Copy Klaim K.lina 2016

LEMBARAN KLAIM/ PERTANGGUNG JAWABAN DANA PELAYANAN KESEHATAN KEBIDANAN DAN NEONATAL NON KAPITASI
PADA BPJS (BADAN PENYELENGGARA JAMINAN SOSIAL)

FASILITAS KESEHATAN TINGKAT PERTAMA
Nama Klinik/Bidan Jejaring

Dasar Klaim
Bulan dan Tahun Klaim
Kepada Yth :
Ketua Tim Pengelola BPJS Keehatan
Kabupaten Aceh Utara
Mita Sehat / BPM Erlinawati.Am.Keb

Surat Edaran Kemenkes HK/ MENKES/31/I/2014
Sep-15
Dengan Hormat,
Bersama ini kami ajukan klaim/ pertanggungjawaban dana Pelayanan Kesehatan Kebidanan dan Neonatal Non Kapitasi yang telah kami berikan (dalam Rupiah)dengan perincian sebagai berikut :
Jenis Pelayanan
Persalinan
ANC
No
Nama Pasien
NO. KTP/KK
Alamat Pasien
No Hp
G.P.A
Total
Tarif
Tarif
Total Tarif
Tarif
Total Tarif Tanggal
Tindakan
Persalinan Persalina
Tindaka
Tarif ANC
ANC
INC
Pra
Normal n Normal
n Pra
Rujukan
Rujukan
K1
K2
K3
K4
G1 P0 A0
2/3/15
1/5/15
3/7/15
1/9/15
50.000
200.000
1/9/15
600.000
G3 P2 A0
3/3/15
2/5/15
4/7/15
1/9/15
50.000
200.000
2/9/15
600.000
G2 P1 A0
2/3/15
3'5/15
5/7/15
1/9/15
50.000
200.000
3/9/15
600.000
600.000 125.000
Pelayanan KB
PNC
KF1
KF4
Pasang
Tarif PNC IUD/Imp Suntik
lant
Total
KF2
KF3
Total Tarif
3/9/15
7/9/15
12/9/15
75.000
75.000
875.000
6/9/15
12/9/15
15/9/15
75.000
75.000
'400.000
5/9/15
9/9/15
14/9/15
75.000
75.000
875.000
Nuraiana
Asmawati
Marwati
981063764
Matang Baroh
3133023
Kuala Cangkoy
1892247535
Matang Baroh
Nurhayati Jaban
1892240436
Matang Baroh
G2 P1 A0
4/3/15
5/5/15
4/7/15
2/9/15
50.000
200.000
3/9/15
600.000
600.000 125.000
5/9/15
9/9/15
14/9/15
75.000
75.000
875.000
Nursiah
Rohana
Juliana
1878506739
Mtg glp 2
G1 P0 A0
2/3/15
4/5/15
3/7/15
5/9/15
50.000
200.000
4/9/15
600.000
600.000 125.000
6/9/15
10/9/15
12/9/15
75.000
75.000
875.000
1121218064
Kjm
G3 P2 A0
4/3/15
6/5/15
3/7/15
5/9/15
50.000
200.000
5/9/15
600.000
600.000 125.000
7/9/15
11/9/15
16/9/15
75.000
75.000
875.000
1382739186
1265993133
1821955645
981028732
1184786649
981940498
1878647117
224444643
98064358
Matang Baroh
Siemeulue
Kd Aron
Gp Glok
Cibrek Baroh
Cibrek Baroh
Buangan
Paya
Kuala Keureuto
G4 P3 A0
G1 P0 A0
G3 P2 A0
G3 P2 A0
G6 P5 A0
G3 P2 A0
G2 P1 A0
G1 P0 A0
G1 P0 A0
5/3/15
6/3/15
7/3/15
1/3/15
7/3/15
12/3/15
15/3/15
14/3/15
12/3/15
6/5/15
4/7/15
5/5/15 7/7/2015
6/5/15
8/7/15
4/5/15
6/7/15
9/5/15
10/7/15
14/5/15 11/7/15
16/9/15 14/7/15
16/5/15 13/7/15
11/5/15 15/7/15
7/9/15
5/9/15
6/9/15
4/9/15
8/9/15
12/9/15
12/9/15
14/9/15
10/9/15
50.000
200.000
9/9/15
10/9/15
14/9/15
17/9/15
16/9/15
17/9/15
17/9/15
18/9/15
22/9/15
13/9/15
14/9/15
19/9/15
24/9/15
19/9/15
21/9/15
21/9/15
22/9/15
26/9/15
18/9/15
19/9/15
22/9/15
28/9/15
24/9/15
26/9/15
26/9/15
27/9/15
30/9/15
75.000
75.000
875.000
200.000
200.000
200.000
200.000
200.000
200.000
200.000
200.000
600.000
600.000
600.000
600.000
600.000
600.000
600.000
600.000
600.000
600.000 125.000
50.000
50.000
50.000
50.000
50.000
50.000
50.000
50.000
7/9/15
8/9/15
10/9/15
12/9/15
14/9/15
17/9/15
15/9/15
16/9/15
20/9/15
75.000
75.000
75.000
75.000
75.000
75.000
75.000
75.000
75.000
75.000
75.000
75.000
75.000
75.000
75.000
75.000
875.000
275.000
275.000
875.000
875.000
875.000
875.000
875.000
1
2
6
7
8
9
10
11
12
13
14
15
Ida Darsiah
Mahfuddah
Yusmanidar
Khairina
Asnidar
Saufi Mulia
Ritawati
Yusrawati
600.000 125.000
-
600.000
600.000
600.000
600.000
600.000
600.000
125.000 125.000
125.000
125.000
125.00
125.000
125.000
125.000
125.000
125.000
1.125.00011.450.000
Total
3.000.000
7.200.000
125.000
Terlampir bersama ini kami sampaikan pula bukti-bukti penunjang yang sah untuk menjadi pertimbangan (Copy identitas/ partograf/Suart Keterangan Kelahiran / register kohort Ibu/Bayi/ Kartu Ibu/ Kartu Nifas dll))
Demikian kami sampaikan, untuk realisasinya diucapkan terima kasih
Mengetahui
Klinik Mita sehat
Nip
Lapang,30 September 2015

Yang Mengajukan Klaim
Erlinawati,Am.Keb
Nip.19740716 200701 2 004
Ket

Dasar Klaim
Kepada Yth :

Oct-15
Dengan Hormat,
Jenis Pelayanan
Persalinan
ANC
No
Nama Pasien
NO. KTP/KK
Alamat Pasien
No Hp
G.P.A
Ket
K1
K2
K3
K4
G2 P1 A0
2/5/15
4/7/15
5/9/15
1/11/15
50.000
200.000
1/11/15 600.000
G1 P0 A0
2/5/15
3/7/15
4/9/15
1/11/15
50.000
200.000
1/11/15 600.000
Pelayanan KB
PNC
Total
Tarif
Tarif
Total Tarif
Tarif
Total Tarif Tanggal
Tindakan
Tindaka
Tarif ANC
ANC
INC
Pra
Normal n Normal
n Pra
Rujukan
Rujukan
KF4
Pasang
lant
Total
KF1
KF2
KF3
Total Tarif
600.000 125.000
3/11/15
7/11/15
10/11/15
75.000
75.000
875.000
600.000 125.000
3/11/15 7/11/2015 10/11/15
75.000
75.000
875.000
1165001275
Paloh Lada
224549897
Cibrek
Duryati
Agusliana
Nurmala
199920148
Lambhuk
G2 P1 A0
2/5/15
3/7/15
5/9/15
2/11/15
50.000
200.000
2/11/15 600.000
600.000 125.000
4/11/15
8/11/15
11/11/15
75.000
75.000
875.000
Diana
224661789
Matang Baroh
G3 P2 A0
1'5'15
3/7/15
5/9/15
2/11/15
50.000
200.000
2/11/15 600.000
600.000 125.000
4/11/15
8/11/15
11/11/15
75.000
75.000
875.000
Maiyuni
Ermawati
Darmawati
1892243463
Kuala Keureuto
G5 P4 A0
1/5/15
3/7/15
2/9/15
1/11/15
50.000
200.000
3/11/15 600.000
7/11/15
12/11/15
75.000
50.000
375.000
225410927
Kuala Keureuto
G1 P0 A0
3/5/15
4/7/15
7/9/15
3/11/15
50.000
200.000
3/11/15 600.000
600.000 125.000
5/11/15
9/11/15
12/11/15
75.000
75.000
875.000
164006504
1904347372
223838861
981032365
224542991
1904344514
3080676
981063505
Kuala Cangkoy
Kuala Keureuto
Dayah aron
Dayah Aron
Ulee Pulo
Kuala Cangkoy
Cibrek Tunong
Matang Baroh
G4 P3 A0
G2 P1 A0
G2 P1 A0
G3 P2 A0
G2 P1 A0
G4 P3 A0
G3 P2 A0
G1 P0 A0
3/5/15
3/5/15
6/5/15
4/5/15
6/5/15
7/5/15
6/11/15
9/5/15
4/7/15
5/7/15
7/7/15
6/7/15
5/7/15
6/7/15
7/7/15
8/7/15
7/9/15
4/9/15
5/9/15
3/9/15
7/9/15
5/9/15
9/9/15
6/9/15
1/11/15
1/11/15
2/11/15
3/11/15
3/11/15
3/11/15
5/11/15
4/11/15
50.000
200.000
5/11/15
5/11/15
6/11/15
8/11/15
8/11/15
9/11/15
11/11/15
9/11/15
9/11/15
10/11/15
10/11/15
12/11/15
12/11/15
13/11/15
15/11/15
12/11/15
12/11/15
13/11/15
15/11/15
15/11/15
15/11/15
16/11/15
18/11/15
75.000
75.000
875.000
200.000
200.000
200.000
200.000
200.000
200.000
200.000
3/11/15
3/11/15
4/11/15
5/11/15
6/11/15
6/11/15
7/11/15
9/11/15
600.000 125.000
50.000
50.000
50.000
50.000
50.000
50.000
50.000
75.000
75.000
75.000
75.000
75.000
75.000
75.000
75.000
75.000
50.000
75.000
75.000
75.000
75.000
875.000
875.000
250.000
875.000
875.000
875.000
875.000
1
2
6
7
8
9
10
11
12
13
14
Samiah
Anil Linda Santi
Nurafni
Erniyana
Ainsyah Ben
Dewi Fitria
Jauhari
600.000
600.000
600.000
600.000
600.000
600.000
600.000
600.000
'-
600.000
600.000
600.000
600.000
600.000
600.000
125.000
125.000
125.000
125.00
125.000
125.000
125.000
125.000
125.000
1.000.00011.125.000
Total
2.800.000
7.200.000
125.000
Mengetahui
Klinik Mita sehat
Nip
Lapang,30 Oktober 2015

