DAFTAR TAGIHAN KLAIM RAWAT JALAN
DAFTAR TAGIHAN KLAIM RAWAT JALAN
JAMKESMAS DI PELAYANAN DASAR
BULAN: JULI, AGUSTUS, SEPTEMBER,
DAN OKTOBER THN:2011
PUSKESMAS: DTP BUNGBULANG
PROPINSI : JAWA BARAT
KABUPATEN : GARUT
|
No
|
Nama
Pasien
|
No.Kartu
Peserta
Jamkesmas
|
Umur
(Thn)
|
Jenis
Kelamin
L/P
|
Tanggal
Kunjungan
|
Diagnosa
|
Pelayanan
kes dan besaran tarip sesuai dengan perda
|
Total
Biaya
|
||||
|
Poli
Umum
|
IGD
|
Poli
Gigi
|
Pemeriksaan
Penunjang
|
Poli
Spesialistik
|
||||||||
|
1
|
Dika
|
000119284322
|
8 th
|
p
|
7/7/2011
|
Pencabutan
gigi.74,75 ulkus,persistensi
|
|
|
RP.35.000
|
|
|
RP.35.000
|
|
2
|
Tn.Ojan
|
0001192822615
|
30th
|
L
|
8/7/20011
|
Pencabutan
gigi.25Gp
|
|
|
RP.20.000
|
|
|
RP.20.000
|
|
3
|
Tn.Ahmad t
|
0001192833347
|
38th
|
L
|
8/7/2011
|
Pencabutan
gigi.16 Gp
|
|
|
RP.20.000
|
|
|
RP.20.000
|
|
4
|
Ny.Saidah
|
0001192964949
|
41th
|
P
|
8/7/2011
|
Pencabutan
gigi.28 infaksi
|
|
|
RP.80.000
|
|
|
RP.80.000
|
|
5
|
Ny.Imas
|
0001192852227
|
46 th
|
P
|
9/7/2011
|
Pencabutan
gigi.48 mesioversi
|
|
|
RP.80.000
|
|
|
RP.80.000
|
|
6
|
Sahrul
|
0000037229935
|
5 th
|
L
|
9/7/2011
|
Pencabutan
gigi.51,61 persistensi
|
|
|
RP.35.000
|
|
|
RP.35.000
|
|
7
|
Wandi
|
0001192886076
|
11 th
|
L
|
13/7/2011
|
Penambalan
gigi.36Gp,46Hp
|
|
|
RP.45.000
|
|
|
RP.45.000
|
|
8
|
Irna
|
0001192963173
|
10 th
|
p
|
13/7/2011
|
Pencabutan
gigi.83,84 persistensi
|
|
|
RP.35.000
|
|
|
RP.35.000
|
|
9
|
Ny.Sumarni
|
0001192842674
|
46 th
|
p
|
16/7/2011
|
pencabutan
gigi.18 infaksi
|
|
|
RP.80.000
|
|
|
RP.80.000
|
|
10
|
Samsul
|
0001192813751
|
22 th
|
L
|
24/7/2011
|
Pencabutan
gigi.16 Gp
|
|
|
RP.55.000
|
|
|
RP.55.000
|
|
11
|
Ny.Ucah
|
0001192853665
|
69 th
|
p
|
24/7/2011
|
Pencabutan
gigi.34 linguoversi
|
|
|
RP.55.000
|
|
|
RP.55.000
|
|
12
|
Abdul soleh
|
0001192993986
|
15 th
|
L
|
25/7/2011
|
Pencabutan
gigi.46Gp,85 p
|
|
|
RP.75.000
|
|
|
RP.75.000
|
|
13
|
Hapsoh
|
0001192962846
|
17 th
|
p
|
25/7/2011
|
Perawatan saraf
gigi.36 Gp
|
|
|
RP.20.000
|
|
|
RP.20.000
|
|
14
|
Agisni
|
0001192912817
|
7 th
|
p
|
8/8/2011
|
Pencabutan
gigi.51,61 P
|
|
|
RP.35.000
|
|
|
RP.35.000
|
|
15
|
Hapsoh
|
0001192962846
|
17 th
|
p
|
25/7/2011
|
Perawatan saraf
gigi.36 Gp
|
|
|
RP.20.000
|
|
|
RP.20.000
|
|
16
|
Agnia
|
0001192865512
|
7 th
|
p
|
8/8/2011
|
Pencabutan
gigi.51,61 p
|
|
|
RP.35.000
|
|
|
RP.35.000
|
|
17
|
Sulhan agis
|
0001192837678
|
8 th
|
L
|
20/8/2011
|
Pencabutan
gigi.71,81p
|
|
|
RP.35.000
|
|
|
RP.35.000
|
|
18
|
Hapsoh
|
0001192962846
|
17 th
|
p
|
25/7/2011
|
Penambalan tetap
gigi.36Gp
|
|
|
RP.30.000
|
|
|
RP.30.000
|
|
19
|
Nida
|
0001192944236
|
8 th
|
p
|
22/8/2011
|
Pencabutan
gigi.51,61 ulcus
|
|
|
RP.35.000
|
|
|
RP.35.000
|
|
20
|
Tn.Tantan t
|
0001192940998
|
36 th
|
L
|
1/9/2011
|
Penambalan
gigi.45,46 HP
|
|
|
RP.55.000
|
|
|
RP.55.000
|
|
21
|
Tn.Iwan s
|
0001192842641
|
26 th
|
L
|
13/10/2011
|
Pencabutan
gigi.38 infaksi
|
|
|
RP.80.000
|
|
|
RP.80.000
|
|
Jumlah :
|
|
|
|
|
|
Rp.960.000
|
||||||
|
Mengetahui,
Kepala
Puskesmas DTP Bungbulang
Dr.Eli Karliman
NIP.19630917200212.1.004
|
Garut,
…………………………2011
Pelaksana
Pelayanan
Bendahara
Jamkesmas
Endun Hamzah, S.IP
NIP.19610412.198603.1.013
|
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