FORMULIR PENGAJUAN KLAIM JAMKESDA

RAWAT JALAN
PONKESDES DUSUN KOMIREAN DESA GUWA-GUWA RAAS
BULAN :JANUARI 2018

NO
TANGGAL NAMA NO.IDENTITAS UMUR ALAMAT DIAGNOSA KARCIS MASUK BIAYA TINDAKAN TOTAL BIAYA PARAF

1 28-12-2017 Sudirmanto 3529220805890002 29 TH Dsn. Komirean Gastritis (K.29) Rp. 7,500 Rp. 7,500
2 Usrifa 3529224512810002 37 TH Dsn. Komirean Common cold ( J.00) Rp. 7,500 Rp. 7,500
3 Hasim 3529221002433323 75 TH Dsn. Komirean Hipertensi (I.10) Rp. 7,500 Rp. 7,500
4 04-01-2018 Yasmani 3529224508630005 55 TH Dsn. komirean Neuralgia ( R. 53) Rp. 7,500 Rp. 7,500
5 06-01-2018 Erwin efendi 3529220911000002 18 TH Dsn. Komirean Common cold(J.00) Rp. 7,500 Rp. 7,500
6 Syarifudin andradi 3529220902010003 17 TH Dsn. Komirean Batuk ( J.10) Rp. 7,500 Rp. 7,500
7 08-01-2018 Sitqi 3529220406820004 36 TH Dsn. Komirean Dermatitis (L.20) Rp. 7,500 Rp. 7,500
8 10-01-2018 Rugina 3529225008800004 58 TH Dsn. Komirean Batuk ( J.10) Rp. 7,500 Rp. 7,500
9 Anna mariyah 3529225205910001 26 TH Dsn. Komirean Nyeri kepala ( R.51) Rp. 7,500 Rp. 7,500
10 11-01-2018 Hainor 3529221004820002 56 TH Dsn. Komirean Neuralgia ( R. 53) Rp. 7,500 Rp. 7,500
11 13-01-2018 Windarwati 3529226702880002 27 TH Dsn. Komirean Karies gigi (k.02) Rp. 7,500 Rp. 7,500
12 Momayya 3529225502730005 45 TH Dsn. komirean Asma ( j. 45 ) Rp. 7,500 Rp. 7,500
13 16-01-2018 Abd. Rahim 3529220808430002 75 TH Dsn. Komirean Hipertensi (I.10) Rp. 7,500 Rp. 7,500
14 17-01-2018 Salwe 3529225107030002 15 TH Dsn. Komirean Dermatitis (L.20) Rp. 7,500 Rp. 7,500
15 Saedah 3529224506460001 72 TH Dsn. Komirean Gastritis ( K.29) Rp. 7,500 Rp. 7,500
16 Haliluddin 3529221206880010 38 TH Dsn. komirean Chepalgia (R.51) Rp. 7,500 Rp. 7,500
17 18-01-2018 Tubne 3529226106820001 36 TH Dsn. Komirean Batuk ( J .10 ) Rp. 7,500 Rp. 7,500
18 Safi 3529220902690001 49 TH Dsn. komirean Neuralgia ( R. 53) Rp. 7,500 Rp. 7,500
19 20-01-2018 Ippatul warda 3529226303080002 10 TH Dsn. komirean Common cold ( J.00) Rp. 7,500 Rp. 7,500
20 23-01-2018 Ach fahri 3529220903100001 8 TH Dsn. Komirean Batuk ( J .10 ) Rp. 7,500 Rp. 7,500
21 Rio susanto 3529221405060002 12 TH Dsn. komirean Common cold ( J.00) Rp. 7,500 Rp. 7,500

Mengetahui, Raas, 25 Januari 2018

KEPALA UPT. PUSKESMAS RA’AS PenanggungJawabPoskesdesDsn. KomireanDesaGuwa-guwa

HERMANTO Hairul
NIP. 19690717 199003 1 007 NITK: 35290411052