Erlinawati,Am.Keb
Nip.19740716 200701 2 004

Dasar Klaim
Kepada Yth :

Januari 2014
Dengan Hormat,
No
Nama
Pasien
NO. KTP/KK
Alamat Pasien
No. HP
G.P.A
Jenis Pelayanan
Persalina
n
ANC
110813107890222
Nurlaila
Lindawati 007/2016/2014
Raihani
PNC
Matang Baroh
G2,P1,A0
7/7/13
6/9/13
8/11/13
7/1/14
25,000 100.000
Total
Tarif
Total Tarif
Tarif
Tarif
Tanggal
Persalinan Persalinan Tindakan Pra Tindaka
INC
Normal
Normal
Rujukan
n Pra
Rujukan
13/1/14 600,000 600,000
125.000
Matang Sijuek Barat
G1,P0,A0
12/7/13
11/9/13
10/11/13 13/1/14
25,000 100.000
20/1/14
600,000
600,000
G1,P0,A0
20/7/13
21/9/13
23/11/13 22/1/14
25,000 100.000
30/1/14
600,000
600,000
1108136603890001 Geulanggang Baro
Total
K1
K2
K3
K4
Tarif ANC
Total Tarif
ANC
300.000
Total
KF1
Pelayanan KB
KF2
K F 3 Tarif PNC
Total
Tarif
PNC
Pasang
Total
IUD/Imp Suntik
Tarif
lant
25,000
700.000
125.000
25,000
700.000
125.000
25,000
700.000
1.800.000
2.100.000
Mengetahui
Klinik Mita Sehat
Lapang, 30 Januari 2014

(_______________________)
Nip
Erlinawati,Am.Keb
Nip.19740716 200701 2 004
Ket

Dasar Klaim
Kepada Yth :

Februari 2014
Dengan Hormat,
Jenis Pelayanan
ANC
No
Nama
Pasien
NO. KTP/KK
Alamat Pasien
No. HP
110813107890222
Nurlaila
Lindawati 007/2016/2014
3 Raihani
1108136603890001
4 Nuraini
1108134107650188
5 Azizah
1108134107780282
6 Baiti Ismail1108134107770177
7 Jariah
1108134107940184
Persalinan
G.P.A
K1
K2
K3
K4
Tarif ANC
Total Tarif
ANC
PNC
Total
Tarif
Total Tarif
Tarif
Tarif
Tanggal
INC
Normal
Normal
Rujukan
n Pra
Rujukan
Matang Baroh
G2,P1,A0
25,000
600,000
125.000
Matang Sijuek Barat
G1,P0,A0
25,000
600,000
125.000
Geulanggang Baro
G1,P0,A0
25,000
600,000
Kuala Keureutou
G5.P4.A0
6/8/13
7/2/14
25,000 100.000
600,000
Matang Baroh
G5.P4.A0
10/8/13 12/10/13 10/12/13 13/2/14
25,000 100.000
Matang Baroh
085360401397 G2.P1.A0
15/8/13 16/10/13 14/12/13 17/2/14
25,000 100.000
082361812827 G2.P1.A0
18/8/13 17/10/13 19/12/13 20/2/14
25,000 100.000
Cibrek
7/10/13
8/12/13
Total
125.000
600,000
125.000
600,000
600,000
125.000
600,000
600,000
125.000
KF2
K F 3 Tarif PNC
13/1/14 16/1/14 21/1/14

20/1/14 23/1/14 28/1/14
31/1/14 3/2/14 9/2/14
125.000
600,000
KF1
Pelayanan KB
Total
Tarif
PNC
Pasang
Total
IUD/Imp Suntik
Tarif
lant
25,000 100.000
25,000 100.000
25,000 100.000
125.000
Total
400.000
1.800.000
125.000
300.000
Mengetahui
Klinik Mita Sehat
Lapang, 28 Februari 2014

(_______________________)
Nip
Erlinawati,Am.Keb
Nip.19740716 200701 2 004
100.000
100.000
100.000
700.000
225.000
700.000
700.000
2.625.000
Ket

Dasar Klaim
Kepada Yth :

Maret 2014
Dengan Hormat,
Jenis Pelayanan
Persalinan
ANC
No
Nama
Pasien
NO. KTP/KK
Alamat Pasien
No. HP
K1
1108134107650188 Kuala Keureutou

Nuraini
Azizah
1108134107780282 Matang Baroh
Baiti Ismail1108134107770177 Matang Baroh
Jariah
1108134107940184 Cibrek
Nuraini
Nora
1108134107810196 Matang Baroh
1
2
7 khatijah
G.P.A
K3
K4
Tarif ANC
Total
Tarif
Total Tarif
Tarif
Tarif
Tanggal
INC
Normal
Normal
Rujukan
n Pra
Rujukan
KF1
KF2
K F 3 Tarif PNC
Total
Tarif
PNC
Pasang
Total
IUD/Imp Suntik
Tarif
lant
G5.P4.A0
25,000
600,000
125.000
12/2/14
15/2/14 20/2/14
25,000
75.000
75.000
G5.P4.A0
25,000
600,000
125.000
23/2/14
2/3/14
20/3/14
25,000
75.000
75.000
085360401397 G2.P1.A0
25,000
600,000
125.000
22/2/14
25/2/14
2/3/14
25,000
75.000
75.000
G2.P1.A0
25,000
600,000
125.000
27/2/14
1/3/14
6/3/14
25,000
75.000
75.000
3/3/14
25,000 100.000
600,000
600.000
125.000
6/3/14
9/3/14
14/3/14
25,000
75.000
775.000
6/1/14
5/3/14
17/1/14 18/3/14
25,000 100.000
25,000 100.000
600,000
600,000
600,000
600,000
125.000
125.000
13/3/14
16/3/14 21/3/14
25,000
25,000
75.000
775.000
700.000
450.000
2.550.000
082361812827
1108135905820001 Keutapang
1108134107750191 Kuala Cangkoy
K2
Total Tarif
ANC
Total
Pelayanan KB
PNC
G3 P2 A0
085277788983 G5 P3 A1
G7 P6 A0
2/9/13
3/11/13
4/9/13 5/11/13
16/9/13 15/11/13
1/1/14
Total
300.000
1.800.000
Mengetahui
Klinik Mita Sehat
Lapang, 31 Maret 2014

(_______________________)
Nip
Erlinawati,Am.Keb
Nip.19740716 200701 2 004
Ket
Dasar Klaim
Kepada Yth :

May-14
Dengan Hormat,
No
Nama
Pasien
NO. KTP/KK
Alamat Pasien
No. HP
G.P.A
Jenis Pelayanan
Persalina
n
ANC
Nurhayati 1108134107790175 Matang Baroh

Juwoiriah 1108134107890247 Kuala Cangkoy
Wahyuni 1108135301890001 Kuala Cangkoy
Yusnaini
1
2
1108134105830002 Kuala Keureuto
Total
Tarif
Total Tarif
Tarif
Tarif
Tanggal
INC
Normal
Normal
Rujukan
n Pra
Rujukan
(_______________________)
Nip
K F 3 Tarif PNC
Pasang
Total
IUD/Imp Suntik
Tarif
lant
K3
K4
082362980980 G5 P4 A0
2/11/13
1/1/14
3/3/14
2/5/14
100.000 100.000
6/5/14
600.00
600.000
125.000
8/5/14
12/5/14 17/5/14 75.000
75.000
775.000
G3 P2 A0
4/11/13
3/1/14
2/3/14
4/5/14
100.000 100.000
9/5/14
600.000
600.000
125.000
11/5/14
15/5/14 20/5/14 75.000
75.000
775.000
7/11/13
8/1/14
6/3/14
7/5/14
100,000 100.000
15/5/14
600.000
600.000
125.000
17/5/14
22/5/14 27/5/14 75.000
75.000
775.000
12/11/13 13/1/14
11/3/14
14/5/14 100.000 100.000
17/5/14
600.000
600.000
125.000
19/5/14
24/5/14 28/5/14 75.000
75.000
775.000
300.000
3.100.000
2.400.000
KF2
Total
Tarif
PNC
K2
G3 P2 A0
KF1
Pelayanan KB
K1
085260320491 G1 P0 A0
Tarif ANC
Total Tarif
ANC
PNC
Total
400.000
Terlampir bersama ini kami sampaikan pula bukti-bukti penunjang yang sah untuk menjadi pertimbangan (Copy identitas/ partograf/Suart Keterangan Kelahiran / regis
Mengetahui
Klinik Mita Sehat
Total
Lapang, 30 Mei 2014

Erlinawati,Am.Keb
Nip.19740716 200701 2 004
Ket

Dasar Klaim
Kepada Yth :

Apr-14
Dengan Hormat,
No
Nama
Pasien
NO. KTP/KK
Alamat Pasien
No. HP
G.P.A
Jenis
Pelayan
an
Total
Persalina
n
ANC
khatijah
Rohani
Murniati
Syamsiah
1
2
K1
K2
K3
K4
Tarif ANC
Total Tarif
ANC
PNC
Total
Tarif
Total Tarif
Tarif
Tarif
Tanggal
INC
Normal
Normal
Rujukan
n Pra
Rujukan
K F 3 Tarif PNC
Pasang
Total
IUD/Imp Suntik
Tarif
lant
125.000
2/4/14
25,000
75.000
75.000
1/10/13
2/12/13
1/2/14
1/4/14
25,000 100.000
2/4/14
600,000
600.000
125.000
5/4/14
8/4/14
13/4/14
25,000
75.000
775.000
1108135101780002 Matang Baroh
085260078141 G4 P3 A0
5/10/13
4/12/13
6/2/14
5/4/14
25,000 100.000
11/4/14
600,000
600.000
125.000
13/4/14
18/4/14 22/4/14
25,000
75.000
775.000
1108134107830250 Matang Baroh
G6 P5 A0
7/10/13
8/12/13
6/2/14
7/4/14
25,000 100.000
15/4/14
600,000
600.000
125.000
17/4/14
21/4/14 26/4/14
25,000
75.000
775.000
Maiyuni
1108234606820001 Kuala Kereuto
Erlinawati 1108136811820001 Matang Baroh
'085277315257 G6 P5 A0
10//10/13 9/12/13
11/2/14
8/4/14
25,000 100.000
15/4/14
600,000
600.000
125.000
18/4/14
21/4/14 26/4/14
25,000
75.000
775.000
085260772757 G3 P2 A0
11/10/13 10/12/13 12/2/14 9//4/14

