1/2023 2/3/2023 2 Rp 600,000 Rp 600,000
7 MESENI 0001038232708 WONOREJO 85546393907 OF 2/1/2023 2/4/2023 3 Rp 900,000 Rp 900,000
8 ASYIFA DWI NUR AINI 0003142982125 PRINGGONDANI 081333256598 OF 2/2/2023 2/7/2023 5 Rp 1,500,000 Rp 1,500,000
9 SRIAMAH 0002627183215 SUMBERBENING 085646544448 VERTIGO 2/5/2023 2/8/2023 3 Rp 900,000 Rp 900,000
10 MARSA AYUNDA 0000678567925 BANDUNGREJO 081235181847 THYPOID 2/3/2023 2/7/2023 4 Rp 1,200,000 Rp 1,200,000
11 CARISSA 0001890367784 BANTUR 081333960294 THYPOID 2/3/2023 2/7/2023 4 Rp 1,200,000 Rp 1,200,000
12 PAINO 0000678158649 REJOSARI 82132791064 OF 2/3/2023 2/7/2023 4 Rp 1,200,000 Rp 1,200,000
13 SUGIANTO 0000680370322 SUMBERBENING 082333985624 R10 2/6/2023 2/9/2023 3 Rp 900,000 Rp 900,000
14 EKO AGUS WAHYUDI 0001844456218 BANTUR 081233487247 K30 2/7/2023 2/10/2023 3 Rp 900,000 Rp 900,000
15 LUTFIYEH 0002604210309 PRINGGONDANI 082230941991 VERTIGO 2/6/2023 2/9/2023 3 Rp 900,000 Rp 900,000
16 NURAINI 0002136790271 SUMBEREJO 081333007262 VOMITING 2/10/2023 2/13/2023 3 Rp 900,000 Rp 900,000
17 WIJIANTO 0000679095753 BANTUR 085784201883 N39 2/10/2023 2/13/2023 3 Rp 900,000 Rp 900,000
18 USWATUL HASANAH 0000678746801 BANTUR 082132368715 OF 2/15/2023 2/18/2023 3 Rp 900,000 Rp 900,000
19 RENI ASTUTIK 0002903537316 SRIGONCO 081230243096 VOMITING 2/16/2023 2/18/2023 2 Rp 600,000 Rp 600,000
20 AMIRUDIN 0000097790163 BANTUR 0813335095168 OF 2/12/2023 2/16/2023 4 Rp 1,200,000 Rp 1,200,000
21 FEBRI ANA 0000678040323 SRIGONCO 082245431146 DIARE 2/17/2023 2/18/2023 1 Rp 300,000 Rp 300,000
22 SUKI 0000677784486 REJOSARI 085803545001 VOMITING 2/9/2023 2/13/2023 4 Rp 1,200,000 Rp 1,200,000
23 WIJIONO 0000146103996 BANTUR 0857878784 VOMITING 2/13/2023 2/16/2023 3 Rp 900,000 Rp 900,000
24 MUHAMAD FARIS NAUFAL 0003237123227 PRINGGONDANI 085785494115 DIARE 2/13/2023 2/16/2023 3 Rp 900,000 Rp 900,000
25 UDIN CAHYONO 0003149808243 BANDUNGREJO 082335298758 OF 2/16/2023 2/20/2023 4 Rp 1,200,000 Rp 1,200,000
26 DIKA SUTARGO 0002600953119 BANTUR 081334469349 VOMITING 2/17/2023 2/20/2023 3 Rp 900,000 Rp 900,000
27 MARVELINO 0001323077376 SRIGONCO 081252834088 OF 2/17/2023 2/20/2023 3 Rp 900,000 Rp 900,000
28 ALFARIEL REGAL 0002922358959 BANDUNGREJO 082244751759 OF 2/21/2023 2/24/2023 3 Rp 900,000 Rp 900,000
29 SHERYL ARSYA 0003142973902 SRIGONCO 085258489638 OF 2/21/2023 2/24/2023 3 Rp 900,000 Rp 900,000
30 NIA SAGITA 0002594350484 PRINGGONDANI 085649952116 VOMITING 2/21/2023 2/24/2023 3 Rp 900,000 Rp 900,000
31 ROFI KENZIE 0002265735767 SUMBERBENING 085230243358 ABDOMINAL PAIN 2/21/2023 2/24/2023 3 Rp 900,000 Rp 900,000
32 PAINEM 0001959313206 SRIGONCO 081210407301 HT 2/23/2023 2/27/2023 4 Rp 1,200,000 Rp 1,200,000
33 ABDUL ROKIM 0000678266267 BANDUNGREJO 085785826903 R10 2/25/2023 2/28/2023 3 Rp 900,000 Rp 900,000
34 MUHAMAD FADIL 0003149799939 SRIGONCO 083111974307 DHF 2/24/2023 2/27/2023 3 Rp 900,000 Rp 900,000
35 POER WENIASIH 0002004875493 WONOREJO 085704942695 DHF 2/15/2023 2/20/2023 5 Rp 1,500,000 Rp 1,500,000
36 VIVI RAMADANI 0002919136836 TUMPAKREJO ASMA 2/19/2023 2/22/2023 3 Rp 900,000 Rp 900,000
37 USWATUN KHASANA 0000678173545 BANTUR 085816168945 R51 2/26/2023 2/28/2023 2 Rp 600,000 Rp 600,000
38 TINTIN ISWAHYUDI 0001038171666 BANTUR '085800619120 OF 2/20/2023 2/23/2023 3 Rp 900,000 Rp 900,000
39 SHEPTI PRISTIANA 0003142980843 PRINGGONDANI 081216246978 DHF 2/20/2023 2/23/2023 3 Rp 900,000 Rp 900,000
40 TRI NOOR JANAH 0000110230064 BANTUR 085755500220 DHF 2/22/2023 2/25/2023 3 Rp 900,000 Rp 900,000
41 SUNARSIH 0000678500357 BANTUR VERTIGO 2/21/2023 2/24/2023 3 Rp 900,000 Rp 900,000
42 EFA FERNANDA 0002603072891 PRINGGONDANI R10 2/21/2023 2/24/2023 3 Rp 900,000 Rp 900,000

Rp 39,000,000
Bantur, FEBRUARI 2023
Kepala UPT Puskesmas Bantur

SOEBAGIJONO, S.Kep, M.Mkes

NIP. 19681009 199003 1 003

REKAP PENGAJUAN KLAIM RIT REKAP PENGAJUAN KLAIM RITP PUSKESMAS BANTUR

BULAN MARET 2023

RAWAT INAP
NO NAMA NO KARTU ALAMAT NO TLPN DIAGNOSA JUMLAH JUMLAH
TGL MASUK TGL KELUAR TARIF PAKET
HARI
 1 FEBRIANTI IKA WAHYUNI 0001834460526 SRIGONCO 6/1 R10 3/1/2023 3/4/2023 3 Rp 900,000 Rp 900,000
2 MARTINI 0000679281197 PUJIHARJO R10 3/3/2023 3/6/2023 3 Rp 900,000 Rp 900,000
3 JADI MAULANA 0000678690641 GOMBANGAN R50 3/3/2023 3/6/2023 3 Rp 900,000 Rp 900,000
4 SARMINI 0000678229536 SUKOREJO R11 3/9/2023 3/13/2023 4 Rp 1,200,000 Rp 1,200,000
5 IMANUEL ABERCIO ESHAR 0003269043898 WONOREJO R50 3/9/2023 3/13/2023 4 Rp 1,200,000 Rp 1,200,000
6 UMARTI RUSMININGSIH 0003246133421 BANTUR TIMUR HT 3/8/2023 3/11/2023 3 Rp 900,000 Rp 900,000
7 YUNIATI 0002075767222 PRINGGODANI VERTIGO 3/6/2023 3/9/2023 3 Rp 900,000 Rp 900,000
8 MUJIANTO 0003168310498 SRIGONCO E11 3/3/2023 3/8/2023 5 Rp 1,500,000 Rp 1,500,000
9 YARSI 0003012689867 SRIGONCO A09 3/7/2023 3/11/2023 4 Rp 1,200,000 Rp 1,200,000
10 MOHAMMAD ADAM 0002161415136 BANTUR 085850198954 R50 3/6/2023 3/9/2023 3 Rp 900,000 Rp 900,000
11 MUJIONO 0002004851002 BANTUR R10 3/7/2023 3/11/2023 4 Rp 1,200,000 Rp 1,200,000
12 LISA ANISATUR ROHMAH 0000351185117 SRIGONCO R50 3/13/2023 3/16/2023 3 Rp 900,000 Rp 900,000
13 RINAWATI 0000678730252 TUMPAKREJO 082257330607 VOMITING 3/12/2023 3/15/2023 3 Rp 900,000 Rp 900,000
14 SLAMET RIADI 0002074778594 BANTUR N39 3/11/2023 3/15/2023 4 Rp 1,200,000 Rp 1,200,000
15 LILIK KUSMIATI 0003267989651 BANTUR 0895613681070 R11 3/9/2023 3/13/2023 4 Rp 1,200,000 Rp 1,200,000
16 RUMLAH 0003512111005 SUMBERBENING I15 3/12/2023 3/16/2023 4 Rp 1,200,000 Rp 1,200,000
17 SUGENG KANDUNG L 0000678534693 BANTUR A09 3/12/2023 3/15/2023 3 Rp 900,000 Rp 900,000
18 SUNDOYO 0000110229748 BANTUR 082229074200 A88 3/14/2023 3/17/2023 3 Rp 900,000 Rp 900,000
19 BRIAN AGUSTIAN ARGATZANI 0002888115336 BANTUR R11 3/14/2023 3/17/2023 3 Rp 900,000 Rp 900,000
20 SRIASIH 0002306904557 SRIGONCO 08120407301 I15 3/11/2023 3/14/2023 3 Rp 900,000 Rp 900,000
21 FINA FAJARWATI 0000679224385 BANTUR 085648474295 R10 3/14/2023 3/17/2023 3 Rp 900,000 Rp 900,000
22 SULASTRI 0000679447203 PRINGGODANI 082132865262 A09 3/15/2023 3/18/2023 3 Rp 900,000 Rp 900,000
23 TOGIMIN 0002865433285 REJOSARI R10 3/15/2023 3/18/2023 3 Rp 900,000 Rp 900,000
24 YULIUS ADI KRAYANTO 0000677412843 WONOREJO R11 3/15/2023 3/18/2023 3 Rp 900,000 Rp 900,000
25 YATEMI 0003512145791 PRINGGODANI A88 3/13/2023 3/16/2023 3 Rp 900,000 Rp 900,000
26 ADNAN HAFIZH ARRASYA 0003513280814 SRIGONCO R50 3/18/2023 3/21/2023 3 Rp 900,000 Rp 900,000
27 RESTIARI 0000110227667 BANTUR 082334553422 A09 3/21/2023 3/24/2023 3 Rp 900,000 Rp 900,000
28 RENI ASTUTIK 0002903537316 SRIGONCO O21 3/16/2023 3/20/2023 4 Rp 1,200,000 Rp 1,200,000
29 0003088264724 SRIGONCO 082257740670 A91 3/18/2023 3/22/2023 4 Rp 1,200,000 Rp 1,200,000
DHINI AGUSTIN SATYO RAHMADHANI
30 TUTIK IRAWATI 0003246177519 BANTUR R10 3/19/2023 3/22/2023 3 Rp 900,000 Rp 900,000
31 RANTIYEM 0003513607672 SRIGONCO 081216246855 I15 3/20/2023 3/24/2023 4 Rp 1,200,000 Rp 1,200,000
32 NUR ASMAWATI ROSIDAH 0003012689542 SRIGONCO 082331772187 A91 3/18/2023 3/20/2023 2 Rp 600,000 Rp 600,000
33 ANGGITA MAULIDYA PUTRI 0003142974418 SRIGONCO R50 3/14/2023 3/16/2023 2 Rp 600,000 Rp 600,000
34 ANIK INDAYANI 0003247469919 GEDANGAN R11 3/17/2023 3/21/2023 4 Rp 1,200,000 Rp 1,200,000
35 JAMI'ATI 0000678288069 SRIGONCO J45 3/20/2023 3/24/2023 4 Rp 1,200,000 Rp 1,200,000
36 SITI FATIMAH 0003070496305 GONDANGLEGI 082230448870 E11 3/21/2023 3/24/2023 3 Rp 900,000 Rp 900,000
37 SENIMAH 0000678249011 BANTUR K30 3/27/2023 3/30/2023 3 Rp 900,000 Rp 900,000
38 MUKLES 0003246260027 KARANGSARI 085791126532 R10 3/21/2023 3/25/2023 4 Rp 1,200,000 Rp 1,200,000
39 LILIK YULIANINGSIH 0002740726203 SRIGONCO 081249076016 R50 3/27/2023 3/30/2023 3 Rp 900,000 Rp 900,000
40 SATRIA ADI CAHYONO 0002733532907 WONOREJO 08581659325 A91 3/22/2023 3/27/2023 5 Rp 1,500,000 Rp 1,500,000
41 AGUS YULIANTO 0002160589184 BANTUR 081331685414 A91 3/21/2023 3/25/2023 4 Rp 1,200,000 Rp 1,200,000
42 ROHMAD 0000678311774 GEDANGAN 081331685414 A88 3/24/2023 3/27/2023 3 Rp 900,000 Rp 900,000
43 PONIDI 0002460668319 SRIGONCO R50 3/26/2023 3/29/2023 3 Rp 900,000 Rp 900,000
44 ABDUL ROZAK 0003337500497 BANTUR 081331685414 A09 3/26/2023 3/29/2023 3 Rp 900,000 Rp 900,000
45 SUYARI 0000678095428 BANTUR 085812410661 E11 3/27/2023 3/30/2023 3 Rp 900,000 Rp 900,000
46 MUJIONO WAHYUDI 0002680645015 BANTUR A01 3/27/2023 3/30/2023 3 Rp 900,000 Rp 900,000
47 SUMIATI 0000678744371 BANTUR R50 3/27/2023 3/29/2023 2 Rp 600,000 Rp 600,000
48 ENI WIDAYATI 0000679188971 BANTUR 085852014479 J45 3/28/2023 3/30/2023 2 Rp 600,000 Rp 600,000
49 BAGAS BDILLAH ZAFIR 0002919483112 BANTUR J18 3/28/2023 3/31/2023 3 Rp 900,000 Rp 900,000
50 SITI 0000678450969 SUMBERBENING 085604576561 K30 3/28/2023 3/30/2023 2 Rp 600,000 Rp 600,000
51 DAMIASRI 0000677901014 SRIGONCO A09 3/29/2023 3/31/2023 2 Rp 600,000 Rp 600,000
52 ISWANTO 0002865436839 BANTUR R50 3/7/2023 3/10/2023 3 Rp 900,000 Rp 900,000

