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P2211000040621
Lambu
FORMULIR PENGAJUAN KLAIM TINGKAT PERTAMA
BPJS Kesehatan Cab. BIMA
Nomor FPK
Provider
Bulan Pelayanan
Pelayanan
Total Data
Total Tagihan
:
:
:
:
:
:
November 2022
RJTP
5
Rp. 1.625.000
NoKunjungan NAMA TANGGAL TINDAKAN HASIL TENAGA MEDIS BIAYA
230402021122P000828 desi ANGGRIANI 04/11/2022 Evakuasi medis / Ambulans Darat 0.00 dr. NUR ARYANI Rp. 325.000
230402021122P000829 IBRAHIM 11/11/2022 Evakuasi medis / Ambulans Darat 0.00
DR. MUHAMMAD WILDANAS
SOLFI
Rp. 325.000
230402021122P000830 JASMAN 15/11/2022 Evakuasi medis / Ambulans Darat 0.00 DR. DEVI FEBRIANI Rp. 325.000
230402021122P000838 ANWAR 16/11/2022 Evakuasi medis / Ambulans Darat 0.00
DR. MUHAMMAD WILDANAS
SOLFI
Rp. 325.000
230402021122P000839 nuraini 28/11/2022 Evakuasi medis / Ambulans Darat 0.00
DR. MUHAMMAD WILDANAS
SOLFI
Rp. 325.000
Tanggal terima FPK,
Verifikator Pengaju Klaim
31/12/2022
Tanggal,

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RUJUKAN 11 2022.pdf

  • 1. P2211000040621 Lambu FORMULIR PENGAJUAN KLAIM TINGKAT PERTAMA BPJS Kesehatan Cab. BIMA Nomor FPK Provider Bulan Pelayanan Pelayanan Total Data Total Tagihan : : : : : : November 2022 RJTP 5 Rp. 1.625.000 NoKunjungan NAMA TANGGAL TINDAKAN HASIL TENAGA MEDIS BIAYA 230402021122P000828 desi ANGGRIANI 04/11/2022 Evakuasi medis / Ambulans Darat 0.00 dr. NUR ARYANI Rp. 325.000 230402021122P000829 IBRAHIM 11/11/2022 Evakuasi medis / Ambulans Darat 0.00 DR. MUHAMMAD WILDANAS SOLFI Rp. 325.000 230402021122P000830 JASMAN 15/11/2022 Evakuasi medis / Ambulans Darat 0.00 DR. DEVI FEBRIANI Rp. 325.000 230402021122P000838 ANWAR 16/11/2022 Evakuasi medis / Ambulans Darat 0.00 DR. MUHAMMAD WILDANAS SOLFI Rp. 325.000 230402021122P000839 nuraini 28/11/2022 Evakuasi medis / Ambulans Darat 0.00 DR. MUHAMMAD WILDANAS SOLFI Rp. 325.000 Tanggal terima FPK, Verifikator Pengaju Klaim 31/12/2022 Tanggal,