16/10/13 17/12/13 15/2/14 16/4/14
25,000 100.000
25,000 100.000
17/4/14
'21/4/14
600,000
600,000
600,000
600,000
125.000
125.000
25,000 75.000
25,000 75.000
775.000
775.000
1108235807950001 Kuala Kereuto
085373105410 G1 P0 A0
7/4/2014 12/4/14
Total
Tarif
PNC
085261256981 G1 P0 A0
G7 P6 A0
600,000
KF2
1108135606930001 Matang Baroh
7 Yulidar
25,000
KF1
Pelayanan KB
19/4/14 23/4/14 28/4/14

23/4/14 27/4/14 30/4/14
Total
600.000
3.600.000
525.000
Lapang,30 Juni 2014

4.725.000
Ket
Erlinawati,Am.Keb
Nip.19740716 200701 2 004
Nip

Dasar Klaim
Kepada Yth :

Juni 2014
Dengan Hormat,
Jenis Pelayanan
ANC
No
Nama
Pasien
NO. KTP/KK
Alamat Pasien
No. HP
G.P.A
K1
1108134203930002 Matang Baroh
Noni
Nilawati
Juhari
Marwati
1108235410890001 Cot Jabet

1108134104920002 Matang Baroh
Nuroini
Fatmawati 1108134107730206 Matang Baroh
1
2
1108104107720140 Desa Ampeh

7 Juliana
1108134606910001 Matang Baroh
8 Siti Khotimah 1108236107850001 Matang Baroh
085360685255 G2 P0 A1
085260152761 G3 P2 A0
-
Persalinan
G5 P4 A0
G1 P0 A0
'085373637361 G2 P0 A1
085261979541 G6 P5 A0
085271132913 G1 P0 A0
G1 P0 A0
-
K2
K3
K4
Tarif ANC
Total Tarif
ANC
PNC
Total
Tarif
Total Tarif
Tarif
Tarif
Tanggal
INC
Normal
Normal
Rujukan
n Pra
Rujukan
Pelayanan KB
Total
KF1
KF2
K F 3 Tarif PNC
Nip
Pasang
Total
IUD/Imp Suntik
Tarif
lant
1/6/14
100.000
100.000
3/6/14
600.000
600.000
125.000
6/6/14
10/6/14 13/6/14
75.000
75.000
775.000
2/12/13 3/2/14
5/4/14
2/6/14
100.000
100.000
4/6/14
600.000
600.000
125.000
7/6/14
11/6/14 14/6/14
75.000
75.000
775.000
6/12/13 5/2/14
4/4/14
7/6/14
100.000
100.000
7/6/14
600.000
600.000
125.000
10/6/14
14/6/14 18/6/14
75.000
775.000
7/12/13 8/2/14
6/4/14
8/6/14
100.000
100.000
10/6/14
600.000
600.000
125.000
13/6/14
16/6/14 21/6/14
75.000
75.000
75.000
'6/12/13 7/2/14
5/4/14
8/6/14
100.000
100.000
13/6/14
600.000
600.000
125.000
16/6/14
19/6/14 24/6/14
75.000
75.000
775.000
12/12/13 10/2/14
19/12/13 20/2/14
7/12/13 8/2/14
11/4/14
18/4/14
10/4/14
2/6/14 100.000
17/6/14 100.000
12/6/14 100.000
100.000
100.000
100.000
19/6/14
22/6/14
600.000
600.000
600,000
600,000
125.000
125.000
21/6/14 25/6/14 29/6/14 75.000

24/6/14 28/6/14 3/7/14
75.000
125.000
27/6/14 30/6/14 4/7/14
75.000
75.000
75.000
775.000
775.000
225.000
600.000
5.650.000
2/12/13 3/2/14
2/4/14
Total
800.000
4.200.000
125.000
Mengetahui
Klinik Mita sehat
Total
Tarif
PNC
Lapang,30 Juni 2014

775.000
Ket

Dasar Klaim
Kepada Yth :

Juli 2014
Dengan Hormat,
Jenis Pelayanan
ANC
No
Nama
Pasien
NO. KTP/KK
Alamat Pasien
No Hp
K1
K2
2/1/14 3/3/14
Yeni Yuslin 1108134307800001 Kuala Keureuto

G3 P2 A0
Ramulan 1108134107850279 Matang Baroh 081364670414 G3 P2 A0
Mutia
1108135509860001 Blang Seunong
G3 P1 A1
Zainabon
1
2
7
8
9
10
Persalinan
G.P.A
K3
K4
Tarif ANC
Total Tarif
ANC
Total
Tarif
Total Tarif Tarif
Tarif
Tanggal
INC
Normal
Normal Rujukan
n Pra
Rujukan
PNC
Pelayanan KB
Total
KF1
KF2
K F 3 Tarif PNC
Total
Tarif
PNC
Pasang
Total
IUD/Imp Suntik
Tarif
lant
4/7/14
100.000
100.000
8/7/14
600.000
600.000 125.000
10/7/14
14/7/14 18/7/14
75.000
75.000
775.000
3/1/14 4/3/14
2/5/14
3/7/14
100.000
100.000
10/7/14 600.000
600.000 125.000
12/7/14
16/7/14 20/7/14
75.000
75.000
775.000
3/1/14 2/3/14
1/5/14
3/7/14
100.000
100.000
600.000 125.000
12/7/14
16/7/14 20/7/14
75.000
4/1/14 3/3/14
5/5/14
4/7/14
100.000
100.000
600.000 125.000
14/7/14
18/7/14 22/7/14
75.000
75.000
75.000
775.000
085358692601 G1 P0 A0
10/7/14 600.000
12/7/14 600.000
Rohani
1108134107830253 Matang Baroh 085260912758 G3 P2 A0
Fitri Zahar 1108196805860001 Rayeuk Kareng 085277069666 G2 P1 A0
4/1/14 5/3/14
6/7/14
6/7/14
100.000
100.000
600.000 125.000
14/7/14
18/7/14 22/7/14
75.000
75.000
775.000
8/5/14
7/5/14
6/5/14
8/5/14
14/5/14
7/7/14
8/7/14
9/7/14
11/7/14
15/7/14
100.000
100.000
100.000
100.000
100.000
100.000
100.000
100.000
100.000
100.000
12/7/14 600.000
14/7/14 600.000
15/7/14 600.000
15/7/14 600.000
18/7/14 600.000
20/7/14 600.000
24/7/14 75.000
28/7/14 75.000
25/7/15 75.000
28/7/14 75.000
31/7/14 75.000
75.000
75.000
75.000
75.000
75.000
775.000
775.000
775.000
775.000
775.000
750.000
7.750.000
Aisyah
Darmawati
Nurmalawati
Yusra
1108236103940001 Matang Baroh
1108134107860234
1108134107800232
1108135108930001
1108134807800001
Matang Baroh
Matang Baroh
Teupin Gapeuh
Merbo Jurong
081376575626
085206665972
085370232018
085359097783
G1 P0 A0
G4 P2 A1
G2 P1 A1
G3 P2 A0
7/1/14
6/1/14
7/1/14
10/1/14
12/1/14
6/3/14
5/3/14
8/3/14
9/3/14
10/3/14
2/5/14
600.000
600.000
600.000
600.000
600.000
125.000
125.000
125.000
125.000
125.000
'16/7/14
17/7/14
17/7/14
20/7/14
22/7/14
20/7/14
21/7/14
21/7/14
24/7/14
26/7/14
Total
1.000.000
6.000.000
Mengetahui
Klinik Mita sehat
Lapang,31 Juli 2014

775.000
Ket
Nip

Dasar Klaim
Kepada Yth :
Mita Sehat / BPM Nurbaiti.Am.Keb

Agustus 2014
Dengan Hormat,
Jenis Pelayanan
ANC
No
Nama
Pasien
NO. KTP/KK
Alamat Pasien
No Hp
K1
Juari
Zuraida
Yusniar
Hayani
Wardani
Zuboidah 1108134107860226
1
2
1108134107720095 Tanjong Dama

K2
K3
K4
Tarif ANC
Total Tarif
ANC
Total
Tarif
Total Tarif Tarif
Tarif
Tanggal
INC
Normal
Normal Rujukan
n Pra
Rujukan
PNC
Pelayanan KB
Total
KF1
KF2
K F 3 Tarif PNC
Pasang
Total
IUD/Imp Suntik
Tarif
lant
G7 P6 A0
25/1/14 29/4/14
17/6/14
27/7/14 25.000
100.000
28/7/14 600.000
600.000 125.000
29/7/14
4/8/14
8/8/14
25.000
75.000
775.000
15/1/14 30/3/14
27/6/14
2/8/14
25.000
100.000
2/8/14
600.000
600.000 125.000
3/8/14
5/8/14
10/8/14
25.000
75.000
775.000
2/2/14 3/5/14
5/7/14
1/8/14
25.000
100.000
2/8/14
600.000 125.000
3/8/14
7/8/14
11/8/14
25.000
3/7/14
2/8/14
25.000
100.000
3/8/14
600.000 125.000
4/8/14
6/8/14
11/8/14
25.000
75.000
75.000
775.000
2/2/14 5/4/14
600.000
600.000
11/2/14 15/4/14
13/7/14
3/8/14
25.000
100.000
3/8/14
600.000
600.000 125.000
4/8/14
6/8/14
11/8/14
25.000
75.000
775.000
8/2/14 4/4/14
7/7/14
4/8/14
25.000
100.000
4/8/14
600.000
600.000 125.000
'5/8/14
7/8/14
13/8/14
25.000
75.000
775.000
450,000
4,650,000
085325948692 G1 P0 A0
G2 P1 A0
G3 P2 A0
-
G3 P2 A0
Total
600,000
3,600,000
Mengetahui
Klinik Mita sehat
Total
Tarif
PNC
85260611188 G4 P3 A0
1108234303900001 Merbo Jurong
Kuala Cangkoy
Persalinan
G.P.A
Lapang,30 Agustus 2014

Nurbaiti,Am.Keb
Nip.19780521 200801 2 002
775.000
Ket
Nip

Dasar Klaim
Kepada Yth :

Januari 2014
Dengan Hormat,
No Nama Pasien
NO. KTP/KK
Alamat
Pasien
No. HP
G.P.A
Jenis Pelayanan
Persali
nan
ANC
K1
K2
Nurlaila
11081310789022Matang Baroh
G2,P1,A0 7/7/13
6/9/13
Lindawati
007/2016/2014 Matang Sijuek Barat
G1,P0,A0 12/7/13
11/9/13 10/11/13 13/1/14 25,000 100.000 20/1/14 600,000
Raihani
11081366038900Geulanggang Baro
G1,P0,A0 20/7/13 21/9/13 23/11/13 22/1/14 25,000 100.000 30/1/14 600,000
Total
PNC
Total
Tarif
Tarif
Total Tarif
Tarif
Tarif Total Tarif Tanggal
Tindaka
K3
K4
Persalina Persalinan
Tindaka
ANC
ANC
INC
n Pra
n Normal Normal
n Pra
Rujukan
Rujukan
8/11/13 7/1/14 25,000 100.000 13/1/14 600,000
600,000 125.000
300.000
Total
Pelayanan KB
Pasa
Total
ng
Sunt Total
Tarif
IUD/I
ik Tarif
PNC
mpla
nt
K
KF1
KF2
KF3 F
Tarif
PNC
4
###
700.000
600,000 125.000
###
700.000
600,000 125.000
###
700.000
1.800.000
2.100.000
Mengetahui
Klinik Mita Sehat
Lapang, 30 Januari 2014