Rp 50,400,000

Bantur, april 2023

Kepala UPT Puskesmas Bantur

SOEBAGIJONO, S.Kep, M.Mkes

NIP. 19681009 199003 1 003

REKAP PENGAJUAN KLAIM RIT REKAP PENGAJUAN KLAIM RITP PUSKESMAS BANTUR

BULAN januari 2023

RAWAT INAP
NO NAMA NO KARTU ALAMAT NO TLPN DIAGNOSA JUMLAH JUMLAH
TGL MASUK TGL KELUAR TARIF PAKET
HARI

1 MUSTAKIM '0000678481108 BANTUR R10 1/9/2023 1/11/2023 2 Rp 360,000 Rp 360,000

2 ANGGI JULIANA 0000678520855 SUMBEREJO R50 1/7/2023 1/11/2023 4 Rp 720,000 Rp 720,000
3 MISELIN 0003137423859 BANDUNGREJO I25 1/9/2023 1/10/2023 1 Rp 180,000 Rp 180,000
4 MATYADI 0000679496984 SRIGONCO R10 1/4/2023 1/7/2023 3 Rp 540,000 Rp 540,000
5 FITRIATUL KHASANAH 0001314703427 BANTUR DHF 1/10/2023 1/12/2023 2 Rp 360,000 Rp 360,000
6 AURA PUSPA DEWI 0000678251518 BANDUNGREJO R06 1/7/2023 1/8/2023 1 Rp 180,000 Rp 180,000
7 WINDI RINDAWATI 0002609131184 SRIGONCO DHF 1/20/2023 1/21/2023 1 Rp 180,000 Rp 180,000
8 ERMIASARI 0000677439213 WONOREJO O90 1/10/2023 1/12/2023 2 Rp 360,000 Rp 360,000
9 ARJUNA RASYA 0003313904264 SRIGONCO OF 1/21/2023 1/24/2023 3 Rp 540,000 Rp 540,000
10 RANTIYEM 0002680659865 BANTUR R10 1/25/2023 1/16/2023 1 Rp 300,000 Rp 300,000

Rp 3,720,000

Bantur, april 2023

Kepala UPT Puskesmas Bantur
 SOEBAGIJONO, S.Kep, M.Mkes
NIP. 19681009 199003 1 003

REKAP PENGAJUAN KLAIM RIT REKAP PENGAJUAN KLAIM RITP PUSKESMAS BANTUR

BULAN APRIL 2023

RAWAT INAP
NO NAMA NO KARTU ALAMAT NO TLPN DIAGNOSA JUMLAH JUMLAH
TGL MASUK TGL KELUAR TARIF PAKET
HARI

1 SITI MAISAROH 0000678200848 BANTUR A91 3/31/2023 4/5/2023 5 Rp 1,250,000 Rp 1,250,000

2 MIFTAKHUL JANAH F 0003010608786 SRIGONCO R50 4/30/2023 4/4/2023 5 Rp 1,250,000 Rp 1,250,000
3 SARKATI 0003237015385 BANTUR E11 4/30/2023 4/2/2023 3 Rp 750,000 Rp 750,000
4 KASMADI 0003335274821 TUMPAKREJO R50 3/31/2023 4/2/2023 2 Rp 500,000 Rp 500,000
5 RUMIATI 0003516062264 SRIGONCO O80 4/1/2023 4/1/2023 1 Rp 800,000 Rp 800,000
6 DUWI ASRI HANDAYANI 0000678727664 SRIGONCO O80 4/3/2023 4/4/2023 1 Rp 800,000 Rp 800,000
7 YEMI 0003246185891 SRIGONCO O80 4/12/2023 4/12/2023 1 Rp 800,000 Rp 800,000
8 USWATUN 0003186448042 BANTUR O81 4/13/2023 4/14/2023 1 Rp 800,000 Rp 800,000
9 AMINAH DAHA SUSANTI 0002604230414 PRINGGODANI A91 4/2/2023 4/6/2023 4 Rp 1,000,000 Rp 1,000,000
10 EKO FIBRIANTO 0001542391266 BANTUR 085850198954 A91 4/5/2023 4/9/2023 4 Rp 1,000,000 Rp 1,000,000
11 RENI 0002601877127 BANTUR A09 4/7/2023 4/11/2023 4 Rp 1,000,000 Rp 1,000,000
12 RUMIANTI 0003246121978 SRIGONCO 081333067582 A09 4/13/2023 4/17/2023 4 Rp 1,000,000 Rp 1,000,000
13 FITRIATUL AMALIA 0000678082498 PRINGGODANI 081227963240 A01 4/8/2023 4/12/2023 4 Rp 1,000,000 Rp 1,000,000
14 HOKLI CAHYONO 0003246262683 BANTUR 085210806120 E11 4/12/2023 4/15/2023 3 Rp 750,000 Rp 750,000
15 SRI UTAMI 0000199524879 BANTUR R50 4/11/2023 4/15/2023 4 Rp 1,000,000 Rp 1,000,000
16 MISTRI 0002865435401 SUMBERBENING I15 4/10/2023 4/13/2023 3 Rp 750,000 Rp 750,000
17 VITA KHOLIFATULANA 0002680673163 BANTUR O21.1 4/11/2023 4/13/2023 2 Rp 500,000 Rp 500,000
18 MUHAMMAD SAABHIQ 0001484649404 SRIGONCO R50 4/6/2023 4/11/2023 5 Rp 1,250,000 Rp 1,250,000
19 YATINEM 0001795976122 PRINGGODANI I15 4/9/2023 4/12/2023 3 Rp 750,000 Rp 750,000
20 SUTIANI 0002247408742 SRIGONCO 081330158496 A91 4/12/2023 4/15/2023 3 Rp 750,000 Rp 750,000
21 FITRI LESTARI 0000679570953 BANTUR A91 4/4/2023 4/8/2023 4 Rp 1,000,000 Rp 1,000,000
22 DWI KURNIAWAN 0000679170936 WONOREJO 085719607149 A91 4/1/2023 4/5/2023 4 Rp 1,000,000 Rp 1,000,000
23 SRIAMAH 000267183215 SUMBERBENING 08569955517 A88.1 4/11/2023 4/15/2023 4 Rp 1,000,000 Rp 1,000,000
24 FITRIANI 0001844456714 BANTUR O80 4/26/2023 4/26/2023 1 Rp 800,000 Rp 800,000
25 ISMAYATUL HANIFAH 0000677881539 PRINGGODANI O80 4/21/2023 4/21/2023 1 Rp 800,000 Rp 800,000
26 ABDUL ROUF 0003246138077 KARANGSARI R50 4/7/2023 4/11/2023 4 Rp 1,000,000 Rp 1,000,000
27 SAIFUDIN 0003246231341 SRIGONCO R50 4/7/2023 4/10/2023 3 Rp 750,000 Rp 750,000
28 TRI WAHYUNI 0003168309813 SRIGONCO 081236686245 O21.1 4/8/2023 4/10/2023 2 Rp 500,000 Rp 500,000
29 MARDIONO 0000678586184 SUMBERBENING R11 4/10/2023 012/04/2023 2 Rp 500,000 Rp 500,000
30 MUDRIKAH 0003246408494 BANTUR 081266477177 R50 4/4/2023 4/7/2023 3 Rp 750,000 Rp 750,000
31 DASIMIN 0003246268972 PRINGGODANI 085856266213 R06 4/2/2023 4/5/2023 3 Rp 750,000 Rp 750,000
32 PRAMINING 0000679211144 BANTUR 081335310974 K30 4/11/2023 4/13/2023 3 Rp 500,000 Rp 500,000
33 GINI 0003516861082 TUMPAKREJO 082144807410 E11 4/6/2023 4/8/2023 2 Rp 500,000 Rp 500,000
34 MISDI 0000679195045 BANTUR 085707579783 I15 4/15/2023 4/17/2023 2 Rp 500,000 Rp 500,000
35 RINIYANI 0000679433139 SRIGONCO 082245353936 R06 4/16/2023 4/18/2023 2 Rp 500,000 Rp 500,000
36 PUPUT TRI WULANDARI 0002873686476 SUMBERBENING R50 4/16/2023 4/18/2023 2 Rp 500,000 Rp 500,000
37 MEHRUNISSA GAZALA ADHA 0002764655706 SIDOARJO 081615800271 A09 4/19/2023 4/21/2023 2 Rp 500,000 Rp 500,000
38 TUKINI 0000678628989 SRIGONCO E11 4/18/2023 4/21/2023 2 Rp 750,000 Rp 750,000
39 ACHMAD NABIL AL BUCHORI 00032464411699 BANTUR 081249076016 R50 4/18/2023 4/21/2023 3 Rp 750,000 Rp 750,000
40 ALY NIAGATE 0001807082289 BANTUR 085771764107 A09 4/21/2023 4/25/2023 3 Rp 1,000,000 Rp 1,000,000
41 KARTIYEM 0003149808682 PRINGGODANI 081331685414 A09 4/23/2023 4/26/2023 4 Rp 750,000 Rp 750,000
42 TRIASIH 0000677637347 BANTUR I15 4/24/2023 4/26/2023 3 Rp 500,000 Rp 500,000
43 SUKARTINI 0003246142656 BANTUR A09 4/24/2023 4/26/2023 2 Rp 500,000 Rp 500,000
44 RIADI 0003337500497 REJOSARI 081556641519 R50 4/4/2023 4/7/2023 2 Rp 250,000 Rp 250,000
45 GALAXY DONI AGRATA 0003245060079 SRIGONCO A09 4/4/2023 4/5/2023 1 Rp 900,000 Rp 900,000
46 ANTON SUJARWO 0000678713771 SRIGONCO R10 4/28/2023 4/30/2023 2 Rp 500,000 Rp 500,000
47 EDI ROHWIYANI 00024444543425 WONOREJO A09 4/26/2023 4/29/2023 3 Rp 750,000 Rp 750,000
48 ROKIM 0001038192546 TUMPAKREJO R11 4/28/2023 4/30/2023 2 Rp 500,000 Rp 500,000
49 RUPINI 0001038171238 BANTUR K30 4/24/2023 4/27/2023 3 Rp 750,000 Rp 750,000