(_______________________)
Nip
Erlinawati,Am.Keb
Nip.19740716 200701 2 004

Dasar Klaim
Kepada Yth :

Februari 2014
Dengan Hormat,
Jenis Pelayanan
ANC
No Nama Pasien
NO. KTP/KK
Alamat
Pasien
No. HP
Nurlaila
2 Lindawati
3 Raihani
4 Nuraini
5 Azizah
6 Baiti Ismail
7 Jariah
1
Persalinan
G.P.A
K1
K2
K3
Total
K4
Tarif
ANC
PNC
Total
Tarif
Tarif
Total Tarif
Tarif
Total Tarif Tanggal
Tindaka
Tindaka
ANC
INC
n Pra
n Normal Normal
n Pra
Rujukan
Rujukan
G2,P1,A0
25,000
600,000
125.000
007/2016/2014 Matang Sijuek Barat
G1,P0,A0
25,000
600,000
125.000
11081366038900Geulanggang Baro
G1,P0,A0
25,000
600,000
125.000
11081341076501Kuala Keureutou
G5.P4.A0 6/8/13
7/10/13 8/12/13 7/2/14 25,000 100.000
600,000
600,000 125.000
G5.P4.A010/8/13 12/10/13 10/12/13 13/2/14 25,000 100.000
600,000
11081341077701Matang Baroh 085360401397 G2.P1.A015/8/13 16/10/13 14/12/13 17/2/14 25,000 100.000
600,000
600,000 125.000
11081341079401Cibrek
600,000
600,000 125.000
082361812827 G2.P1.A018/8/13 17/10/13 19/12/13 20/2/14 25,000 100.000
Pelayanan KB
K
KF1
KF2
Tarif
KF3 F
PNC
Total
Tarif
PNC
Pasa
ng
Sunt Total
IUD/I
ik Tarif
mpla
nt
13/1/1416/1/1421/1/14
13/2/14 ### 100.000
20/1/1423/1/1428/1/14
20/2/14 ### 100.000
31/1/14 3/2/14 9/2/14
28/2/14 ### 100.000
125.000 125.000
Total
400.000
1.800.000
125.000
300.000
Mengetahui
Klinik Mita Sehat

(_______________________)
Nip
Erlinawati,Am.Keb
Nip.19740716 200701 2 004
100.000
100.000
100.000
700.000
225.000
700.000
700.000
2.625.000

Dasar Klaim
Kepada Yth :

Maret 2014
Dengan Hormat,
Jenis Pelayanan
Persalinan
ANC
No Nama Pasien
NO. KTP/KK
Alamat
Pasien
No. HP
G.P.A
K1
11081341076501Kuala Keureutou
Nuraini
G5.P4.A0
Azizah
G5.P4.A0
Baiti Ismail 11081341077701Matang Baroh 085360401397 G2.P1.A0
K2
K3
K4
Tarif
ANC
Total
Tarif
Tarif
Total Tarif
Tarif
Total Tarif Tanggal
Tindaka
Tindaka
ANC
INC
n Pra
n Normal Normal
n Pra
Rujukan
Rujukan
Total
Pelayanan KB
PNC
K
KF1
KF2
Tarif
KF3 F
PNC
Total
Tarif
PNC
Pasa
ng
Sunt Total
IUD/I
ik Tarif
mpla
nt
25,000
600,000
125.000
12/2/14 15/2/14 20/2/14
### 75.000
75.000
25,000
600,000
125.000
23/2/14 2/3/14 20/3/14
### 75.000
75.000
25,000
600,000
125.000
22/2/14 25/2/14 2/3/14
### 75.000
75.000
25,000
600,000
125.000
27/2/14 1/3/14
6/3/14
### 75.000
75.000
600,000
600.000 125.000
6/3/14
9/3/14 14/3/14
### 75.000
775.000
600,000
600,000
600,000 125.000
600,000 125.000
13/3/14 16/3/14 21/3/14
### 75.000
###
775.000
700.000
Total
300.000
1.800.000
450.000
1
2
3
4 Jariah
5
6
Nuraini
Nora
7 khatijah
11081341079401Cibrek
082361812827 G2.P1.A0
G3 P2 A0 2/9/13 3/11/13 1/1/14 3/3/14 25,000 100.000

085277788983 G5 P3 A1 4/9/13 5/11/13 6/1/14 5/3/14 25,000 100.000
11081359058200Keutapang
11081341077501Kuala Cangkoy
G7 P6 A0 16/9/13 15/11/13 17/1/14 18/3/14 25,000 100.000
Mengetahui
Klinik Mita Sehat
Lapang, 31 Maret 2014

(_______________________)
Nip
Erlinawati,Am.Keb
Nip.19740716 200701 2 004
2.550.000
Dasar Klaim
Kepada Yth :

May-14
Dengan Hormat,
No Nama Pasien
NO. KTP/KK
Alamat
Pasien
No. HP
G.P.A
Jenis Pelayanan
Persali
nan
ANC
K1
1
2
3
Nurhayati
Juwoiriah
Wahyuni
4 Yusnaini
Total
Tarif
ANC
Total
Tarif
Tarif
Total Tarif
Tarif
Total Tarif Tanggal
Tindaka
Tindaka
ANC
INC
n Pra
n Normal Normal
n Pra
Rujukan
Rujukan
Pelayanan KB
K
1/1/14
3/3/14
2/5/14 100.000 100.000
6/5/14
600.00
600.000
125.000
8/5/14 12/5/14 17/5/14 75.000 75.000
775.000
3/1/14
2/3/14
4/5/14 100.000 100.000
9/5/14 600.000
600.000
125.000
11/5/14 15/5/14 20/5/14 75.000 75.000
775.000
8/1/14
6/3/14
7/5/14 100,000 100.000 15/5/14 600.000
600.000
125.000
17/5/14 22/5/14 27/5/14 75.000 75.000
775.000
G3 P2 A012/11/13 13/1/14 11/3/14 14/5/14 100.000 100.000 17/5/14 600.000
600.000
125.000
19/5/14 24/5/14 28/5/14 75.000 75.000
2.400.000
KF3 F
Total
Tarif
PNC
11081341077901Matang Baroh 082362980980 G5 P4 A0 2/11/13
Total
400.000
Terlampir bersama ini kami sampaikan pula bukti-bukti penunjang yang sah untuk menjadi pertimbangan (Copy identitas/ partograf/Suart Keteranga
KF2
Tarif
PNC
K3
11081341058300Kuala Keureuto
KF1
Pasa
ng
Sunt Total
IUD/I
ik Tarif
mpla
nt
K2
G3 P2 A0 4/11/13
11081353018900Kuala Cangko 085260320491 G1 P0 A 7/11/13
K4
PNC
300.000
Mengetahui
Klinik Mita Sehat
Lapang, 30 Mei 2014

(_______________________)
Nip
Erlinawati,Am.Keb
Nip.19740716 200701 2 004
775.000
3.100.000

Dasar Klaim
Kepada Yth :

Apr-14
Dengan Hormat,
No Nama Pasien
NO. KTP/KK
Alamat
Pasien
No. HP
G.P.A
Jenis
Pelayan
an
Total
Persali
nan
ANC
K1
khatijah
Rohani
Murniati
K2
K3
K4
Tarif
ANC
Total
Tarif
Tarif
Total Tarif
Tarif
Total Tarif Tanggal
Tindaka
Tindaka
ANC
INC
n Pra
n Normal Normal
n Pra
Rujukan
Rujukan
25,000
G7 P6 A0
PNC
600,000
125.000
Pelayanan KB
K
KF1
KF2
2/4/14
###
KF3 F
Tarif
PNC
Total
Tarif
PNC
Pasa
ng
Sunt Total
IUD/I
ik Tarif
mpla
nt
12/4/14
### 75.000
75.000
2/12/13
1/2/14
1/4/14 25,000 100.000
2/4/14 600,000
600.000
125.000
5/4/14
8/4/14 13/4/14
### 75.000
775.000
11081351017800Matang Baroh 085260078141 G4 P3 A0 5/10/13 4/12/13

G6 P5 A0 7/10/13 8/12/13
6/2/14
5/4/14 25,000 100.000 11/4/14 600,000
600.000
125.000
13/4/14 18/4/14 22/4/14
### 75.000
775.000
6/2/14
7/4/14 25,000 100.000 15/4/14 600,000
600.000
125.000
17/4/14 21/4/14 26/4/14
### 75.000
775.000
600.000 125.000
18/4/14 21/4/14 26/4/14
### 75.000
775.000
600,000 125.000
600,000 125.000
19/4/14 23/4/14 28/4/14

23/4/14 27/4/14 30/4/14
### 75.000
### 75.000
775.000
775.000
Total
600.000
3.600.000
525.000
2
3
4 Syamsiah
5
6
Maiyuni
Erlinawati
7 Yulidar
11081356069300Matang Baroh 085261256981 G1 P0 A0 1/10/13
11082346068200Kuala Kereuto '085277315257 G6 P5 A010//10/13 9/12/13 11/2/14 8/4/14 25,000 100.000 15/4/14 600,000
11081368118200Matang Baroh 085260772757 G3 P2 A011/10/13 10/12/13 12/2/14 9//4/14 25,000 100.000 17/4/14 600,000
11082358079500Kuala Kereuto085373105410 G1 P0 A016/10/13 17/12/13 15/2/14 16/4/14 25,000 100.000 '21/4/14 600,000
Lapang,30 Juni 2014

4.725.000
Erlinawati,Am.Keb
Nip.19740716 200701 2 004
Nip

Dasar Klaim
Kepada Yth :

Juni 2014
Dengan Hormat,
Jenis Pelayanan
No Nama Pasien
NO. KTP/KK
Alamat
Pasien
ANC
No. HP
K1
1
2
3
Noni
Nilawati
Juhari
4 Marwati
5
6
Nuroini
Fatmawati
7 Juliana
8 Siti Khotimah
Persalinan
G.P.A
K2
11081342039300Matang Baroh085360685255 G2 P0 A1 2/12/13 3/2/14
K3
K4
2/4/14 1/6/14
Tarif
ANC
PNC
Total
Tarif
Tarif
Total Tarif
Tarif
Total Tarif Tanggal
Tindaka
Tindaka
ANC
INC
n Pra
n Normal Normal
n Pra
Rujukan
Rujukan
Pelayanan KB
K
KF1
KF2
KF3 F
Tarif
PNC
100.000 100.000 3/6/14
600.000
600.000
125.000
6/6/14 10/6/14 13/6/14 75.000
Total
Tarif
PNC
Pasa
ng
Sunt Total
IUD/I
ik Tarif
mpla
nt
Total
75.000
775.000
11081041077201Desa Ampeh 085260152761 G3 P2 A0 2/12/13 3/2/14
5/4/14
2/6/14
100.000 100.000 4/6/14
600.000
600.000
125.000
7/6/14 11/6/14 14/6/14 75.000
75.000
775.000
11081341077401Kuala Cangko
4/4/14
7/6/14
100.000 100.000 7/6/14
600.000
600.000
125.000
10/6/14 14/6/14 18/6/14 75.000
'-
6/4/14
8/6/14
100.000 100.000 10/6/14 600.000
600.000
125.000
13/6/14 16/6/14 21/6/14 75.000
75.000
75.000
775.000
11082354108900Cot Jabet
G5 P4 A0 6/12/13 5/2/14
G1 P0 A0 7/12/13 8/2/14
11081341049200Matang Baroh085373637361 G2 P0 A1'6/12/13 7/2/14
5/4/14
8/6/14
100.000 100.000 13/6/14 600.000
600.000 125.000
16/6/14 19/6/14 24/6/14 75.000
75.000
775.000
11081341077302Matang Baroh085261979541 G6 P5 A012/12/13 10/2/14

11081346069100Matang Baroh085271132913 G1 P0 A019/12/13 20/2/14
G1 P0 A07/12/13 8/2/14
-
11/4/14 2/6/14 100.000 100.000 19/6/14 600.000

18/4/14 17/6/14 100.000 100.000 22/6/14 600.000
10/4/14 12/6/14 100.000 100.000
600,000 125.000
600,000 125.000
21/6/14 25/6/14 29/6/14 75.000

24/6/14 28/6/14 3/7/14 75.000
125.000
27/6/14 30/6/14 4/7/14
75.000
75.000
75.000
775.000
775.000
225.000
600.000
5.650.000
Total
800.000
4.200.000
125.000
Mengetahui
Klinik Mita seh
Lapang,30 Juni 2014

775.000
Erlinawati,Am.Keb
Nip.19740716 200701 2 004
Nip

Dasar Klaim
Kepada Yth :

Juli 2014
Dengan Hormat,
Jenis Pelayanan
No Nama Pasien
NO. KTP/KK
Alamat
Pasien
ANC
No Hp
K1
1
2
3
7
8
9
10
K2
K3
K4
Tarif
ANC
PNC
Total
Tarif
Tarif
Total Tarif
Tarif
Total Tarif Tanggal
Tindaka
Tindaka
ANC
INC
n Pra
n Normal Normal
n Pra
Rujukan
Rujukan
Pelayanan KB
K
KF1
KF2
KF3 F
Tarif
PNC
Total
Tarif
PNC
Pasa
ng
Sunt Total
IUD/I
ik Tarif
mpla
nt
Total
Yeni Yuslina 11081343078000Kuala Keureu

G3 P2 A0 2/1/14 3/3/14
Ramulan
11081341078502Matang Baroh081364670414 G3 P2 A0 3/1/14 4/3/14
Mutia
11081355098600Blang Seunon
G3 P1 A1 3/1/14 2/3/14
100.000 100.000 8/7/14 600.000
600.000
125.000
10/7/14 14/7/14 18/7/14 75.000
75.000
775.000
2/5/14
3/7/14
100.000 100.000 10/7/14 600.000
600.000
125.000
12/7/14 16/7/14 20/7/14 75.000
75.000
775.000
1/5/14
3/7/14
600.000
125.000
12/7/14 16/7/14 20/7/14 75.000
5/5/14
4/7/14
600.000
125.000
14/7/14 18/7/14 22/7/14 75.000
75.000
75.000
775.000
11082361039400Matang Baroh085358692601 G1 P0 A0 4/1/14 3/3/14
100.000 100.000 10/7/14 600.000

100.000 100.000 12/7/14 600.000
Rohani
11081341078302Matang Baroh085260912758 G3 P2 A0 4/1/14 5/3/14
Fitri Zahara 11081968058600Rayeuk Karen085277069666 G2 P1 A0 7/1/14 6/3/14
6/7/14
6/7/14
100.000 100.000 12/7/14 600.000
600.000 125.000
14/7/14 18/7/14 22/7/14 75.000
75.000
775.000
8/5/14
7/5/14
6/5/14
8/5/14
14/5/14
7/7/14
8/7/14
9/7/14
11/7/14
15/7/14
100.000
100.000
100.000
100.000
100.000
'16/7/14
17/7/14
17/7/14
20/7/14
.
75.000
75.000
75.000
75.000
75.000
775.000
775.000
775.000
775.000
775.000
750.000
7.750.000
4 Zainabon
5
Persalinan
G.P.A
Aisyah
Darmawati
Nurmalawati
Yusra
11081341078602Matang Baroh081376575626 G1 P0 A0 6/1/14

11081341078002Matang Baroh085206665972 G4 P2 A1 7/1/14
11081351089300Teupin Gapeu085370232018 G2 P1 A1 10/1/14
11081348078000Merbo Jurong085359097783 G3 P2 A012/1/14
5/3/14
8/3/14
9/3/14
10/3/14
2/5/14 4/7/14
100.000
100.000
100.000
100.000
100.000
14/7/14 600.000
600.000
15/7/14 600.000
600.000
15/7/14 600.000
600.000
18/7/14 600.000
600.000
20/7/14 600.000 600.000
125.000
125.000
125.000
125.000
125.000
20/7/14
21/7/14
21/7/14
24/7/14
26/7/14
24/7/14
28/7/14
25/7/15
28/7/14
31/7/14
Total
1.000.000
6.000.000
75.000
75.000
75.000
75.000
75.000
775.000
Mengetahui
Klinik Mita seh
Lapang,31 Juli 2014


Dasar Klaim
Kepada Yth :

Sep-14
Dengan Hormat,
Jenis Pelayanan
No Nama Pasien
NO. KTP/KK
Alamat
Pasien
ANC
No Hp
K1
1
2
3
5
6
7
8
9
10
Nurhayati
Diana
Rosmani
Rusmani
Irhamna
Mardiah
Tarif
ANC
Total
Tarif
Tarif
Total Tarif
Tarif
Total Tarif Tanggal
Tindaka
Tindaka
ANC
INC
n Pra
n Normal Normal
n Pra
Rujukan
Rujukan
Pelayanan KB
K
Total
Tarif
PNC
6/7/14
8/9/14 100.000 100.000 6/9/14 600.000
600.000
125.000
6/9/14 10/9/14 15/9/14 75.000
75.000
775.000
G3 P2 A0 7/3/14
6/5/14
8'7'14
7/7/14 100.000 100.000 6/9/14 600.000
600.000
125.000
8/9/14 12/9/14 17/9/14 75.000
75.000
775.000
7/5/14
6/7/14
125.000
9/9/14 13/9/14 18/9/14 75.000
75.000
775.000
6/5/14
7/7/14
8/9/14 100.000 100.000 7/9/14 600.000

6/9/14 100.000 100.000 9/9/14 600.000
600.000
G1 P0 A0 6/3/14
G1 P0 A0 8/3/14
600.000
125.000
11/9/14 15/9/14 20/9/14 75.000
75.000
775.000
11740345078600Langsa
G2 P1 A1 6/3/14
7/5/14
8/7/14
7/9/14 100.000 100.000 10/9/14 600.000
600.000 125.000
13/9/14 16/9/14 21/9/14 75.000
75.000
775.000
13/9/14 600.000
14/9/14 600.000
15/9/14 600.000
600.000
18/9/14 600.000
600.000 125.000
600.000 125.000
600.000 125.000
125.000
600.000 125.000
15/9/14
16/9/14
17/9/14
21/9/14
20/9/14
75.000
75.000
75.000
75.000
75.000
775.000
775.000
775.000
175.000
775.000
750.000
7.150.000
9/9/14
7/9/14
8/9/14
9/9/14
13/9/14
100.000
100.000
100.000
100.000
100.000
100.000
100.000
100.000
100.000
100.000
KF3 F
Tarif
PNC
7/5/14
8/5/14 6/7/14
G3 P2 A0 7/3/14
11081341078201Merbo Jurong
G3 P2 A0 6/3/14
7/5/14 8/7/14
G1 P0 A0 7/3/14
8/5/14 6/7/14
11081348068200Kuala Cangko082363733986 G4 P2 A1 11/3/14 10/5/14 12/7/14
11081344039800Kuala Cangko085294230082 G1 P0 A0 13/3/14 14/5/14 12/7/14
KF2
Total
G1 P0 A0 6/3/14
KF1
Pasa
ng
Sunt Total
IUD/I
ik Tarif
mpla
nt
K3
K4
PNC
K2
Nurbayani 11082342039400Kuala Keureu

Nuraina
11081345078300Merbo Jurong
Mira Misdian 11082353038900Matang Baroh
4 Nitawati
Persalinan
G.P.A
19/9/14
20/9/14
21/9/14
25/9/14
24/9/14
24/9/14
25/9/14
26/9/14
30/9/14
'30/9/14
75.000
75.000
75.000
75.000
75.000
Total
1.000.000
5.400.000
Mengetahui
Klinik Mita seh
Nip
Lapang,30 September 2014

Erlinawati,Am.Keb
Nip.19740716 200701 2 004

Dasar Klaim
Kepada Yth :

Oct-14
Dengan Hormat,
Jenis Pelayanan
No Nama Pasien
NO. KTP/KK
Alamat
Pasien
ANC
No Hp
K1
1
2
3
11081341078302Kuala Keureu
Rohani
Rahmayani 11081355049400Cibrek
Nurmawati 11081341078902Cibrek
4 Nurjanah
5
6
Juwairiah
Warzati
7 Desi Susanti
8 Mariana
Persalinan
G.P.A
K2
K3
K4
Tarif
ANC
PNC
Total
Tarif
Tarif
Total Tarif
Tarif
Total Tarif Tanggal
Tindaka
Tindaka
ANC
INC
n Pra
n Normal Normal
n Pra
Rujukan
Rujukan
G3 P2 A0 2/4/14
1/6/14
3/8/14 2/10/14 50.000
200.000 2/10/14 600.000
G1 P0 A0 4/4/14
3/6/14
5/8/14 2/10/14 50.000
200.000 3/10/14 600.000
8/6/14
6/8/14 5/10/14 50.000
11081341077401Cibrek
G2 P1 A1 7/4/14
G3 P2 A1 6/4/14
7/6/14
8/8/14 5/10/14 50.000
200.000 8/10/14 600.000