Rp 7,150,000

Bantur, Mei 2023

Kepala UPT Puskesmas Bantur

SOEBAGIJONO, S.Kep, M.Mkes

NIP. 19681009 199003 1 003

REKAP PENGAJUAN KLAIM RIT REKAP PENGAJUAN KLAIM RITP PUSKESMAS BANTUR

BULAN MEI 2023

RAWAT INAP
NO NAMA NO KARTU ALAMAT NO TLPN DIAGNOSA JUMLAH JUMLAH
TGL MASUK TGL KELUAR TARIF PAKET
HARI

1 SRIANI 0002698504931 BANTUR I15 4/27/2023 5/1/2023 4 Rp 1,000,000 Rp 1,000,000

2 DEWI NURPUJIASIH PUTRI 0002860539131 BANTUR A91 4/28/2023 5/2/2023 4 Rp 1,000,000 Rp 1,000,000
3 RELGA YAFIS SAPUTRA 0003501764076 BANTUR R50 4/29/2023 5/3/2023 4 Rp 1,000,000 Rp 1,000,000
 4 MUJI BATUN NA'IMAH 0003246233275 SUMBERBENING R10 4/29/2023 5/3/2023 4 Rp 1,000,000 Rp 1,000,000
5 JUWARTIK 0003175938156 SUMBERBENING E11 5/4/2023 5/6/2023 2 Rp 500,000 Rp 500,000
6 RIRIN SETYOWATI 0003246266081 BANTUR O80 5/7/2023 5/8/2023 1 Rp 800,000 Rp 800,000
7 ANITA SARI 0000678810036 SUMBERBENING O80 5/2/2023 5/3/2023 1 Rp 800,000 Rp 800,000
8 MISKAT 0003246420565 SUMBERBENING D64.9 5/2/2023 5/5/2023 3 Rp 750,000 Rp 750,000
9 LIA DWI ARISANTI 0003012689248 SRIGONCO O80 5/13/2023 5/13/2023 1 Rp 800,000 Rp 800,000
10 KEN AMELAS 0001831121572 WONOREJO I15 5/2/2023 5/5/2023 3 Rp 750,000 Rp 750,000
11 ABYU AZMY RADEYA FADHIL 0002916715983 SRIGONCO A09 5/2/2023 5/5/2023 3 Rp 750,000 Rp 750,000
12 HERMIN 0003176636196 SRIGONCO R51 5/5/2023 5/8/2023 3 Rp 750,000 Rp 750,000
13 TRUBUS 0002159152031 TUMPAKREJO J45 5/4/2023 5/8/2023 4 Rp 1,000,000 Rp 1,000,000
14 YEMI SUSANTI 0002865600909 GEDANGAN R11 5/5/2023 5/8/2023 3 Rp 750,000 Rp 750,000
15 ASMANI 0002134054541 PRINGGODANI I15 5/9/2023 5/12/2023 3 Rp 750,000 Rp 750,000
16 MOCHAMAD ARDI FIRMANSYAH 0002266124466 BANTUR R10 5/10/2023 5/13/2023 3 Rp 750,000 Rp 750,000
17 MARI 0002627182552 SUMBERBENING R11 5/10/2023 5/13/2023 3 Rp 750,000 Rp 750,000
18 RICO ABDURROHMAN 0003012685986 PRINGGODANI B01.9 5/9/2023 5/12/2023 3 Rp 750,000 Rp 750,000
19 SAMIN 0002134054539 PRINGGODANI R10 5/9/2023 5/12/2023 3 Rp 750,000 Rp 750,000
20 SARU 0000678696265 KARANGSARI A09 5/17/2023 5/20/2023 3 Rp 750,000 Rp 750,000
21 ANDRE SAHAT OLOAN MANULANG 0001809994094 KALIMANTAN R50 5/15/2023 5/19/2023 4 Rp 1,000,000 Rp 1,000,000
22 SURYATI 0003174937953 PRINGGODANI R50 5/15/2023 5/19/2023 4 Rp 1,000,000 Rp 1,000,000
23 SARINEM 0003149796598 PRINGGODANI R11 5/15/2023 5/19/2023 4 Rp 1,000,000 Rp 1,000,000
24 ALIFAHUZNA ORIZATY IRAWAN 0003149801201 SRIGONCO A15 5/13/2023 5/17/2023 4 Rp 1,000,000 Rp 1,000,000
25 SILAS SOETRISNO 0002623244139 WONOREJO K30 5/15/2023 5/18/2023 3 Rp 750,000 Rp 750,000
26 AISYA QOIRIL NUR SETYANINGSIH 0002601958588 BANTUR R11 5/8/2023 5/11/2023 3 Rp 750,000 Rp 750,000
27 IIS WIDAYANTI 0000684758755 BANTUR A09 5/7/2023 5/11/2023 4 Rp 1,000,000 Rp 1,000,000
28 DHIKA NUR ALTHAFARIZ 0002230224243 BALIKPAPAN A09 5/6/2023 5/9/2023 3 Rp 750,000 Rp 750,000
29 LIA LISTIANA 0002605395644 PRINGGODANI A09 5/24/2023 5/27/2023 3 Rp 750,000 Rp 750,000
30 SUNARDI 0001139321709 SRIGONCO R10 5/14/2023 5/15/2023 1 Rp 250,000 Rp 250,000
31 TRIONO 0002132851634 BANTUR I15 5/12/2023 5/16/2023 4 Rp 1,000,000 Rp 1,000,000
32 SUYATI 0002083094662 SRIGONCO R10 5/12/2023 5/15/2023 3 Rp 750,000 Rp 750,000
33 SAIMAN 0000677927889 SRIGONCO N39.0 5/11/2023 5/13/2023 2 Rp 500,000 Rp 500,000
34 SUDARSONO 0001038182073 BANTUR E11 5/2/2023 5/5/2023 3 Rp 750,000 Rp 750,000
35 AHMAD ZIDNI 0002681999054 SRIGONCO R50 5/15/2023 5/19/2023 4 Rp 1,000,000 Rp 1,000,000
36 AH HASAN 0002011291986 BANTUR A09 5/1/2023 5/4/2023 3 Rp 750,000 Rp 750,000
37 MISTIYEH 0000678779166 PRINGGODANI A09 5/1/2023 5/4/2023 3 Rp 750,000 Rp 750,000
38 ERINIA YULIA ADYTA 0000678132178 SUMBERBENING O21.1 5/13/2023 5/16/2023 3 Rp 750,000 Rp 750,000
39 jaenah 0003274795282 BANTUR I15 5/5/2023 5/8/2023 3 Rp 750,000 Rp 750,000
40 KHARISMA GITA SHAFILA 0003246237167 PRINGGODANI R11 5/6/2023 5/9/2023 3 Rp 750,000 Rp 750,000
41 FAADILA ZAHRA CHANDANI SETYONO 0003075667435 BANTUR A09 5/9/2023 5/12/2023 3 Rp 750,000 Rp 750,000
42 ADINDA LAVANYA ARASELY 0003142985354 WONOREJO A09 5/5/2023 5/9/2023 4 Rp 1,000,000 Rp 1,000,000
43 SITI ROFIKA 0002627086814 SRIGONCO R50 5/10/2023 5/14/2023 4 Rp 1,000,000 Rp 1,000,000
44 RM PETRUS SULUH 0001038169102 WONOREJO E63.9 5/9/2023 5/14/2023 5 Rp 1,250,000 Rp 1,250,000
45 MISTI 0000678293504 BANTUR A09 5/27/2023 5/30/2023 3 Rp 750,000 Rp 750,000
46 MURIYONO 0002423529044 BANTUR I15 5/22/2023 5/25/2023 3 Rp 750,000 Rp 750,000
47 PURWOTO 0003245060147 SRIGONCO A09 5/23/2023 5/26/2023 3 Rp 750,000 Rp 750,000
48 MARNITI 0000678081644 PRINGGODANI K30 5/21/2023 5/24/2023 3 Rp 750,000 Rp 750,000
49 WAKINI 0000678320065 BANDUNGREJO A88.1 5/20/2023 5/23/2023 3 Rp 750,000 Rp 750,000
50 SUWARNI 0002505859705 TUMPAKREJO H81,1 5/23/2023 5/26/2023 3 Rp 750,000 Rp 750,000
51 MUHAMMAD FAISAL 0003246420262 KARANGSARI A09 5/27/2023 5/30/2023 3 Rp 750,000 Rp 750,000
52 HABIBAH 0000677743345 BANTUR R10 5/24/2023 5/27/2023 3 Rp 750,000 Rp 750,000
53 SATIRAN 0003335857277 TUMPAKREJO M51.9 5/4/2023 5/7/2023 3 Rp 750,000 Rp 750,000
54 UMIYATI 0002160587823 REJOSARI K30 5/21/2023 5/24/2023 3 Rp 750,000 Rp 750,000
55 ALENA AULIA PUTRI 0003238369367 BANTUR R50 5/28/2023 5/30/2023 2 Rp 500,000 Rp 500,000
56 samadi 0003523823908 PRINGGODANI I15 5/22/2023 5/25/2023 3 Rp 750,000 Rp 750,000
57 TATIA ASIH JANA PRATIWI 0000677426973 WONOREJO O80 5/24/2023 5/24/2023 1 Rp 800,000 Rp 800,000

Rp 45,700,000

Bantur, JUNI 2023

Kepala UPT Puskesmas Bantur

SOEBAGIJONO, S.Kep, M.Mkes

NIP. 19681009 199003 1 003

REKAP PENGAJUAN KLAIM RIT REKAP PENGAJUAN KLAIM RITP PUSKESMAS BANTUR

BULAN JUNI 2023

RAWAT INAP
NO NAMA NO KARTU ALAMAT NO TLPN DIAGNOSA JUMLAH JUMLAH
TGL MASUK TGL KELUAR TARIF PAKET
HARI

1 MAJI '0000678276696 BANTUR L03.9 5/29/2023 6/1/2023 3 Rp 750,000 Rp 750,000

2 SUPARMI '0000679389625 PRINGGODANI E11 5/30/2023 6/3/2023 4 Rp 1,000,000 Rp 1,000,000
3 MURIADI '0003247275418 BANTUR L02.9 5/30/2023 6/2/2023 3 Rp 750,000 Rp 750,000
4 riwayati '0001804893142 BANTUR R50 5/29/2023 6/1/2023 3 Rp 750,000 Rp 750,000
5 SAMINTEN '0002680661992 BANTUR R50 5/31/2023 6/3/2023 3 Rp 750,000 Rp 750,000
6 PONIMAH '0002603026203 BANTUR R10 5/31/2023 6/3/2023 3 Rp 750,000 Rp 750,000
7 SAFIRA CINTIA PUTRI '0002842756817 SRIGONCO J45 5/30/2023 6/2/2023 3 Rp 750,000 Rp 750,000
8 LUSIANA ALZAHRO '0003306304258 PRINGGODANI A09 5/30/2023 6/2/2023 3 Rp 750,000 Rp 750,000
9 ARSYILA FARZANA ALFIDI '0003087692829 SRIGONCO R11 5/31/2023 6/3/2023 3 Rp 750,000 Rp 750,000
10 M FATONI '0002604230234 SRIGONCO L03 5/30/2023 6/2/2023 3 Rp 750,000 Rp 750,000
11 SUWARI '0000677531316 TUMPAKREJO R10 6/1/2023 6/4/2023 3 Rp 750,000 Rp 750,000
12 DASEMI '0000678405238 BANTUR E11 6/6/2023 6/10/2023 4 Rp 1,000,000 Rp 1,000,000
13 MISIYEM '0002602023445 BANTUR R50 6/5/2023 6/8/2023 3 Rp 750,000 Rp 750,000
14 REVANO ARDIANSYAH PRATAMA '0003246622222 TUMPAKREJO A09 6/4/2023 6/8/2023 4 Rp 1,000,000 Rp 1,000,000
15 SUMIARAH '0002083063419 BANTUR E11 6/7/2023 6/9/2023 2 Rp 500,000 Rp 500,000
16 NAZILAH 0000678057096 REJOSARI A09 6/1/2023 6/5/2023 4 Rp 1,000,000 Rp 1,000,000
17 LIMAN '0003081477701 PRINGGODANI A01 6/3/2023 6/6/2023 3 Rp 750,000 Rp 750,000
18 SANIKEM '0003246411082 BANTUR E16.2 6/5/2023 6/8/2023 3 Rp 750,000 Rp 750,000
19 cetta al qurthubi '0003096710548 BANTUR R50 6/4/2023 6/7/2023 3 Rp 750,000 Rp 750,000
20 WULAN HANA SAVITRI '0003246129134 WONOREJO R50 6/8/2023 6/11/2023 3 Rp 750,000 Rp 750,000
21 BAGAS ABDILLAH ZAFIR '0002919483112 BANTUR J18.0 6/6/2023 6/10/2023 4 Rp 1,000,000 Rp 1,000,000
22 WAHYUDI '0003246326054 PRINGGODANI R11 6/2/2023 6/5/2023 3 Rp 750,000 Rp 750,000
23 ELSAMANTHA PRADHANY '0002274281526 WONOREJO R50 6/3/2023 6/6/2023 3 Rp 750,000 Rp 750,000
24 TATIK '0002201413206 SRIGONCO R06 6/5/2023 6/8/2023 3 Rp 750,000 Rp 750,000
25 ANDHIKA AVIV SAPUTRA '0002774550947 BANTUR R50 6/5/2023 6/8/2023 3 Rp 750,000 Rp 750,000
26 SUPIATUN '0003186455231 BANTUR I15 6/10/2023 6/13/2023 3 Rp 750,000 Rp 750,000
27 Nifatul khoiro '0003527838505 PRINGGODANI R50 6/10/2023 6/13/2023 3 Rp 750,000 Rp 750,000
28 DIAN LUSIANA NINGSIH '0002004877181 BANTUR I15 6/12/2023 6/15/2023 3 Rp 750,000 Rp 750,000
29 ALIF NURUL HIDAYAH '0002889727479 BANTUR R50 6/15/2023 6/18/2023 3 Rp 750,000 Rp 750,000
30 SAPON MULYADI '0002222399294 BANTUR I63.9 6/13/2023 6/17/2023 4 Rp 1,000,000 Rp 1,000,000
31 VIVI FARISTA HANA PRATIWI '0002482451414 BANTUR A09 6/19/2023 6/23/2023 4 Rp 1,000,000 Rp 1,000,000
32 JAKINEM '0000678144846 BANTUR L30.9 6/19/2023 6/22/2023 3 Rp 750,000 Rp 750,000
33 PONIDI '0000678801249 BANTUR H81.1 6/20/2023 6/23/2023 3 Rp 750,000 Rp 750,000
34 NADIA RINDA KHARISMA '0003010609899 SRIGONCO R50 6/20/2023 6/23/2023 3 Rp 750,000 Rp 750,000
35 MUKIYAT '0003246155256 BANDUNGREJO R10 6/20/2023 6/24/2023 4 Rp 1,000,000 Rp 1,000,000
36 RISKA FITRI AULIA '0002865434106 BANTUR R50 6/22/2023 6/25/2023 3 Rp 750,000 Rp 750,000
37 WARSINI '0000677467067 TUMPAKREJO L27.0 6/23/2023 6/26/2023 3 Rp 750,000 Rp 750,000
38 SULIADI '0003246621862 TUMPAKREJO R10 6/23/2023 6/26/2023 3 Rp 750,000 Rp 750,000
39 SELAMIN '0001056915819 TUMPAKREJO A09 6/23/2023 6/26/2023 3 Rp 750,000 Rp 750,000
40 vicky dimas saputra '0001787793851 BANTUR R50 6/24/2023 6/27/2023 3 Rp 750,000 Rp 750,000
41 AURORA ILEANA GAURI PATRA '0003075906701 BANTUR R50 6/25/2023 6/28/2023 3 Rp 750,000 Rp 750,000
42 MISIJAR '0002745714273 SRIGONCO I15 6/17/2023 6/20/2023 3 Rp 750,000 Rp 750,000
43 LIA KURNIASARI '0003529342923 PRINGGODANI R50 6/17/2023 6/20/2023 3 Rp 750,000 Rp 750,000
44 TUTIK MARIYAH '0000110231065 SRIGONCO E11 6/24/2023 6/28/2023 4 Rp 1,000,000 Rp 1,000,000
45 MUJIONO WAHYUDI '0002680645015 BANTUR R50 6/26/2023 6/29/2023 3 Rp 750,000 Rp 750,000
46 NAUVAL JERIKO WILLYAM '0003142981034 SRIGONCO R11 6/26/2023 6/29/2023 3 Rp 750,000 Rp 750,000
47 DWI SANTOSO '0002601949105 BANTUR R50 6/1/2023 6/4/2023 3 Rp 750,000 Rp 750,000
48 SUKIRNO '0003149791569 BANTUR I15 6/3/2023 6/6/2023 3 Rp 750,000 Rp 750,000
49 INTAN NAINI '0002278117225 REJOYOSO K30 6/1/2023 6/4/2023 3 Rp 750,000 Rp 750,000
50 INDRAWATI '0002627140151 SRIGONCO R50 6/7/2023 6/10/2023 3 Rp 750,000 Rp 750,000
51 EKO CAHYONO '0001439396212 REJOSARI R50 6/7/2023 6/10/2023 3 Rp 750,000 Rp 750,000
52 SUYONO '0002865436413 BANTUR R10 6/8/2023 6/11/2023 3 Rp 750,000 Rp 750,000
53 SARMINI '0000678229536 TUMPAKREJO I15 6/9/2023 6/12/2023 3 Rp 750,000 Rp 750,000
54 SUPARMIN '0003246148899 BANTUR I15 6/10/2023 6/14/2023 4 Rp 1,000,000 Rp 1,000,000
55 SAKIR '0003502508962 BANDUNGREJO J44.9 6/11/2023 6/14/2023 3 Rp 750,000 Rp 750,000
56 RAMIATI '0000679531566 BANTUR K30 6/14/2023 6/17/2023 3 Rp 750,000 Rp 750,000
57 SUTIANI '0002627002541 SRIGONCO J45 6/14/2023 6/17/2023 3 Rp 750,000 Rp 750,000
58 NUR HASIM '0000678402944 SUMBERBENING R50 6/12/2023 6/15/2023 3 Rp 750,000 Rp 750,000
59 IIN WURIANI '0002601877149 BANTUR R10 6/15/2023 6/18/2023 3 Rp 750,000 Rp 750,000
60 YATEMI '0002218290434 SRIGONCO R10 6/25/2023 6/28/2023 3 Rp 750,000 Rp 750,000