200.000 9/10/14 600.000
G8 P4 A3 8/4/14
7/6/14
9/8/14 6/10/14 50.000
200.000 10/10/14 600.000
600.000 125.000
11710443079000Rukoh
11081055049200Cibrek Tunong
11081057078400Gp Kulam
8/6/14 10/8/14 7/10/14 50.000

G2 P1 A1 9/4/14
G2 P1 A1 10/4/14 9/6/14 11/8/14 8/10/14 50.000
G3 P2 A0 11/4/14 10/6/14 12/10/14 9/10/14 50.000
200.000 11/10/14 600.000

200.000 12/10/14 600.000
200.000 14/10/14 600.000
600.000 125.000
600.000 125.000
600.000 125.000
Pelayanan KB
K
KF1
KF2
KF3 F
Tarif
PNC
Nip
Total
125.000 125.000 7/10/14 10/10/1415/10/14 75.000
75.000
400.000
600.000
125.000
6/10/14 10/10/1415/10/14 75.000
75.000
875.000
600.000
125.000
10/10/1414/10/1419/10/14 75.000
75.000
875.000
125.000 125.000 13/10/1420/10/1427/10/14 75.000
75.000
400.000
13/10/1416/10/1421/10/14 75.000
75.000
875.000
14/10/1418/10/1423/10/14 75.000
15/10/1419/10/1424/10/14 75.000
21/10/1425/10/1430/10/14 75.000
75.000
75.000
75.000
875.000
875.000
875.000
600.000
6.050.000
Total
1.600.000
3.600.000
250.000
Mengetahui
Klinik Mita seh
Total
Tarif
PNC
Pasa
ng
Sunt Total
IUD/I
ik Tarif
mpla
nt

Erlinawati,Am.Keb
Nip.19740716 200701 2 004

Dasar Klaim
Kepada Yth :
Dengan Hormat,

Jan-16
Jenis Pelayanan
Persalinan
ANC
No Nama Pasien
1
2
3
Alamat
Pasien
11081341078302Kuala Keureu
Rohani
Rahmayani 11081355049400Cibrek
Nurmawati 11081341078902Cibrek
4 Nurjanah
5
NO. KTP/KK
Juwairiah
Warzati
7 Desi Susanti
8 Mariana
No Hp
G.P.A
K1
K2
K3
K4
Tarif
ANC
Total
Tarif
Tarif
Total Tarif
Tarif
Total Tarif Tanggal
Tindaka
Tindaka
ANC
INC
n Pra
n Normal Normal
n Pra
Rujukan
Rujukan
G3 P2 A0 2/4/14
1/6/14
3/8/14 2/10/14 50.000
200.000 2/10/14 600.000
3/6/14
5/8/14 2/10/14 50.000
G1 P0 A0 4/4/14
G2 P1 A1 7/4/14
8/6/14
6/8/14 5/10/14 50.000
200.000 3/10/14 600.000

200.000 8/10/14 600.000
11081341077401Cibrek
G3 P2 A1 6/4/14
7/6/14
8/8/14 5/10/14 50.000
200.000 9/10/14 600.000
G8 P4 A3 8/4/14
7/6/14
9/8/14 6/10/14 50.000
200.000 10/10/14 600.000
600.000 125.000
11710443079000Rukoh
11081055049200Cibrek Tunong
11081057078400Gp Kulam
8/6/14 10/8/14 7/10/14 50.000

G2 P1 A1 9/4/14
G2 P1 A1 10/4/14 9/6/14 11/8/14 8/10/14 50.000
G3 P2 A0 11/4/14 10/6/14 12/10/14 9/10/14 50.000
200.000 11/10/14 600.000

200.000 12/10/14 600.000
200.000 14/10/14 600.000
600.000 125.000
600.000 125.000
600.000 125.000
Pelayanan KB
PNC
K
KF1
KF2
Tarif
KF3 F
PNC
4
Nip
Pasa
ng
Sunt Total
IUD/I
ik Tarif
mpla
nt
Total
125.000 125.000 7/10/14 10/10/1415/10/14 75.000
75.000
400.000
600.000
125.000
6/10/14 10/10/1415/10/14 75.000
75.000
875.000
600.000
125.000
10/10/1414/10/1419/10/14 75.000
75.000
75.000
875.000
13/10/1416/10/1421/10/14 75.000
75.000
875.000
14/10/1418/10/1423/10/14 75.000
15/10/1419/10/1424/10/14 75.000
21/10/1425/10/1430/10/14 75.000
75.000
75.000
75.000
875.000
875.000
875.000
600.000
6.050.000
125.000 125.000 13/10/1420/10/1427/10/14 75.000
Total
1.600.000
3.600.000
250.000
Mengetahui
Klinik Mita seh
Total
Tarif
PNC

Erlinawati,Am.Keb
Nip.19740716 200701 2 004
400.000

Dasar Klaim
Kepada Yth :
Ketua Tim Pengelola BPJS Kesehatan

Jan-16
Dengan Hormat,
Jenis Pelayanan
Persalinan
ANC
No Nama Pasien
1
2
3
Syamsiah
Wahyuni
Khairu
4 Verayani
5
Sutriah
NO. BPJS
Alamat
Pasien
225556244
Matang Baroh
1965151978
Blang Nibong
224732474
Matang Baroh
1965135161
Matang Baroh
No Hp
G.P.A
K1
K2
K3
K4
Tarif
ANC
Pelayanan KB
PNC
Total
Tarif
Tarif
Total Tarif
Tarif
Total Tarif Tanggal
Tindaka
Tindaka
ANC
INC
n Pra
n Normal Normal
n Pra
Rujukan
Rujukan
K
KF1
KF2
Tarif
KF3 F
PNC
Total
Tarif
PNC
Pasa
ng
Sun- Total
IUD/
tik Tarif
Impl
ant
Total
G5 P4 A0 26/6/15 27/8/15 29/10/15 28/1/16 50.000

4/9/16 7/11/16 3/1/16 50.000
G1 P0 A0 2/7/15
200.000 7/1/16 600.000

200.000 10/1/16 600.000
600.000
125.000
9/1/16 13/1/16 16/1/16 75.000
75.000
875.000
600.000
125.000
12/1/16 16/1/16 19/1/16 75.000
75.000
875.000
G3 P2 A0 28/6/15 25/8/15 20/10/15 4/1/16 50.000

3/9/15 4/11/15 6/1/16 50.000
G2 P1 A0 2/7/15
200.000 11/1/16 600.000

200.000 13/1/16 600.000
600.000
125.000
13/1/16 17/1/16 20/1/16 75.000
875.000
600.000
125.000
15/1/16 19/1/16 22/1/16 75.000
75.000
75.000
G3 P2 A0 7/7/15
200.000 17/1/16 600.000
600.000
125.000
19/1/16 23/1/16 26/1/16 75.000
75.000
875.000
5/9/15
3/11/15 10/1/16 50.000
875.000
Jamiah
1965137815 Matang Baroh

224512749 Kuala Keureuto
224039981
Gp. Nga
Mengetahui
Klinik Mita seh
Nip
6/9/15 4/11/15 11/1/16 50.000

G3 P2 A0 7/7/15
G5 P4 A0 8/7/15
9/9/15 7/11/15 10/1/16 50.000
G1 P0 A0 14/7/15 13/9/15 15/11/1512/1/2016 50.000
200.000 18/1/16 600.000

200.000 19/1/16 600.000
200.000 19//1/16 600.000
600.000 125.000
20/1/16 24/1/16 27/1/16 75.000 75.000
21/1/16 25/1/16 28/1/16 75.000 75.000
600.000 125.000
22/1/16 26/1/16 29/1/16 75.000 75.000
600.000 125.000
Total
4.800.000
1.800.000
600.000
Terlampir bersama ini kami sampaikan pula bukti-bukti penunjang yang sah untuk menjadi pertimbangan (Copy identitas/ partograf/Surat Keterangan Kelahiran / register kohort Ibu/Bayi/ Kartu Ibu/ Kartu Nifas dll))
6
7 Sakdiah
8 Noratul Islamiya
Lapang,31 Januari 2016

Erlinawati,Am.Keb
Nip.19740716 200701 2 004
875.000
875.000
875.000
7.000.000

Dasar Klaim
Kepada Yth :

Feb-16
Dengan Hormat,
Jenis Pelayanan
Persalinan
ANC
No Nama Pasien
1
2
3
Nurlaili
Azizah
Sadariah
Alamat
Pasien
No Hp
G.P.A
K1
K2
K3
K4
Tarif
ANC
1108125007960000
Matang Baroh085359654943G2 P1 A0 17/7/15 20/9/15 22/11/15 23/1/16 50.000
200.000
1108134107820148
Kuala Keureuto085358977712G4 P3 A0 17/7/15 14/9/16 21/11/16 28/1/16 50.000
0000223679733
Punti PA
082362980018G2 P1 A0 28/7/15 30/9/15 4/12/15 2/2/16 50.000
7/1/16
K
KF3 F
Tarif
PNC
Pasa
ng
Sun- Total
IUD/
tik Tarif
Impl
ant
Total
KF1
KF2
4/2/16
8/2/16 11/2/16 75.000
75.000
875.000
600.000
125.000
200.000 10/1/16 600.000
600.000
125.000
6/2/16 10/2/16 13/2/16 75.000
75.000
875.000
600.000
125.000
12/2/16 16/2/16 19/2/16 75.000
75.000
875.000
600.000
125.000
21/2/16 25/2/16 28/2/16 75.000
75.000
875.000
600.000
125.000
21/2/16 25/2/16 28/2/16 75.000
75.000
875.000
375.000
4.375.000
1108184702960002
Matang Baroh 085358411080G1 P0 A0 5/8/15
7/10/15 10/12/15 12/2/16 50.000
Darmayanti 0000224429444Kuala Cangkoy085215681783G1 P0 A0 6/8/15
5/10/15 7/12/15 12/2/16 50.000
200.000 19/2/16 600.000
3.000.000
Total
1.000.000
Mengetahui
Klinik Mita seh
Total
Tarif
PNC
600.000
200.000 10/2/16 600.000

200.000 19/2/16 600.000
4 Nuraini
5
NO. BPJS
Pelayanan KB
PNC
Total
Tarif
Tarif
Total Tarif
Tarif
Total Tarif Tanggal
Tindaka
Tindaka
ANC
INC
n Pra
n Normal Normal
n Pra
Rujukan
Rujukan
Lapang,29 Februari 2016

Nip
Erlinawati,Am.Keb
Nip.19740716 200701 2 004

Dasar Klaim
Kepada Yth :

Mar-16
Dengan Hormat,
Jenis Pelayanan
Persalinan
ANC
No Nama Pasien
Fauziah
Darniyati
Rohani
Alamat
Pasien
NO. BPJS
No Hp
G.P.A
K1
K2
K3
K4
Tarif
ANC
Pelayanan KB
PNC
Total
Tarif
Tarif
Total Tarif
Tarif
Total Tarif Tanggal
Tindaka
Tindaka
ANC
INC
n Pra
n Normal Normal
n Pra
Rujukan
Rujukan
K
KF1
KF2
Tarif
KF3 F
PNC
Total
Tarif
PNC
Pasa
ng
Sun- Total
IUD/
tik Tarif
Impl
ant
Total
11/11/15 15/1/16 25/2/16 50.000
200.000 3/3/16 600.000
600.000
125.000
5/3/16
9/3/16 12/3/16 75.000
75.000
875.000
Kuala Cangkoy082367489039G1 P0 A0 11/9/15
3/11/15
2/1/16
1/3/16 50.000
200.000 5/3/16 600.000
600.000
125.000
7/3/16 11/3/16 14/3/16 75.000
75.000
875.000
1108234506900001
5/11/15
5/1/16
8/3/16 50.000
600.000
125.000
13/3/16 17/3/16 20/3/16 75.000
6/11/15
4/1/16
8/3/16 50.000
600.000
125.000
15/3/16 19/3/16 22/3/16 75.000
75.000
75.000
875.000
1108235210910002
200.000 11/3/16 600.000

200.000 12/3/16 600.000
200.000 18/3/16 600.000
200.000 20/3/16 600.000
200.000 21/3/16 600.000
50.000
375.000
'981064765 Kuala Keureuto085361183923G1 P0 A0 10/9/15 11/11/15 9/1/16 11/3/16 50.000

600.000 125.000
22/3/16 26/3/16 29/3/16 75.000 75.000
7 Maulina
Kuala Keureuto085360939223G1 P0 A0 5/9/15 14/11/15 17/1/16 11/3/16 50.000
23/3/16 27/3/16 30/3/16 75.000 75.000
1108236701910001
600.000 125.000
Total
3.600.000
1.400.000
125.000
500.000
875.000
875.000
1
2
3
4 Irmayanti
5
6
1108236505890001
Kuala Keureuto085253606072G2 P1 A0 8/9/15
224443675
Nuraina Ali
Nuraini
225046326
Mengetahui
Klinik Mita seh
Nip
Merbo Jurong 082284812474G6 P5 A0 10/9/15
8/11/15 12/1/16 10/1/16 50.000
125.000 125.000
23/3/16 27/3/16 75.000
Lapang,31 Maret 2016

Erlinawati,Am.Keb
Nip.19740716 200701 2 004
875.000
5.625.000

Dasar Klaim
Kepada Yth :

Apr-16
Dengan Hormat,
Jenis Pelayanan
No Nama Pasien
1
2
3
Hartati
Aisyah
Mardiana
4 Suryati
5
6
7
8
9
NO. BPJS
Alamat
Pasien
K1
K2
K3
K4
Tarif
ANC
Total
Tarif
Tarif
Total Tarif
Tarif
Total Tarif Tanggal
Tindaka
Tindaka
ANC
INC
n Pra
n Normal Normal
n Pra
Rujukan
Rujukan
K
Tarif
KF3 F
PNC
Total
Tarif
PNC
Pasa
ng
Sun- Total
IUD/
tik Tarif
Impl
ant
Total
KF1
KF2
4/4/16
8/4/16 11/4/16 75.000
75.000
875.000
8/4/16 15/4/16 75.000
50.000
375.000
6/4/16 10/4/16 13/4/16 75.000

15/4/16 20/4/16 75.000
75.000
50.000
375.000
17/4/16 21/4/16 24/4/16 75.000
75.000
875.000
17/4/16 21/4/16 24/4/16 75.000
75.000
875.000
2/2/16 27/3/16 50.000
200.000 2/4/16 600.000
600.000
1108134107830242 Kuala Cangkoy 085370770541
G6 P5 A0 28/9/15 30/11/15 27/1/16 24/3/16 50.000
0000981063358
Matang Baroh
082277716460
600.000
0000225559449
Matang Baroh
0852755117259
G2 P1 A0 23/9/15 25/11/15 26/1/16 25/3/16 50.000

G1 P0 A0 2/10/15 1/12/15 3/2/16 2/4/16 50.000
200.000 3/4/16 600.000

200.000 4/4/16 600.000
200.000 8/4/16 600.000
085362172154
G5 P4 A0 8/10/15
8/4/16 50.000
200.000 15/4/16 600.000
600.000
125.000
085277902391
200.000 15/4/16 600.000
600.000
125.000
081364143526
G4 P3 A0 28/10/15 27/12/15 29/2/16 10/4/16 50.000

G1 P0 A0 25/10/15 27/12/15 24/2/16 12/4/16 50.000
200.000 17/4/16 600.000
600.000
125.000
20/4/16 24/4/16 27/4/16 75.000
75.000
875.000
085371275472
G2 P1 A0 10/10/15 12/12/15
9/2/16 13/4/16 50.000
200.000 19/4/16 600.000
600.000
125.000
20/4/16 24/4/16 27/4/16 75.000
75.000
875.000
082367059756
G3 P2 A0 19/10/15 24/12/15 20/2/16 12/4/16 50.000
600.000
125.000
G1 P0 A0 8/10/15 10/12/15 22/1/16 18/4/16 50.000
22/4/16 26/4/16 29/4/16 75.000

27/4/16 30/4/16 75.000
125.000 125.000 -
75.000
50.000
875.000
'1108234904900001 Kuala Cangkoy 082368905859
200.000 20/4/16 600.000

200.000 23/4/16 600.000
675.000
7.250.000
0000526762359
Kuala Cangkoy 082311503810
Ainol Marliah0000223758674 Ulee Tanoh

Salbiah
Mustika Junit 0001120777828 Ds. Ara
Juwairiyah 00000224509061 Cibrek
0000981071627
Ulee Tanoh
Idawati
10 Rahmi Marlina
No Hp
G1 P0 A0 4/10/15 10/12/15
7/12/15
9/2/16
125.000
125.000 125.000
125.000
125.000 125.000
-
Total
4.200.000
2.000.000
375.000
Mengetahui
Klinik Mita seh
Nip
Lapang,30 April 2016

Erlinawati,Am.Keb
Nip.19740716 200701 2 004
875.000
375.000
LEMBARAN KLAIM/ PERTAN

Dasar Klaim
Kepada Yth :
Dengan Hormat,
Bersama ini kami ajukan klaim/ pertanggungjawaban dana Pelayanan Kesehatan Kebidanan dan Neona
No
Nama Pasien
NO. KTP/KK
223688035
Nurhayati
Zubaidah
196092314
Mulyani Dewi 1310948717
Rita Mutia
1
2
225032027
Alamat Pasien
No Hp
Kuala Keureuto
Kuala Cangkoy
Matang Tunong
Merbo Jurong
Total
Terlampir bersama ini kami sampaikan pula bukti-bukti penunjang yang sah untuk menjadi pertimbangan
Mengetahui
Klinik Mita sehat
Nip
MBARAN KLAIM/ PERTANGGUNG JAWABAN DANA PELAYANAN KESEHATAN KE

PADA BPJS (BADAN PENYELENGGARA JAMINAN
Mita Sehat / BPM Azizah.Am.Keb

Feb-16
n Kesehatan Kebidanan dan Neonatal Non Kapitasi yang telah kami berikan (dalam Rupiah)dengan perincian sebaga
Jen
Pe
ANC
G.P.A
K1
K2
K3
K4
Tarif ANC
Total Tarif
ANC
Tanggal
INC
G5 P4 A0
10/8/15
8/11/15
6/1/16
6/2/16
50.000
200.000
10/2/16
G3 P2 A0
7/8/15
10/11/15 8/1/16
9/2/16
50.000
200.000
14/2/16
G4 P2 A1
G1 P0 A0
25/8/15 23/11/15 20/1/16
5/2/16
50.000
200.000
19/2/16
21/8/15 20/11/15 16/1/16 12/2/16
50.000
200.000
20/2/16
800.000
g sah untuk menjadi pertimbangan (Copy identitas/ partograf/Suart Keterangan Kelahiran / register kohort Ibu/Bayi/ K
KESEHATAN KEBIDANAN DAN NEONATAL NON KAPITASI

GARA JAMINAN SOSIAL)
KAT PERTAMA
engan perincian sebagai berikut :

Jenis Pelayanan
Persalinan
Total
Tarif
Tarif
Total Tarif
Tarif
Tindakan
Tindaka
Pra
Normal n Normal
n Pra
Rujukan
Rujukan
PNC
KF1
KF2
KF3
KF4
Tarif PNC
600.000
600.000 125.000
10/2/16 13/2/16 18/2/16
75.000
600.000
600.000 125.000
14/2/16 17/2/16 21/2/16
75.000
600.000
600.000
600.000 125.000
19/2/16 21/2/16 27/2/16
75.000
6000.000 125.000
21/2/16 23/2/16 29/2/16
75.000
2.400.000
gister kohort Ibu/Bayi/ Kartu Ibu/ Kartu Nifas dll))
300.000
Lapang,30 November 2014

Erlinawati,Am.Keb
Nip.19740716 200701 2 004
Pelayanan KB
Pasang
IUD/Imp Suntik
lant
Total
875.000
875.000
875.000
875.000
3.500.000
Ket

a Klinik/Bidan Jejaring
Dasar Klaim
an dan Tahun Klaim
Kepada Yth :
Pengelola BPJS Keehatan
bupaten Aceh Utara