Rp 47,250,000

Bantur, JULI 2023

Kepala UPT Puskesmas Bantur
 SOEBAGIJONO, S.Kep, M.Mkes
NIP. 19681009 199003 1 003

REKAP PENGAJUAN KLAIM RIT REKAP PENGAJUAN KLAIM RITP PUSKESMAS BANTUR

BULAN JULI 2023

RAWAT INAP
NO NAMA NO KARTU ALAMAT NO TLPN DIAGNOSA JUMLAH JUMLAH
TGL MASUK TGL KELUAR TARIF PAKET
HARI

1 PAERAH ‘0000679729691 SUMBERBENING R11 6/29/2023 7/2/2023 3 Rp 750,000 Rp 750,000

2 SUPARIN ‘0000679033539 SRIGONCO A09 6/27/2023 7/1/2023 4 Rp 1,000,000 Rp 1,000,000
3 DIAN ROHMAH YUSTININGRUM ‘0002460584889 BANTUR J45.9 6/30/2023 7/4/2023 4 Rp 1,000,000 Rp 1,000,000
4 MARSINI ‘0000110226339 BANTUR A09.9 6/29/2023 7/1/2023 2 Rp 500,000 Rp 500,000
5 ALIF NURUL HIDAYAH ‘0002889727479 BANTUR R11 6/29/2023 7/2/2023 3 Rp 750,000 Rp 750,000
6 ACHMAD TUKIMIN ‘0001728235956 PRINGGODANI A09 7/1/2023 7/4/2023 3 Rp 750,000 Rp 750,000
7 JUMAL ‘0000678312303 BANTUR J44 7/5/2023 7/8/2023 3 Rp 750,000 Rp 750,000
8 TRIMAN ‘0002865437267 BANTUR J44 7/1/2023 7/4/2023 3 Rp 750,000 Rp 750,000
9 MUKRI ‘0000677974241 TUMPAKREJO I22.9 7/1/2023 7/4/2023 3 Rp 750,000 Rp 750,000
10 WAHYUDI ‘0003246326054 KARANGSARI R10 7/7/2023 7/9/2023 2 Rp 500,000 Rp 500,000
11 MISTRI ‘0002680656186 BANTUR B00 7/10/2023 7/12/2023 2 Rp 500,000 Rp 500,000
12 SHEVA ZILDJIAN AL MUHAJIRIN ‘0003535941036 TUMPAKREJO R50 7/23/2023 7/26/2023 3 Rp 750,000 Rp 750,000
13 SUNARSIH ‘0002159152064 TUMPAKREJO R10 7/16/2023 7/20/2023 4 Rp 1,000,000 Rp 1,000,000
14 SUMIANI ‘0001339614707 BANTUR R10 7/9/2023 7/13/2023 4 Rp 1,000,000 Rp 1,000,000
15 SUPIATUN ‘0003186455231 BANTUR I10 7/12/2023 7/15/2023 3 Rp 750,000 Rp 750,000
16 HANIN RAIHANA SYAHIRA ‘0002885232543 SRIGONCO A09 7/8/2023 7/12/2023 4 Rp 1,000,000 Rp 1,000,000
17 SINTA ‘0000678148672 BANTUR A88.1 7/8/2023 7/11/2023 3 Rp 750,000 Rp 750,000
18 TUNI ‘0002273870744 SRIGONCO R06 7/8/2023 7/12/2023 4 Rp 1,000,000 Rp 1,000,000
19 SUMIATI ULWA DILLAH ‘0001732049741 KARANGSARI A09 7/10/2023 7/13/2023 3 Rp 750,000 Rp 750,000
20 rivki ridho pratama ‘0002090195414 SUMBERBENING R50 7/11/2023 7/14/2023 3 Rp 750,000 Rp 750,000
21 ADNAN HAFIZH ARRASYA ‘0003513280814 SRIGONCO R11 7/14/2023 7/17/2023 3 Rp 750,000 Rp 750,000
22 SAMURI ‘0000678910454 KARANGSARI A09 7/11/2023 7/14/2023 3 Rp 750,000 Rp 750,000
23 KHALISA AGHNIA MIKAILA SATYA ‘0003098710552 BANTUR R50 7/13/2023 7/16/2023 3 Rp 750,000 Rp 750,000
24 SINARTI DARMIATI ‘0001869613659 REJOSARI A09 7/14/2023 7/16/2023 2 Rp 500,000 Rp 500,000
25 ACHMAD SAMSUL SODIK ‘0001093651918 BANTUR J20.9 7/14/2023 7/18/2023 4 Rp 1,000,000 Rp 1,000,000
26 RIANTI ‘0001818654928 BANTUR E11 7/14/2023 7/18/2023 4 Rp 1,000,000 Rp 1,000,000
27 IKA PUTRI AFRILIA ‘0002916431019 SRIGONCO K29 7/15/2023 7/19/2023 4 Rp 1,000,000 Rp 1,000,000
28 CIKO PUTRA ALDANI ‘0003143383784 TUMPAKREJO R50 7/16/2023 7/21/2023 5 Rp 1,250,000 Rp 1,250,000
29 MARSINI ‘0000110226339 BANTUR A09 7/16/2023 7/20/2023 4 Rp 1,000,000 Rp 1,000,000
30 ERLAN WIBISONO ‘0002245362895 JABUNG A09 7/17/2023 7/20/2023 3 Rp 750,000 Rp 750,000
31 LIA NURJANAH ‘0002609131105 SRIGONCO O21.1 7/18/2023 7/21/2023 3 Rp 750,000 Rp 750,000
32 NABILA BILQIS HUMAIRO ‘0003186448907 BANTUR A09 7/19/2023 7/23/2023 4 Rp 1,000,000 Rp 1,000,000
33 MISTIKAH ‘0002004843115 BANTUR R100 7/20/2023 7/24/2023 4 Rp 1,000,000 Rp 1,000,000
34 subandi ‘0001817764942 BANTUR A09 7/21/2023 7/24/2023 3 Rp 750,000 Rp 750,000
35 SITINAH ‘0000680075188 TUMPAKREJO J45.9 7/1/2023 7/6/2023 5 Rp 1,250,000 Rp 1,250,000
36 AGUS SUSILO JUNIANTO ‘0002263382122 BANTUR R50 7/22/2023 7/26/2023 4 Rp 1,000,000 Rp 1,000,000
37 FARIDATUL AMALIA ‘0002883428289 SUMBERBENING A09 7/23/2023 7/26/2023 3 Rp 750,000 Rp 750,000
38 RUSMINING ‘0002004851834 BANTUR A09 7/22/2023 7/26/2023 4 Rp 1,000,000 Rp 1,000,000
39 ACHMAD GALANG SAPUTRA ‘0003142977243 BANTUR R50 7/24/2023 7/27/2023 3 Rp 750,000 Rp 750,000
40 JUPRI ‘0000408744639 TUMPAKREJO A09 7/24/2023 7/27/2023 3 Rp 750,000 Rp 750,000
41 RENDIK A ‘0001038171587 BANTUR R11 7/25/2023 7/28/2023 3 Rp 750,000 Rp 750,000
42 SURIYATI ‘0000110227252 REJOSARI A09 7/20/2023 7/23/2023 3 Rp 750,000 Rp 750,000
43 SUYATMI ‘0002842910662 TUMPAKREJO I15 7/26/2023 7/29/2023 3 Rp 750,000 Rp 750,000
44 SLAMET ‘0000679366091 PRINGGODANI A09 7/27/2023 7/30/2023 3 Rp 750,000 Rp 750,000
45 KANTHI RAHAYU ‘0000677411829 WONOREJO A09 7/26/2023 7/29/2023 3 Rp 750,000 Rp 750,000
46 PAIT ZULKARNAIN ‘0000678354614 TUMPAKREJO E11 7/9/2023 7/12/2023 3 Rp 750,000 Rp 750,000
47 DITA INDAH RAMADHANA ‘0003012689171 SRIGONCO A09.9 7/15/2023 7/19/2023 4 Rp 1,000,000 Rp 1,000,000
48 LASMINTEN ‘0000679924686 BANTUR J11 7/19/2023 7/22/2023 3 Rp 750,000 Rp 750,000
49 SUTIANI ‘0000678565203 BANDUNGREJO A09 7/25/2023 7/28/2023 3 Rp 750,000 Rp 750,000
50 SUTJIPTO ADI ‘0001831113674 WONOREJO I15 7/7/2023 7/11/2023 4 Rp 1,000,000 Rp 1,000,000
51 IKLIL ZAKARIYA ‘0003085467952 PRINGGODANI A09 7/3/2023 7/6/2023 3 Rp 750,000 Rp 750,000

Rp 42,250,000

Bantur, Agustus 2023

Kepala UPT Puskesmas Bantur

SOEBAGIJONO, S.Kep, M.Mkes

NIP. 19681009 199003 1 003
 REKAP PENGAJUAN KLAIM PERSALINAN PUSKESMAS BANTUR
Bulan DESEMBER 2022
PERSALINAN JUMLAH
TGL TARIF BIDAN
NO NAMA NO KARTU ALAMAT NO TLPN DIAGNOSA
PELAYANAN PAKET

1 FINA KUMALA SARI 0001038258854 SRIGONCO O80 25/12/2022 Rp 700,000 dr auliana

TOTAL

Bantur, JANUARI 2023

Kepala UPT Puskesmas Bantur

SOEBAGIJONO, S.Kep, M.Mkes

NIP. 19681009 199003 1 003

REKAP PENGAJUAN KLAIM PERSALINAN PUSKESMAS BANTUR

Bulan DESEMBER 2022
PERSALINAN JUMLAH
TGL TARIF BIDAN
NO NAMA NO KARTU ALAMAT NO TLPN DIAGNOSA
 BIDAN
NO NAMA NO KARTU ALAMAT NO TLPN DIAGNOSA
PELAYANAN PAKET

1 FINA KUMALA SARI 0001038258854 SRIGONCO O80 25/12/2022 Rp 700,000 dr auliana

TOTAL

Bantur, JANUARI 2023

Kepala UPT Puskesmas Bantur

SOEBAGIJONO, S.Kep, M.Mkes

NIP. 19681009 199003 1 003

REKAP PENGAJUAN KLAIM PERSALINAN PUSKESMAS BANTUR

Bulan JULI 2023
PERSALINAN JUMLAH
TGL TARIF BIDAN
NO NAMA NO KARTU ALAMAT NO TLPN DIAGNOSA
PELAYANAN PAKET

1 AMELIA ADE SAFITRI ‘0002754608782 O80 7/3/2023 Rp 800,000 Rp 800,000 sukemi

2 LINDA CHOIRUM NINGSIH ‘0002842757515 O80 7/7/2023 Rp 800,000 Rp 800,000 sukemi
3
 TOTAL Rp1,600,000 Rp 1,600,000

Bantur, AGUSTUS 2023

Kepala UPT Puskesmas Bantur

SOEBAGIJONO, S.Kep, M.Mkes

NIP. 19681009 199003 1 003

REKAP PENGAJUAN KLAIM PERSALINAN PUSKESMAS BANTUR

Bulan JUNI 2023
PERSALINAN JUMLAH
TGL TARIF BIDAN
NO NAMA NO KARTU ALAMAT NO TLPN DIAGNOSA
PELAYANAN PAKET

1 IKE RETNASARI '0003246252581 BANTUR O80 6/17/2023 Rp 800,000 Rp 800,000 sukemi

2 SITI MUSYAROFAH '0000677614904 BANTUR O80 6/13/2023 Rp 800,000 Rp 800,000 dr nevy
3 GAFITRA NINGSIH '0003012689733 SRIGONCO O80 6/5/2023 Rp 800,000 Rp 800,000 sukemi
4 NIDA OHANA '0000677989732 BANDUNGREJO O80 6/15/2023 Rp 800,000 Rp 800,000 sukemi
5 SITI LUTVIANA '0001038169956 BANTUR O80 6/30/2023 Rp 800,000 Rp 800,000
6 PUJI LESTARI '0003237016217 BANTUR O80 6/30/2023 Rp 800,000 Rp 800,000
7
8
9
10
11 TOTAL Rp4,800,000 Rp 4,800,000

Bantur, JULI 2023

Kepala UPT Puskesmas Bantur
SOEBAGIJONO, S.Kep, M.Mkes
NIP. 19681009 199003 1 003
 REKAP PENGAJUAN KLAIM RJTP ( Ambulance ) PUSKESMAS BANTUR
BULAN januari 2023
ALASAN DOKTER FASKES TGL TGL KM NO POL
AMBULANC DRIVER TARIF
NO NAMA NO KARTU ALAMAT DIAGNOSA DIRUJUK PERUJUK TUJUAN MRS DIRUJUK E

PERAWATAN LEBIH
1 MISNAH 0000677863416 SRIGONCO CVA INTENSIF DR NEVY RSUDK 1/1/2023 1/1/2023 29 N1403EP SUPARDI Rp250,000

PERAWATAN LEBIH
2 SURATIN 0001038170889 BANTUR APENDIK INTENSIF DR NEVY RSUDK 1/5/2023 1/5/2023 29 N 1174 EP SUPARDI Rp250,000

PERAWATAN LEBIH
3 YANTI 000067783604 SRIGONCO PREMATUR RUPTUR INTENSIF DR NEVY RS BEN MARI 1/5/2023 1/5/2023 30 N 1174 EP PITOYO Rp280,000

PERAWATAN LEBIH
4 SYAFIATUN 0000108770218 SRIGONCO DHF INTENSIF DR NEVY RSUDK 1/3/2023 1/4/2023 29 N 1174 EP SUPARDI Rp250,000

PERAWATAN LEBIH
5 SALSABILA IRDINA 0002454178803 SUMBERBENING OF INTENSIF DR NEVY RSUDK 1/10/2023 1/10/2023 29 N 1403 EP PITOYO Rp250,000

PERAWATAN LEBIH
6 SANTI 0000110799369 BANTUR CVA INTENSIF DR NEVY RSUDK 1/13/2023 1/14/2023 29 N 1403 EP PITOYO Rp250,000

PERAWATAN LEBIH
7 MISELIN 0003137423859 SUMBERBENING CHF INTENSIF DR NEVY RSUDK 1/9/2023 1/9/2023 29 N 1403 EP SUPARDI Rp250,000

PERAWATAN LEBIH
8 MATYADI 0000679496984 SRIGONCO ABDOMINAL PAIN INTENSIF DR NEVY RSUDK 1/4/2023 1/7/2023 29 N 1403 EP PITOYO Rp250,000

PERAWATAN LEBIH
9 FITRIATUL KHASANAH 0001314703427 BANTUR DIARE INTENSIF DR NEVY RSIG 1/10/2023 1/12/2023 20 N 1174 EP PITOYO Rp180,000

PERAWATAN LEBIH
10 AURA PUSPA DEWI 000678251518 BANDUNGREJO R06 INTENSIF DR NEVY RSUDK 1/7/2023 1/8/2023 29 N 1174 EP PITOYO Rp250,000

PERAWATAN LEBIH
11 REGITA 0003010605581 SRIGONCO TAKIKARDIA INTENSIF DR AULIANA RSUDK 1/20/2023 1/20/2023 29 N 1174 EP SUPARDI Rp250,000

PERAWATAN LEBIH
12 SATUN 0000678147489 PRINGGONDANI DHF INTENSIF DR AULIANA RSIG 1/21/2023 1/21/2023 20 N 1403 EP SUPARDI Rp180,000

PERAWATAN LEBIH
13 PONIYEM 0000679867896 BANTUR HF INTENSIF DR AULIANA RSUDK 1/23/2023 1/23/2023 29 N 1174 EP PITOYO Rp250,000

PERAWATAN LEBIH
14 WINDI 0002609131184 SRIGONCO DHF INTENSIF DR AULIANA RS MITRA DELIMA 1/20/2023 1/21/2023 29 N 1174 EP SUPARDI Rp400,000

PERAWATAN LEBIH
15 LUTFIATUN 0003056785773 SRIGONCO OF INTENSIF DR AULIANA RSUDK 1/22/2023 1/22/2023 29 N 1174 EP PITOYO Rp250,000

PERAWATAN LEBIH
16 ERMIA SARI 0000677439213 WONOREJO O90 INTENSIF DR NEVY RSUDK 1/12/2023 1/12/2023 29 N 1174 EP SUPARDI Rp250,000

PERAWATAN LEBIH
17 SALDAT SAIDINA 0002680655499 REJOSARI CVA INTENSIF DR AULIANA RSUDK 1/26/2023 1/26/2023 29 N 1403 EP PITOYO Rp340,000

PERAWATAN LEBIH
18 LUTFI ANITA 0000678417063 SRIGONCO O80 INTENSIF DR AULIANA RSUDK 1/30/2023 1/30/2023 29 N 1403 EP PITOYO Rp340,000

PERAWATAN LEBIH
19 VELINO HANESA 0003149796284 BANTUR PNEUMONIA INTENSIF DR AULIANA RSUDK 1/26/2023 1/26/2023 29 N 1403 EP SUPARDI Rp340,000

PERAWATAN LEBIH
20 MARIAH 0000679074399 SRIGONCO COPD INTENSIF DR AULIANA RSUDK 1/24/2023 1/24/2023 29 N 1174 EP PITOYO Rp340,000

PERAWATAN LEBIH
21 JEMARI 0000677549597 TUMPAKREJO CVA INTENSIF DR AULIANA RSUDK 1/30/2023 1/30/2023 29 N 1174 EP SUPARDI Rp340,000

PERAWATAN LEBIH
22 ARJUNA RASYA 0003313904264 SRIGONCO OF INTENSIF DR AULIANA RSUDK 1/24/2023 1/24/2023 29 N 1403 EP PITOYO Rp340,000

PERAWATAN LEBIH
23 IDA ASTUTI 0001477444893 BANTUR R06 INTENSIF DR AULIANA RS MITRA DELIMA 1/31/2023 1/31/2023 31 N 1174 EP PITOYO Rp360,000

PERAWATAN LEBIH
24 PONIMAN 0001038171328 BANTUR CVA INTENSIF DR AULIANA RS MITRA DELIMA 1/25/2023 1/25/2023 31 N 1174 EP PITOYO Rp360,000

PERAWATAN LEBIH
25 RANTIYEM 0002680659865 BANTUR ABDOMINAL PAIN INTENSIF DR AULIANA RSUDK 1/26/2023 1/26/2023 29 N 1403 EP SUPARDI Rp340,000
 Rp7,140,000

Bantur, FEBRUARI 2023

Kepala UPT Puskesmas Bantur

SOEBAGIJONO, S.Kep, M.Mkes

NIP. 19681009 199003 1 003

REKAP PENGAJUAN KLAIM RJTP ( Ambulance ) PUSKESMAS BANTUR

BULAN januari 2023
ALASAN DOKTER FASKES TGL TGL KM NO POL
AMBULANC DRIVER TARIF
DIRUJUK PERUJUK TUJUAN MRS DIRUJUK E
NO NAMA NO KARTU ALAMAT DIAGNOSA

PERAWATAN LEBIH
1 BAYU EKO SETIAWAN 0000677446659 WONOREJO T75 INTENSIF DR NEVY RS MITRA DELIMA 2/1/2023 2/1/2023 31 N 1174 EP SUPARDI Rp360,000
PERAWATAN LEBIH
2 TRIANINGSIH 0002769373146 SRIGONCO O14 INTENSIF DR NEVY RSUD KANJURUHAN 2/4/2023 2/4/2023 29 N 1174 EP SUPARDI Rp340,000
PERAWATAN LEBIH
3 KASTI 0000678690279 TUMPAKREJO CVA INTENSIF DR NEVY RSUD KANJURUHAN 2/5/2023 2/5/2023 29 N 1174 EP SUPARDI Rp340,000
PERAWATAN LEBIH
4 PAINO 0000678158649 REJOSARI OF INTENSIF DR NEVY RSIG 2/3/2023 2/7/2023 20 N 1174 EP PITOYO Rp250,000
PERAWATAN LEBIH
5 WIYONO 0003010765149 SUMBERBENING I50 INTENSIF DR NEVY RSUD KANJURUHAN 2/9/2023 2/9/2023 29 N 1174 EP PITOYO Rp340,000
PERAWATAN LEBIH
6 YUSILUL CHABIBAH 0002311754229 BANTUR CVA INTENSIF DR NEVY RSUD KANJURUHAN 2/8/2023 2/8/2023 29 N 1174 EP PITOYO Rp340,000
PERAWATAN LEBIH
7 ARIFIN 0000678809777 BANTUR K62 INTENSIF DR NEVY RSUD KANJURUHAN 2/15/2023 2/15/2023 29 N 1174 EP SUPARDI Rp340,000
PERAWATAN LEBIH
8 MULYANI 0000677874374 TUMPAKREJO CHEST PAIN INTENSIF DR AULIANA RSUD KANJURUHAN 2/16/2023 2/16/2023 29 N 1174 EP PITOYO Rp340,000
PERAWATAN LEBIH
9 HERU WIDIANTO 0002600952107 BANTUR CVA INTENSIF DR AULIANA RSUD KANJURUHAN 2/16/2023 2/16/2023 29 N 1174 EP PITOYO Rp340,000
PERAWATAN LEBIH
10 NGATIYEM 0000679661201 TUMPAKREJO R06 INTENSIF DR AULIANA RSUD KANJURUHAN 2/16/2023 2/16/2023 29 N 1174 EP PITOYO Rp340,000
PERAWATAN LEBIH
11 SITI ASPIYAH 0000110797672 BANTUR HT INTENSIF DR AULIANA RSUD KANJURUHAN 2/17/2023 2/17/2023 29 N 1174 EP SUPARDI Rp340,000
PERAWATAN LEBIH
12 SUPATEMI 0000110260708 TUMPAKREJO CVA INTENSIF DR AULIANA RSUD KANJURUHAN 2/13/2023 2/13/2023 29 N 1174 EP PITOYO Rp340,000
PERAWATAN LEBIH
13 SUWARTI TRIANINGSIH 0000678926002 BANDUNGREJO O42 INTENSIF DR AULIANA WAVA 2/18/2023 2/18/2023 29 N 1174 EP SUPARDI Rp340,000
PERAWATAN LEBIH
14 RIRIN 0000678629711 SRIGONCO K56 INTENSIF DR AULIANA RSIG 2/22/2023 2/22/2023 20 N 1174 EP SUPARDI Rp250,000
PERAWATAN LEBIH
15 USWATUN KHASANA 0000678173545 BANTUR HT INTENSIF DR AULIANA RS MITRA DELIMA 2/26/2023 2/28/2023 31 N 1174 EP SUPARDI Rp360,000
 PERAWATAN LEBIH
16 TUNI 0002273870744 SRIGONCO HT INTENSIF DR AULIANA RSUD KANJURUHAN 2/28/2023 2/28/2023 29 N 1174 EP PITOYO Rp340,000
PERAWATAN LEBIH
17 MUNANTI 0001430810381 BANTUR CVA INTENSIF DR NEVY RSUD KANJURUHAN 2/9/2023 2/9/2023 29 N 1174 EP PITOYO Rp340,000
18
19

Rp5,640,000

Bantur, APRIL 2023

Kepala UPT Puskesmas Bantur

SOEBAGIJONO, S.Kep, M.Mkes

NIP. 19681009 199003 1 003

REKAP PENGAJUAN KLAIM RJTP ( Ambulance ) PUSKESMAS BANTUR

BULAN MARET 2023
ALASAN DOKTER FASKES TGL TGL KM NO POL
AMBULANC DRIVER TARIF
DIRUJUK PERUJUK TUJUAN MRS DIRUJUK E
NO NAMA NO KARTU ALAMAT DIAGNOSA

PERAWATAN LEBIH
1 MARTIAH 0000677696242 WONOREJO R16 INTENSIF DR NEVY RSUD KANJURUHAN 3/3/2023 3/3/2023 29 N 1174 EP SOEPARDI Rp340,000
PERAWATAN LEBIH
2 JASMUN 0002421156587 BANTUR DM INTENSIF DR NEVY RSUD KANJURUHAN 3/3/2023 3/3/2023 29 N 1174 EP SOEPARDI Rp340,000
PERAWATAN LEBIH
3 MAUL 0002606603916 REJOSARI R06 INTENSIFLEBIH DR NEVY RSUD KANJURUHAN 3/5/2023 3/5/2023 29 N 1174 EP PITOYO Rp340,000
PERAWATAN
4 KARSIIN 0003246326458 BANTUR R10 INTENSIF DR NEVY RS MITRA DELIMA 3/5/2023 3/5/2023 31 N 1174 EP PITOYO Rp360,000
PERAWATAN LEBIH
5 MISDI 0003336963388 PAGAK R07 INTENSIF DR NEVY RSUD KANJURUHAN 3/6/2023 3/7/2023 29 N 1174 EP PITOYO Rp340,000

PERAWATAN LEBIH
6 SRI UTAMI 0000678528505 BANDUNGREJO O42 INTENSIF DR NEVY RS WAVA 3/9/2023 3/9/2023 29 N 1174 EP PITOYO Rp340,000
PERAWATAN LEBIH
7 BY NY NURIN ERNAWATI 0003512771943 BANDUNGREJO ASPIXIA INTENSIF DR NEVY RSUD KANJURUHAN 3/15/2023 3/15/2023 29 N 1174 EP PITOYO Rp340,000
PERAWATAN LEBIH
8 ISWANTO 0002865436839 BANTUR OF INTENSIF DR NEVY RS WAVA 3/10/2023 3/10/2023 29 N 1174 EP SOEPARDI Rp340,000
PERAWATAN LEBIH
9 SIDEM 0000679003367 TUMPAKREJO I63 INTENSIF DR AULIANA RSUD KANJURUHAN 3/23/2023 3/23/2023 29 N 1174 EP SOEPARDI Rp340,000
PERAWATAN LEBIH
10 MANITA 0003246232195 SUMBERBENING O98 INTENSIF DR AULIANA RS WAVA 3/26/2023 3/27/2023 29 N 1174 EP SOEPARDI Rp340,000
PERAWATAN LEBIH
11 NUR ASMAWATI 0003012689542 SRIGONCO A91 INTENSIF DR AULIANA RSUD KANJURUHAN 3/18/2023 3/20/2023 29 N 1174 EP SOEPARDI Rp340,000
PERAWATAN LEBIH
12 ANGGITA 0003142974418 SRIGONCO OF INTENSIF DR AULIANA RSUD KANJURUHAN 3/13/2023 3/16/2023 29 N 1174 EP PITOYO Rp340,000
PERAWATAN LEBIH
13 SUMIATI 0000678744371 BANTUR R10 INTENSIF DR AULIANA RS MITRA DELIMA 3/27/2023 3/29/2023 31 N 1174 EP PITOYO Rp360,000
PERAWATAN LEBIH
14 NGATIMAN 0003246407886 BANTUR OF INTENSIF DR AULIANA RS MITRA DELIMA 3/29/2023 3/29/2023 31 N 1174 EP PITOYO Rp360,000

Rp4,820,000
 Kepala UPT Puskesmas Bantur

SOEBAGIJONO, S.Kep, M.Mkes

NIP. 19681009 199003 1 003

REKAP PENGAJUAN KLAIM RJTP ( Ambulance ) PUSKESMAS BANTUR

BULAN MARET 2023
ALASAN DOKTER FASKES TGL TGL KM NO POL
AMBULANC DRIVER TARIF
DIRUJUK PERUJUK TUJUAN MRS DIRUJUK E
NO NAMA NO KARTU ALAMAT DIAGNOSA

PERAWATAN LEBIH
1 SURATIN 0001038170889 BANTUR APENDICITIS INTENSIF DR NEVI RSUD KANJURUHAN 1/5/2023 1/5/2023 29 N 1174 EP PITOYO Rp340,000
PERAWATAN LEBIH
2 YANTI 0000677846034 SRIGONCO O42 INTENSIF DR NEVI RS BENMARI 1/5/2023 1/5/2023 36 N 1174 EP PITOYO Rp410,000
PERAWATAN LEBIH
3 SALSABILA IRDINA 0002454178803 BANDUNGREJO OF INTENSIF DR NEVI RSUD KANJURUHAN 1/10/2023 1/10/2023 29 N 1174 EP SOEPARDI Rp340,000
PERAWATAN LEBIH
4 SANTI 0000110799369 BANTUR CVA INTENSIFLEBIH DR NEVI RS WAVA 1/13/2023 1/13/2023 29 N 1174 EP SOEPARDI Rp340,000
PERAWATAN
5 MISELIN 0003137423859 BANDUNGREJO I25 INTENSIF DR NEVI RSUD KANJUURUHAN 1/10/2023 1/10/2023 29 N 1174 EP SOEPARDI Rp340,000
PERAWATAN LEBIH
6 MATYADI 0000679496984 SRIGONCO R10 INTENSIF DR NEVI RSUD KANJURUHAN 1/4/2023 1/7/2023 29 N 1174 EP PITOYO Rp340,000
PERAWATAN LEBIH
7 FITRIATUL KHASANAH 0001314703427 BSANTUR A91 INTENSIF DR NEVI RSI GONDANGLEGI 1/10/2023 1/12/2023 20 N 1174 EP PITOYO Rp250,000
PERAWATAN LEBIH
8 AURA PUSPA DEWI 0000678251518 BANDUNGREJO R06 INTENSIF DR NEVI RSUD KANJURUHAN 1/7/2023 1/8/2023 29 N 1174 EP PITOYO Rp340,000
PERAWATAN LEBIH
9 REGINA JALESTIANA 0003010605581 SRIGONCO TAKIKARDI INTENSIF DR AULIANA RSUD KANJURUHAN 1/20/2023 1/20/2023 29 N 1174 EP SOEPARDI Rp340,000
PERAWATAN LEBIH
10 SATUN 0000678147489 PRINGGOINDANI DHF INTENSIF DR AULIANA RSI GONDANGLEGI 1/21/2023 1/21/2023 20 N 1174 EP SOEPARDI Rp250,000
PERAWATAN LEBIH
11 PONIYEM 0000679867896 BANTUR HF INTENSIF DR AULIANA RSUD KANJURUHAN 1/23/2023 1/23/2023 29 N 1174 EP PITOYO Rp340,000
PERAWATAN LEBIH
12 WINDI RINDAWATI 0002609131184 SRIGONCO DHF INTENSIF DR AULIANA RS MITRA DELIMA 1/21/2023 1/21/2023 32 N 1174 EP PITOYO Rp360,000
PERAWATAN LEBIH
13 LUTFIATUN NAFIAH 0003056785773 SRIGONCO OF INTENSIF DR AULIANA RSUD KANJURUHAN 1/22/2023 1/22/2023 29 N 1174 EP SOEPARDI Rp340,000
PERAWATAN LEBIH
14 ERMIA SARI 0000677439213 WONOREJO O90 INTENSIF DR NEVI RSUD KANJURUHAN 1/12/2023 1/12/2023 29 N 1174 EP PITOYO Rp340,000

Rp4,670,000

Kepala UPT Puskesmas Bantur

SOEBAGIJONO, S.Kep, M.Mkes

NIP. 19681009 199003 1 003
 REKAP PENGAJUAN KLAIM RJTP ( Ambulance ) PUSKESMAS BANTUR
BULAN januari 2023
ALASAN DOKTER FASKES TGL TGL KM NO POL
AMBULANC DRIVER TARIF
DIRUJUK PERUJUK TUJUAN MRS DIRUJUK E
NO NAMA NO KARTU ALAMAT DIAGNOSA

PERAWATAN LEBIH
1 BAYU EKO SETIAWAN 0000677446659 WONOREJO T75 INTENSIF DR NEVY RS MITRA DELIMA 2/1/2023 2/1/2023 31 N 1174 EP SUPARDI Rp360,000
PERAWATAN LEBIH
2 TRIANINGSIH 0002769373146 SRIGONCO O14 INTENSIF DR NEVY RSUD KANJURUHAN 2/4/2023 2/4/2023 29 N 1174 EP SUPARDI Rp340,000
PERAWATAN LEBIH
3 KASTI 0000678690279 TUMPAKREJO CVA INTENSIF DR NEVY RSUD KANJURUHAN 2/5/2023 2/5/2023 29 N 1174 EP SUPARDI Rp340,000
PERAWATAN LEBIH
4 PAINO 0000678158649 REJOSARI OF INTENSIF DR NEVY RSIG 2/3/2023 2/7/2023 20 N 1174 EP PITOYO Rp250,000
PERAWATAN LEBIH
5 WIYONO 0003010765149 SUMBERBENING I50 INTENSIF DR NEVY RSUD KANJURUHAN 2/9/2023 2/9/2023 29 N 1174 EP PITOYO Rp340,000
PERAWATAN LEBIH
6 YUSILUL CHABIBAH 0002311754229 BANTUR CVA INTENSIF DR NEVY RSUD KANJURUHAN 2/8/2023 2/8/2023 29 N 1174 EP PITOYO Rp340,000
PERAWATAN LEBIH
7 ARIFIN 0000678809777 BANTUR K62 INTENSIF DR NEVY RSUD KANJURUHAN 2/15/2023 2/15/2023 29 N 1174 EP SUPARDI Rp340,000
PERAWATAN LEBIH
8 MULYANI 0000677874374 TUMPAKREJO CHEST PAIN INTENSIF DR AULIANA RSUD KANJURUHAN 2/16/2023 2/16/2023 29 N 1174 EP PITOYO Rp340,000
PERAWATAN LEBIH
9 HERU WIDIANTO 0002600952107 BANTUR CVA INTENSIF DR AULIANA RSUD KANJURUHAN 2/16/2023 2/16/2023 29 N 1174 EP PITOYO Rp340,000
PERAWATAN LEBIH
10 NGATIYEM 0000679661201 TUMPAKREJO R06 INTENSIF DR AULIANA RSUD KANJURUHAN 2/16/2023 2/16/2023 29 N 1174 EP PITOYO Rp340,000
PERAWATAN LEBIH
11 SITI ASPIYAH 0000110797672 BANTUR HT INTENSIF DR AULIANA RSUD KANJURUHAN 2/17/2023 2/17/2023 29 N 1174 EP SUPARDI Rp340,000
PERAWATAN LEBIH
12 SUPATEMI 0000110260708 TUMPAKREJO CVA INTENSIF DR AULIANA RSUD KANJURUHAN 2/13/2023 2/13/2023 29 N 1174 EP PITOYO Rp340,000
PERAWATAN LEBIH
13 SUWARTI TRIANINGSIH 0000678926002 BANDUNGREJO O42 INTENSIF DR AULIANA WAVA 2/18/2023 2/18/2023 29 N 1174 EP SUPARDI Rp340,000
PERAWATAN LEBIH
14 RIRIN 0000678629711 SRIGONCO K56 INTENSIF DR AULIANA RSIG 2/22/2023 2/22/2023 20 N 1174 EP SUPARDI Rp250,000
PERAWATAN LEBIH
15 USWATUN KHASANA 0000678173545 BANTUR HT INTENSIF DR AULIANA RS MITRA DELIMA 2/26/2023 2/28/2023 31 N 1174 EP SUPARDI Rp360,000
PERAWATAN LEBIH
16 TUNI 0002273870744 SRIGONCO HT INTENSIF DR AULIANA RSUD KANJURUHAN 2/28/2023 2/28/2023 29 N 1174 EP PITOYO Rp340,000
PERAWATAN LEBIH
17 MUNANTI 0001430810381 BANTUR CVA INTENSIF DR NEVY RSUD KANJURUHAN 2/9/2023 2/9/2023 29 N 1174 EP PITOYO Rp340,000
18
19

Rp5,640,000

Bantur, APRIL 2023

Kepala UPT Puskesmas Bantur

SOEBAGIJONO, S.Kep, M.Mkes

NIP. 19681009 199003 1 003

4 PONIMAN 0001038171328 BANTUR THYPOID 11/1/2022 11/4/2022 3 Rp 540,000 ###

5 PURNOMO 0002923258566 BANTUR ABDOMINAL PAIN 11/1/2022 11/4/2022 3 Rp 540,000 ###
 6 BUNASI 0000678478601 BANTUR HT 11/2/2022 11/6/2022 4 Rp 720,000 ###
7 AHMAD YOMA 0002320418204 SRIGONCO OF 11/2/2022 11/5/2022 3 Rp 540,000 ###
8 DIMAS ADI PRAYOGA 0002604023212 PRINGGONDANI OF 11/2/2022 11/5/2022 3 Rp 540,000 ###
9 AHMAD ZAINURI 0001702350729 SUMBERBENING DIARE 11/2/2022 11/5/2022 3 Rp 540,000 ###
10 KASMIN 0001038171622BANTUR ABDOMINAL PAIN 11/5/2022 11/8/2022 3 Rp 540,000 ###
11 BAMBANG 0000678939592 PRINGGONDANI VERTIGO 11/5/2022 11/8/2022 3 Rp 540,000 ###
12 SELAMET EFENDI 0002680659213 PRINGGONDANI OF 11/4/2022 11/7/2022 3 Rp 540,000 ###
13 SURATNO 0003214736098 BANTUR 082132489712 COPD 11/3/2022 11/7/2022 4 Rp 720,000 ###
14 KHUMAIROTUL AMALIA 0002209845396 BANTUR 085604248731 VERTIGO 11/4/2022 11/7/2022 3 Rp 540,000 ###
15 NURJIKIN 0000678746474 BANTUR OF 11/4/2022 11/7/2022 3 Rp 540,000 ###
16 SYAHRONI ROHMAN 0002159892909 BANDUNGREJO OF 11/7/2022 11/10/2022 3 Rp 540,000 ###
17 WIJAYANTO 0000679095753 BANTUR 085855955788 OF 11/7/2022 11/10/2022 3 Rp 540,000 ###
18 ARVINO DAVIANDRA 0003142980549 WONOREJO DIARE 11/6/2022 11/10/2022 4 Rp 720,000 ###
19 WAHYU 0001800095365 GOMBANGAN 085755907346 OF 11/6/2022 11/10/2022 4 Rp 720,000 ###
20 SUWAJI 0003174940528 BANTUR 085869438699 DHF 11/8/2022 11/11/2022 3 Rp 540,000 ###
21 SIMIN 0002327639062 BANTUR HT 11/8/2022 11/11/2022 3 Rp 540,000 ###
22 MUHAMAD ALI 0003149806241 SRIGONCO 081359228890 OF 11/7/2022 11/11/2022 4 Rp 720,000 ###
23 YULIK 0002004875324 WONOREJO 085692208062 OF 11/10/2022 11/13/2022 3 Rp 540,000 ###
24 PARMINTO 0002026278898 TUMPAKREJO COPD 11/7/2022 11/11/2022 4 Rp 720,000 ###
25 ASY SYIFA PUTRI 0001874804365 BANTUR VOMITING 11/10/2022 11/14/2022 4 Rp 720,000 ###
26 DJOAWARINI 0001897443393 BANTUR HT 11/11/2022 11/14/2022 3 Rp 540,000 ###
27 MITA RISMAWATI 0003149805767 BANTUR OF 11/11/2022 11/14/2022 3 Rp 540,000 ###
28 DEVI NUR ANGGRAENI 0000678533679 SUMBERBENING OF 11/12/2022 11/15/2022 3 Rp 540,000 ###
29 MISTIKAH 0002004843115 BANTUR OF 11/14/2022 11/17/2022 3 Rp 540,000 ###
30 FITAATI AULIA SARI 0000684549696 BANTUR OF 11/14/2022 11/17/2022 3 Rp 540,000 ###
31 SAID 0000679251262 SRIGONCO 085955251119 HF 15/11/2022/ 1/2/1900 3 Rp 540,000 ###
32 PAINEM 0001959313206 SRIGONCO 085755403776 OF 11/15/2022 11/18/2022 3 Rp 540,000 ###
33 SUWAJI 0003174940528 BANTUR VOMITING 11/16/2022 11/19/2022 3 Rp 540,000 ###
34 SUMINAH 0003149806329 BANTUR VOMITING 11/18/2022 11/21/2022 3 Rp 540,000 ###
35 PUJI LESTARI 0002004902471 BANDUNGREJO 08595449012 VERTIGO 11/17/2022 11/21/2022 4 Rp 720,000 ###
36 ARSYLA NAUFAL 0002238128741 SRIGONCO DHF 11/17/2022 11/20/2022 3 Rp 540,000 ###
37 VANESSA YUMNA 0003186444576 PRINGGONDANI OF 11/18/2022 11/21/2022 3 Rp 540,000 ###
38 AJENG ANGGELINA 0002004877787 BANTUR 082257183110 OF 11/18/2022 11/21/2022 3 Rp 540,000 ###
39 ISMIA USWATUN 0003010605579 SRIGONCO DIARE 11/19/2022 11/23/2022 4 Rp 720,000 ###
40 ALMA NUR AUYLIA 0002468856273 SRIGONCO 081217039158 OF 11/21/2022 11/24/2022 3 Rp 540,000 ###
41 AGNES DIFA 0000678404507 SRIGONCO OF 11/21/2022 11/24/2022 3 Rp 540,000 ###
42 SUTRI 0003012731098 CIPTOMULYO VOMITING 11/21/2022 11/24/2022 3 Rp 540,000 ###
43 DWI NURSULISTYOWATI 0000678431889 BANDUNGREJO 081330160882 THYPOID 11/25/2022 11/28/2022 3 Rp 540,000 ###
44 NIDI 0002603095334 KARANGSARI DIARE 11/27/2022 11/30/2022 3 Rp 540,000 ###
45 JUSUB 0002605407726 REJOSARI DHF 11/26/2022 11/29/2022 3 Rp 540,000 ###
46 NOVIN DWI 0003121471394 GOMBANGAN OF 11/22/2022 11/25/2022 3 Rp 540,000 ###
47 TIRON 0002730018756 BANTUR 082233299535 CELULITIS 11/25/2022 11/28/2022 3 Rp 540,000 ###

###
Pembuat Daftar

SOEBAGIJONO, S.Kep, M.Mkes

NIP. 19681009 199003 1 003 RIZKI VATVIANTO
NIP. 199506272019031005
 REKAP PENGAJUAN KLAIM RJTP ( Ambulance ) PUSKESMAS BANTUR
BULAN november 2022
ALASAN DOKTER FASKES TGL TGL KM NO POL DRIVER TARIF
DIRUJUK PERUJUK TUJUAN MRS DIRUJUK AMBULANCE
NO NAMA NO KARTU ALAMAT DIAGNOSA

PERAWATAN LEBIH
1 HADIYONO 0002635188344 DERMOGANTI ABDOMINAL PAIN
INTENSIF
DR NEVY RSUD KANJURUHAN+H282:H293 11/1/2022 11/1/2022 26 N 1174 EP PITOYO Rp250,000

PERAWATAN LEBIH
2 AHMAD UBAIDILLAH 0002456273744 SUMBERBENING G61
INTENSIF
DR NEVY RSSA 11/2/2022 11/2/2022 45 N 1174 EP PITOYO Rp370,000

PERAWATAN LEBIH
3 WAKINI 0000678245488 SRIGONCO R06
INTENSIF
DR NEVY RSUD KANJURUHAN 11/3/2022 11/3/2022 26 N 1174 EP SUPARDI Rp250,000

PERAWATAN LEBIH
4 PARIMAN 0001438407898 GEDANGAN ABDOMINAL PAIN
INTENSIF
DR NEVY RSUD KANJURUHAN 11/4/2022 11/4/2022 26 N 1174 EP SUPARDI Rp250,000

PERAWATAN LEBIH
6 MISELIN 0003137423859 SUMBERBENING BRONKITIS
INTENSIF
DR NEVY RSUD KANJURUHAN 11/2/2022 11/2/2022 26 N 1174 EP SUPARDI Rp250,000

PERAWATAN LEBIH
7 SURATNO 0003214736098 BANTUR COPD
INTENSIF
DR NEVY RSUD KANJURUHAN 11/3/2022 11/7/2022 26 N 1174 EP PITOYO Rp250,000

PERAWATAN LEBIH
8 ERNI 0000678240077 BANTUR I15
INTENSIF
DR NEVY RSUD KANJURUHAN 7/11/20222 11/7/2022 26 N 1174 EP PITOYO Rp250,000

PERAWATAN LEBIH
9 MUHAMAD RIZQI 0003186444104 BANTUR OF
INTENSIF
DR NEVY RSI GONDANGLEGI 11/9/2022 11/9/2022 20 N 1174 EP PITOYO Rp180,000

PERAWATAN LEBIH
10 ririn puspitawati 0003149793099 SUMBERBENING O14 INTENSIF DR NEVY RSUD KANJURUHAN 11/11/2022 11/11/2022 26 N 1174 EP PITOYO Rp250,000
PERAWATAN LEBIH
11 ARSYLA NAUFALYN 0002238128741 SRIGONCO A91 INTENSIF DR AULIANA RSIG 11/17/2022 11/20/2022 20 N 1174 EP SUPARDI Rp180,000

Rp2,480,000

Bantur NOVEMBER 2022

Kepala UPT Puskesmas Bantur Pembuat Daftar

SOEBAGIJONO, S.Kep, M.Mkes RIZKI VATVIANTO

NIP. 19681009 199003 1 003 NIP. 199506272019031005

REKAP PENGAJUAN KLAIM RJTP ( Ambulance ) PUSKESMAS BANTUR

BULAN April 2023

NO POL
NO NAMA NO KARTU ALAMAT DIAGNOSA ALASAN DOKTER PERU FASKES TUJUAN TGL MRS TGL DIRUJUK KM AMBULANC DRIVER TARIF
E

PERAWATAN LEBIH
1 RUSEMI 0002926094343 BANTUR E11 INTENSIF DR NEVY RS MITRA DELIMA 4/15/2023 4/15/2023 31 N1140E0P SUPARDI Rp360,000

PERAWATAN LEBIH
2 PONIYEM 0000679867896 BANTUR R06 INTENSIF DR NEVY RS WAVA HUSADA 4/5/2023 4/5/2023 29 N1140E0P SUPARDI Rp340,000

PERAWATAN LEBIH
3 NURUL UMA URAFA IDA 0000678984862 BANTUR O021.1 INTENSIF DR NEVY RS MITRA DELIMA 4/12/2023 4/12/2023 31 N 1058 EP PITOYO Rp360,000
 PERAWATAN LEBIH
4 RENDY ARDIANSYAG S 0002263383663 BANTUR A91 INTENSIF DR NEVY RSUDK 4/10/2023 4/11/2023 29 N1140E0P SUPARDI Rp340,000

PERAWATAN LEBIH
5 SITI AIZAH 0000679399288 TUMPAKREJO J45.9 INTENSIF DR NEVY RSI GONDANGLEGI 4/14/2023 4/14/2023 20 N 1058 EP PITOYO Rp250,000

PERAWATAN LEBIH
6 MEGA ERINA 0001178635858 WONOREJO R50 INTENSIF DR NEVY RSUDK 4/14/2023 4/14/2023 29 N 1058 EP PITOYO Rp340,000

PERAWATAN LEBIH
7 IKA DHEA PERMATASARI 0002865434231 BANTUR O63.0 INTENSIF DR NEVY RS WAVA HUSADA 4/8/2023 4/8/2023 29 N1140E0P SUPARDI Rp340,000

PERAWATAN LEBIH
8 JUNARNO 0003246252963 PRINGGONDANI R07.4 INTENSIF DR NEVY RSI GONDANGLEGI 4/12/2023 4/12/2023 20 N1140E0P SUPARDI Rp250,000

PERAWATAN LEBIH
9 SURATEMAN 0003138225636 PAGELARAN R10 INTENSIF DR NEVY RSUDK 4/4/2023 4/4/2023 29 N1140E0P SUPARDI Rp340,000

PERAWATAN LEBIH
10 BUSIMAN 0003503020792 SUMBERBENING R50 INTENSIF DR AULIANA RSI GONDANGLEGI 4/13/2023 4/17/2023 20 N 1058 EP PITOYO Rp250,000

PERAWATAN LEBIH
11 GINI 0003516861082 TUMPAKREJO E11 INTENSIF DR NEVY RSUDK 4/6/2023 4/8/2023 29 N 1058 EP PITOYO Rp340,000

PERAWATAN LEBIH
12 SRIAMAH 0002627183215 SUMBERBENING A91 INTENSIF DR NEVY RSUDK 4/12/2023 4/15/2023 29 N1140E0P SUPARDI Rp340,000

PERAWATAN LEBIH
13 GALAXY DONY A 000324500079 SRIGONCO A91 INTENSIF DR NEVY RSUDK 4/4/2023 4/5/2023 29 N 1058 EP PITOYO Rp340,000

PERAWATAN LEBIH
14 MUJIONO 0002004851002 SRIGONCO E11 INTENSIF DR AULIANA RS MITRA DELIMA 4/21/2023 4/21/2023 31 N 1058 EP PITOYO Rp360,000

PERAWATAN LEBIH
15 MARSI 0002627002124 SRIGONCO B16 INTENSIF DR AULIANA RSI GONDANGLEGI 4/20/2023 4/20/2023 20 N1140E0P SUPARDI Rp250,000

PERAWATAN LEBIH
16 NUR SRI ANDAYANI 0003513878267 BANTUR O42.9 INTENSIF DR NEVY RSUDK 4/8/2023 4/8/2023 29 N 1058 EP PITOYO Rp340,000

PERAWATAN LEBIH
17 DIKA CANDRA 0000678638799 SUMBERBENING O32.9 INTENSIF DR AULIANA RSUDK 4/27/2023 4/27/2023 29 N 1058 EP PITOYO Rp340,000

PERAWATAN LEBIH
18 RIANI 0003519535004 SRIGONCO O14.9 INTENSIF DR AULIANA RSUDK 4/27/2023 4/27/2023 29 N1140E0P SUPARDI Rp340,000

PERAWATAN LEBIH
19 TATIK HARIANI 0002004929785 TUMPAKREJO R06 INTENSIF DR AULIANA RSUDK 4/27/2023 4/28/2023 29 N1140E0P SUPARDI Rp340,000

PERAWATAN LEBIH
20 ROKIM 0001038192546 TUMPAKREJO R11 INTENSIF DR AULIANA RSUDK 4/29/2023 4/30/2023 29 N 1058 EP PITOYO Rp340,000

PERAWATAN LEBIH
21 SENIWATI 0000677549597 TUMPAKREJO CVA INTENSIF DR AULIANA RSI GONDANGLEGI 4/17/2023 4/18/2023 20 N 1058 EP PITOYO Rp250,000

PERAWATAN LEBIH
22 RUPINI 0001038171238 BANTUR K30 INTENSIF DR AULIANA RSUDK 4/24/2023 4/27/2023 29 N 1058 EP PITOYO Rp340,000

PERAWATAN LEBIH
23 MISNAN 0003246233095 PRINGGONDANI I10 INTENSIF DR NEVY RSI GONDANGLEGI 4/29/2023 4/29/2023 20 N 1058 EP PITOYO Rp250,000

Rp7,340,000

Bantur, Mei 2023

Kepala UPT Puskesmas Bantur

SOEBAGIJONO, S.Kep, M.Mkes

NIP. 19681009 199003 1 003

REKAP PENGAJUAN KLAIM RJTP ( Ambulance ) PUSKESMAS BANTUR

BULAN JULI 2023

NO POL
NO NAMA NO KARTU ALAMAT DIAGNOSA ALASAN DOKTER PERU FASKES TUJUAN TGL MRS TGL DIRUJUK KM AMBULANC DRIVER TARIF
E
 NO POL
NO NAMA NO KARTU ALAMAT DIAGNOSA ALASAN DOKTER PERU FASKES TUJUAN TGL MRS TGL DIRUJUK KM AMBULANC DRIVER TARIF
E

PERAWATAN LEBIH
1 SAKRI 0003247278491 TUMPAKREJO R60.1 INTENSIF DR NEVY RS MITRA DELIMA 7/4/2023 7/4/2023 31 N1140E0P SUPARDI Rp360,000

PERAWATAN LEBIH
2 BUDI SANTOSO 0002919129344 BANTUR E87.5 INTENSIF DR NEVY RSUDK 7/5/2023 7/5/2023 29 N1140E0P SUPARDI Rp340,000

PERAWATAN LEBIH
3 SIMIN 0002327639062 BANTUR I63.9 INTENSIF DR NEVY RSUDK 7/18/2023 7/18/2023 29 N 1058 EP PITOYO Rp340,000

PERAWATAN LEBIH
4 PAIT ZULKARNAIN 0000678354614 TUMPAKREJO E11 INTENSIF DR NEVY RS MITRA DELIMA 7/9/2023 7/12/2023 31 N1140E0P SUPARDI Rp360,000

PERAWATAN LEBIH
5 JAKINEM 0000678144846 BANTUR R06 INTENSIF DR NEVY RSUDK 7/22/2023 7/22/2023 29 N 1058 EP PITOYO Rp340,000

PERAWATAN LEBIH
6 SITI 0000677880718 SUMBERBENING I50.9 INTENSIF DR NEVY RS MITRA DELIMA 7/27/2023 7/27/2023 31 N 1058 EP PITOYO Rp360,000

PERAWATAN LEBIH
7 HADI SUNARKO 0001105466747 KEPANJEN S83.1 INTENSIF DR NEVY RS SOEPRAOEN 7/28/2023 7/28/2023 46 N 1058 EP PITOYO Rp510,000

PERAWATAN LEBIH
8 WIJIATI 0003246167013 PRINGGONDANI I50.9 INTENSIF DR NEVY RS MITRA DELIMA 7/30/2023 7/30/2023 31 N 1058 EP PITOYO Rp360,000

PERAWATAN LEBIH
9 WIWIT TRISNAWATI 0002680652092 SUMBERBENING O73.0 INTENSIF DR NEVY RS WAVA HUSADA 7/7/2023 7/7/2023 29 N 1058 EP PITOYO Rp340,000

PERAWATAN LEBIH
10 HALIMAH 0000678089766 BANTUR D64.9 INTENSIF DR NEVY RS WAVA HUSADA 7/1/2023 7/1/2023 29 N 1058 EP PITOYO Rp340,000

Rp3,650,000

Bantur, Agustus 2023

Kepala UPT Puskesmas Bantur

SOEBAGIJONO, S.Kep, M.Mkes

NIP. 19681009 199003 1 003
 REKAP PENGAJUAN KLAIM ANC-INC-PNC DI FASKES TK I

TANGGAL JENIS PELAYANAN BESARAN TARIF NAKES YANG

NO NAMA PENDERITA NOMOR KARTU BPJS ALAMAT NO.TELP /HP
PELAYANAN (ANC/INC/PNC) PAKET MELAYANI

1 RUSIASEH 0003186443529 SUMBERBENING 2/21/2023 ANC Rp 140,000 DR NEVY

2 FITRI FEBRIANI 0000679127073 BANDUNGREJO 2/21/2023 ANC Rp 140,000 DR NEVY

3 SUNARTI 0000678093118 BANTUR 2/21/2023 ANC Rp 140,000 DR NEVY

4 WIWIT ISMAWATI 0000679577883 WONOREJO 2/21/2023 ANC Rp 140,000 DR NEVY

5 HOSTIYEH 0003012683398 BANTUR 2/28/2023 ANC Rp 140,000 DR NEVY

6 MISTRIA 0003110912381 SRIGONCO 2/28/2023 ANC Rp 140,000 DR NEVY

7 NOFA APRILIANA 0000758705038 BANTUR 2/28/2023 ANC Rp 140,000 DR NEVY

8 TITIN FITRIA 0003186451427 SRIGONCO 2/28/2023 ANC Rp 140,000 DR NEVY

Rp 1,120,000

REKAP PENGAJUAN KLAIM ANC-INC-PNC DI FASKES TK I

 TANGGAL JENIS PELAYANAN BESARAN TARIF NAKES YANG
NO NAMA PENDERITA NOMOR KARTU BPJS ALAMAT NO.TELP /HP
PELAYANAN (ANC/INC/PNC) PAKET MELAYANI
1 ERNI 0000679161159 PRINGGODANI 4/3/2023 ANC Rp 80,000 DR NEVY
2 MERRY CRISTIANI KOILAM 0002136891442 TUMPAKREJO 4/4/2023 ANC DENGAN USG Rp 140,000 DR NEVY
3 MITA IVA ROYANI 0002733532762 BANTUR 4/4/2023 ANC DENGAN USG Rp 140,000 DR NEVY

4 WIWIT PILUM 0003511668835 REJOSARI 4/4/2023 ANC DENGAN USG Rp 140,000 DR NEVY

5 DURORUL MAKRIFAH 0002842756209 BANTUR 4/4/2023 ANC Rp 80,000 DR NEVY

6 ERNA PUJI ASTUTI 0002004876066 BANTUR 4/6/2023 ANC Rp 80,000 DR NEVY

7 SUYATI 0000677934303 SRIGONCO 4/6/2023 ANC Rp 80,000 DR NEVY

8 DWI NURSULISTYOWATI 0000678431889 SUMBERBENING 4/6/2023 ANC Rp 80,000 DR NEVY

9 AYUN DANA SAFITRI 0002599636577 BANDUNGREJO 4/11/2023 ANC DENGAN USG Rp 140,000 DR NEVY

10 BINTI MAHMUDAH 0000678836586 BANDUNGREJO 4/11/2023 ANC DENGAN USG Rp 140,000 DR NEVY

11 GAFITRA NINGSIH 0003012689733 SRIGONCO 4/11/2023 ANC DENGAN USG Rp 140,000 DR NEVY

12 ANITA SARI 0000678810036 SUMBERBENING 4/11/2023 ANC DENGAN USG Rp 140,000 DR NEVY

13 EVILIA AGUSTINA 0003246134949 BANTUR 4/11/2023 ANC DENGAN USG Rp 140,000 DR NEVY

14 PUDYANING TRIFENA INDRASWARI 0002730018622 WONOREJO 4/13/2023 ANC Rp 80,000 DR NEVY

15 TATIA ASIH JAN PRATIWI 0000677426973 WONOREJO 4/18/2023 ANC DENGAN USG Rp 140,000 DR NEVY

16 EMELIA RUWAIDHATUL UMUMI 0002135585046 BANTUR 4/18/2023 ANC DENGAN USG Rp 140,000 DR NEVY

Rp 1,880,000

Kepala UPT Puskesmas Bantur

 SOEBAGIJONO, S.Kep, M.Mkes
NIP. 19681009
199003 1 003

REKAP PENGAJUAN KLAIM ANC-INC-PNC DI FASKES TK I BULAN JULI

TANGGAL JENIS PELAYANAN BESARAN TARIF NAKES YANG

NO NAMA PENDERITA NOMOR KARTU BPJS ALAMAT NO.TELP /HP
PELAYANAN (ANC/INC/PNC) PAKET MELAYANI
1 PURWATI NURSIATI 0000677839735 BANTUR 7/4/2023 ANC DENGAN USG Rp 140,000 DR NEVY

2 RIWAYATI 0003335836342 TUMPAKREJO 7/4/2023 ANC DENGAN USG Rp 140,000 DR NEVY

3 I'IF PRAVITA SARI 0002229041103 BANTUR 7/4/2023 ANC DENGAN USG Rp 140,000 DR NEVY

4 TITIK RIWAYATI 0003335496478 TUMPAKREJO 7/4/2023 ANC DENGAN USG Rp 140,000 DR NEVY

5 TITI 0003116740612 SRIGONCO 7/4/2023 ANC DENGAN USG Rp 140,000 DR NEVY

6 SUMIANI 0000677916099 SUMBERBENING 7/4/2023 ANC DENGAN USG Rp 140,000 DR NEVY

7 LAILATUL FITRIAH 0002004874582 SUMBERBENING 7/4/2023 ANC DENGAN USG Rp 140,000 DR NEVY

8 ISNAINI RAHAYU 0001396086232 SURABAYA 7/4/2023 ANC DENGAN USG Rp 140,000 DR NEVY

9 UTI HANIAN 0003528634217 BANTUR 7/11/2023 ANC DENGAN USG Rp 140,000 DR NEVY

10 FAIDATUL FATONAH 0003246172345 SUMBERBENING 7/11/2023 ANC DENGAN USG Rp 140,000 DR NEVY

11 ULFA MAWADDATURROKHMAH 0000718580272 MEGERSARI 7/11/2023 ANC DENGAN USG Rp 140,000 DR NEVY

12 SITI JUBA'IDAH 0003523484608 SUMBERBENING 7/11/2023 ANC DENGAN USG Rp 140,000 DR NEVY

13 CITRA 0000677841164 BANDUNGREJO 7/11/2023 ANC DENGAN USG Rp 140,000 DR NEVY

14 LUTFIATUN NAFI'A 0003246414963 BANTUR 7/11/2023 ANC DENGAN USG Rp 140,000 DR NEVY
15 SITI KOMARIYAH 0002680658741 BANTUR 7/18/2023 ANC DENGAN USG Rp 140,000 DR NEVY

16 SITI LESTARI 0002873854653 SRIGONCO 7/18/2023 ANC DENGAN USG Rp 140,000 DR NEVY

17 RIWAYATI MAYANGSARI 0000678509403 BANTUR 7/18/2023 ANC DENGAN USG Rp 140,000 DR NEVY

18 MISENAH 0000679064861 TUMPAKREJO 7/18/2023 ANC DENGAN USG Rp 140,000 DR NEVY

19 IKA PUJIATI 0002680654702 SRIGONCO 7/18/2023 ANC DENGAN USG Rp 140,000 DR NEVY

20 ERNI 0000679161159 PRINGGODANI 7/18/2023 ANC DENGAN USG Rp 140,000 DR NEVY

21 ERY NUR BHAETHY ROHMA 0002803714402 SUMBERBENING 7/18/2023 ANC DENGAN USG Rp 140,000 DR NEVY

22 SUMIATI 0000678742817 BANTUR 7/25/2023 ANC DENGAN USG Rp 140,000 DR NEVY

23 SITI MUDAIYAH 0003246145503 BANTUR 7/25/2023 ANC DENGAN USG Rp 140,000 DR NEVY

24 SANTIA DESY WULANDARI 0001594888683 WONOREJO 7/25/2023 ANC DENGAN USG Rp 140,000 DR NEVY

25 LAILATUL FITRIYAH 0003337044906 KANIGORO 7/28/2023 ANC DENGAN USG Rp 140,000 DR NEVY

Rp 3,500,000

Bantur, AGUSTUS 2023

Kepala UPT
Puskesmas Bantur

SOEBAGIJONO, S.Kep, M.Mkes

NIP. 19681009
199003 1 003
 REKAP PENGAJUAN KLAIM RJTP ( KB ) PUSKESMAS BANTUR
BULAN JANUARI 2023
TANGGAL JENIS TARIF
BIDAN
PELY KB PAKET
NO NAMA NO KARTU ALAMAT DIAGNOSA

1 SRI BAWON 0002004853015 BANTUR Z30.4 1/2/2023 SUNTIK Rp 15,000 SITI YUNI M
2 INDRA NUR 0000103871271 BANTUR Z30.4 1/5/2023 SUNTIK Rp 15,000 SITI YUNI M
3 RATIH RATNASARI 0000679549915 BANTUR Z30.4 1/6/2023 SUNTIK Rp 15,000 SITI YUNI M
4 DWI LUVIANINGSIH 0000677430718 WONOREJO Z30.8 1/3/2023 IMPLANT Rp 100,000 SITI YUNI M
5 NURLIZA AINUNJZA 0000679891375 BANTUR Z30.4 1/9/2023 SUNTIK Rp 15,000 SITI YUNI M
6 IDA AYU SANDRA 0002305646627 REJOSARI Z30.8 1/9/2023 IMPLANT Rp 100,000 SITI YUNI M
7 MISTINAH 0000678989981 SRIGONCO Z30.4 1/9/2023 SUNTIK Rp 15,000 SITI YUNI M
8 SITI JUMIATIN 0002077262572 BANTUR Z30.8 1/9/2023 IMPLANT Rp 100,000 SITI YUNI M
9 LIDAYATI 0003010609225 BANTUR Z30.8 1/14/2023 IMPLANT Rp 100,000 SITI YUNI M
10 SRI UTAMININGSIH 0002004850574 BANTUR Z30.4 1/14/2023 SUNTIK Rp 15,000 SITI YUNI M
11 CINDY NOVITA 0001982538854 BANTUR Z30.4 1/16/2023 SUNTIK Rp 15,000 SITI YUNI M
12 NURUL IKAWATI 0000678234655 BANDUNGREJO Z30.4 1/16/2023 SUNTIK Rp 15,000 SITI YUNI M
13 ARYANTI SAPITRI 0001195523133 BANTUR Z30.8 1/19/2023 IMPLANT Rp 100,000 SITI YUNI M
14 MARGARET 0002629577259 WONOREJO Z30.4 1/19/2023 SUNTIK Rp 15,000 SITI YUNI M
15 MAYA RINI 0003278015019 SRIGONCO Z30.4 1/21/2023 SUNTIK Rp 15,000 SITI YUNI M
16 USWATUL HASANAH 0000678746801 BANTUR Z30.4 1/20/2023 SUNTIK Rp 15,000 SITI YUNI M
17 SITI KHOLIFAH 0000678173411 BANTUR Z30.8 1/25/2023 IMPLANT Rp 105,000 SITI YUNI M
18 SITI MAESAROH 0002219398615 BANTUR Z30.4 1/25/2023 SUNTIK Rp 20,000 SITI YUNI M
19 WAGIYEM 0001480385193 BANTUR Z30.4 1/25/2023 SUNTIK Rp 20,000 SITI YUNI M
20 FERAWATI 0002682000336 BANTUR Z30.4 1/25/2023 SUNTIK Rp 20,000 SITI YUNI M
21 SAADAH '0002452760482 BANTUR Z30.8 1/30/2023 IMPLANT Rp 105,000 SITI YUNI M

Rp 935,000
Bantur, FEBRUARI 2023
Kepala UPT Puskesmas Bantur

SOEBAGIJONO, S.Kep, M.Mkes

NIP. 19681009 199003 1 003