###
Dengan Hormat,
nan dan Neonatal Non Kapitasi yang telah kami berikan (dalam Rupiah)dengan perincian sebagai berikut :
Jenis Pelayanan
Persalinan
ANC
No
1
2
3
4
5
Nama
Pasien
NO. KTP/KK
Alamat Pasien
No Hp
G.P.A
K1
Azizah N981060568
Fauziah 1108134107860215
Salwati 225090415
Safriani 981061007
Suriani 224443607
K2
K3
Nip
Total
Tarif
ANC
Total
Total
Tarif
Tarif
Tarif
Tarif
Tangga Persalin
Tindaka
Persali
Tindaka
l INC
an
n Pra
nan
n Pra
Normal
Rujukan
Normal
Rujukan
KF1
KF2
KF3
Tarif
PNC
Total
Tarif
PNC
Pasan
g
Sun Total
IUD/Im tik Tarif
plant
Total
G3 P2 A0 11/5/14 9/8/14 10/10/149/11/14 50.000 200.00010/11/14600.000 600.000 125.000
10/11/14 12/11/14 17/11/14 75.000
75.000
875.000
G1 P0 A0 13/5/14 15/8/1415/10/1413/11/1450.000 200.00014/11/14600.000 600.000 125.000
15/11/14 17/11/14 20/11/14 75.000
75.000
875.000
G3 P2 A0 16/5/14 17/8/1416/10/1416/11/1450.000 200.00017/11/14600.000 600.000 125.000
17/11/14 20/11/14 23/11/14 75.000
75.000
875.000
Geulanggang Kulam
G1 P0 A0 17/5/14 18/8/1416/10/1417/11/1450.000 200.00018/11/14600.000 600.000 125.000
18/11/14 20/11/14 24/11/14 75.000
75.000
875.000
Merbo Jurong
G2 P1 A0 21/5/14 20/8/1422/10/1419/11/1450.000 200.00020/11/14600.000 600.000 125.000
21/11/14 23/11/14 27/11/14 75.000
75.000
875.000
375.000
4.375.000
Simpang Empat
Matang Tunong
Tanjong Dama
Total
bangan (Copy identitas/ partograf/Suart Keterangan Kelahiran / register kohort Ibu/Bayi/ Kartu Ibu/ Kartu Nifas dll))
, untuk realisasinya diucapkan terima kasih
Mengetahui
Klinik Mita sehat
K4
Tarif
ANC
Pelayanan KB
PNC
1.000.000
3.000.000

Azizah,Am.Keb
Nip.19740716 200701 2 004
ma Klinik/Bidan Jejaring
Dasar Klaim
an dan Tahun Klaim
Kepada Yth :
Pengelola BPJS Keehatan
bupaten Aceh Utara

Nov-15
Dengan Hormat,
nan dan Neonatal Non Kapitasi yang telah kami berikan (dalam Rupiah)dengan perincian sebagai berikut :
Jenis Pelayanan
Persalinan
ANC
No
1
2
3
Nama
Pasien
Cut Yah
Juhari
Badriah
Azizah
NO. KTP/KK
Alamat Pasien
No Hp
G.P.A
K1
1108235009940001
Matang Tunong
1108134306860001
Matang Tunong
1108237101910001
Kuala Cangkoy
K2
K3
Nip
Total
Total
Tarif
Tarif
Tarif
Tarif
Tangga Persalin
Tindaka
Persali
Tindaka
l INC
an
n Pra
nan
n Pra
Normal
Rujukan
Normal
Rujukan
KF1
KF2
KF3
Tarif
PNC
Total
Tarif
PNC
Pasan
g
Sun Total
IUD/Im tik Tarif
plant
Total
125.000
125.000
7/11/15
15/11/15
25.000
50.000
375.000
3/7/15 4/10/15 4/11/15 50.000 200.000 5/11/15
125.000
125.000
9/11/15
17/11/15
25.000
50.000
375.000
875.000
G1 P0 A0 4/5/15
085246625705 G2 P1 A0 7/5/15
085276681882 G4 P2 A1 11/5/15
Mengetahui
Klinik Mita sehat
Total
Tarif
ANC
085276282473 G1 P0 A0 20/4/15 18/7/15 23/9/15 2/11/15 50.000 200.000 3/11/15
6/7/15 5/10/15 7/11/15 50.000 200.000 8/11/15 600.000 600.000

Total
bangan (Copy identitas/ partograf/Suart Keterangan Kelahiran / register kohort Ibu/Bayi/ Kartu Ibu/ Kartu Nifas dll))
, untuk realisasinya diucapkan terima kasih
4
K4
Tarif
ANC
Pelayanan KB
PNC
7/7/15 10/10/15 9/11/15 50.000 200.000 10/11/15 600.000 600.000

800.000
1.200.000
9/11/15
14/11/15 18/11/15
25.000
75.000
11/11/15 15/11/15 19/11/15
25.000
75.000
875.000
250.000
2.500.000
250.000

Azizah,Am.Keb
Nip.19740716 200701 2 004

Dasar Klaim
Kepada Yth :

Dec-14
Dengan Hormat,
Jenis Pelayanan
Persalinan
ANC
No
Nama Pasien
NO. KTP/KK
Alamat Pasien
No Hp
G.P.A
Tarif
ANC
Total Tarif
ANC
K1
K2
K3
K4
G1 P0 A0
2/6/14
3/8/14
2/10/14
4/12/14
150.000
6/12/14
600.000
G2 P1 A0
3/6/14
4/8/14
6/10/14
5/12/14
150.000
7/12/14
600.000
G2 P1 A0
4/6/14
6/8/14
5/10/14
4/12/14
150.000
9/12/14
600.000
600.000
9/12/14
600.000
Rosmaniar
Nurhanifah
Suryati
224746042
Matang Baroh
981056632
Cibrek
224501152
Cibrek
Diah Megawati
224064257
Merbo Jurong
G3 P2 A0
4/6/14
5/8/14
7/10/14
6/12/14
150.000
1108134607900001
Prie
G2 P1 A0
6/6/14
8/8/14
5/10/14
7/12/14
150.000
Syafwati
Diana
981063786
Matang Baroh
6/6/14
7/8/14
6/10/14
7/12/14
150.000
7
8
Siti Hazanah
Juraida
1108105711900002
225032534
Dayah Aron
Meucat
G3 P2 A0
G2 P1 A0
G5 P4 A0
10/6/14
16/6/14
9/8/14 11/10/14 8/12/14

17/8/14 15/10/14 18/12/14
150.000
150.000
1
2
Tarif
Tarif
Total Tarif
Tanggal
Tindakan
Persalinan Persalinan
INC
Pra
Normal
Normal
Rujukan
Pelayanan KB
PNC
Total
Tarif
Tindak
an Pra
Rujuka
n
KF1
KF2
KF3
Tarif
PNC
Total
Tarif
PNC
Pasang
IUD/Imp Suntik
lant
Total
Total Tarif
600.000
125.000
8/12/14
12/12/14
17/12/14
75.000
75.000
75.000
825.000
600.000
125.000
9/12/14
13/12/14
18/12/14
75.000
75.000
75.000
400.000
125.000
11/12/14
15/12/14
20/12/14
75.000
75.000
75.000
875.000
600.000
125.000
11/12/14
15/12/14
20/12/14
75.000
75.000
75.000
875.000
11/12/14 600.000
600.000
125.000
13/12/14
13/12/14
17/12/14
75.000
75.000
75.000
875.000
12/12/14 600.000
14/12/14 600.000
18/12/14 600.000
600.000
125.000
14//12/14
18/12/14
23/12/14
75.000
75.000
875.000
600.000
600.000
125.000
125.000
16/12/14
20/12/14
75.000
75.000
75.000
75.000
75.000
875.000
875.000
20/12/14
24/12/14
25/12/14
29/12/14
75.000
75.000
Total
1.200.000
4.800.000
Mengetahui
Klinik Mita sehat
600.000
Lapang,30 Desember 2014

Erlinawati,Am.Keb
Nip.19740716 200701 2 004
Nip
600.000 6.600.000

Dasar Klaim
Kepada Yth :

Feb-15
Dengan Hormat,
Jenis Pelayanan
Persalinan
ANC
No
Nama Pasien
NO. KTP/KK/JKN
Alamat Pasien
No Hp
G.P.A
K1
K2
K3
K4
Tarif
ANC
Total Tarif
ANC
Tarif
Tarif
Total Tarif
Tanggal
Tindakan
INC
Pra
Normal
Normal
Rujukan
Nurhayati
Kadriah
Salbiah
224510782
Lhok Iboh
085361844644
G1 P0 A0
2/8/14
3/10/14
2/12/14
1/2/15
175.000
3/2/15
600.000
225413921
Kuala Keureuto
082304242952
G7 P5 A1
1/8/14
2/10/14
4/12/14
2/2/15
175.000
4/2/15
600.000
225559708
Matang Baroh
081376575626
G4 P3 A0
3/8/14
4/10/14
5/12/14
3/2/15
175.000
6/2/15
600.000
600.000
Saidah
1820457696
Kuala Cangkoy
G2 P1 A0
5/8/14
6/10/14
5/12/14
7/2/15
175.000
8/2/15
600.000
223318361
Mesjid Pirak
082364124799
G2 P1 A0
1/8/14
3/10/14
2/12/14
4/2/15
175.000
Nurhalida
Ela Sanova
223757583
Matang Baroh
085372838219
7/8/14
6/10/14
8/12/14
6/2/15
175.000
11/2/15
7
8
Irma Suryani
Juraidah
1827917021
224436036
Kuala Cangkoy
Gp. Mesjid
G2 P1 A0
G2 P1 A0
G2 P1 A0
6/8/14
9/8/14
5/10/14 7/12/14
10/10/14 8/12/14
8/2/15
11/2/15
175.000
175.000
17/2/15
1
2
082360948589
082368420380
081287886053
Pelayanan KB
PNC
Total
Tarif
Tindak
an Pra
Rujuka
n
KF1
KF2
KF3
Tarif
PNC
Total
Tarif
PNC
Total
Pasang
IUD/Imp Suntik
lant
Total Tarif
600.000
125.000
6/2/15
10/2/15
14/2/15
75.000
75.000
75.000
850.000
600.000
125.000
6/2/15
10/2/15
15/2/15
75.000
75.000
75.000
850.000
125.000
8/2/15
12/2/15
17/2/15
75.000
75.000
75.000
850.000
600.000
125.000
10/2/15
14/2/15
19/2/15
75.000
75.000
75.000
850.000
600.000
125.000
20/2/15
25/2/15
28/2/15
75.000
75.000
75.000
250.000
600.000
600.000
600.000
600.000
125.000
13/2/15
17/2/15
22/2/15
75.000
75.000
850.000
600.000
125.000
125.000
75.000
75.000
75.000
75.000
75.000
250.000
850.000
22/2/15
19/2/15
25/2/15
23/2/15
S
28/2/15
75.000
75.000
Total
1.400.000
3.600.000
600.000 5.600.000
600.000
Mengetahui
Klinik Mita sehat

Erlinawati,Am.Keb
Nip.19740716 200701 2 004
Nip

Dasar Klaim
Kepada Yth :

Apr-15
Dengan Hormat,
Jenis Pelayanan
Persalinan
ANC
No
Nama Pasien
NO. KTP/KK
Alamat Pasien
No Hp
G.P.A
K1
K2
K3
K4
Tarif
ANC
Total Tarif
ANC
Tarif
Tarif
Total Tarif
Tanggal
Tindakan
INC
Pra
Normal
Normal
Rujukan
KF2
KF3
Tarif
PNC
Pasang
IUD/Imp Suntik
lant
Total
Total Tarif
Safwati
Darwati
Yusnawati
1840634212
Matang Baroh
85261852295
G2 P1 A0
2/10/14
3/12/14
1/2/15
3/4/15
50.000
200.000
600.000
125.000
6/4/15
10/4/15
15/4/15
75.000
75.000
875.000
1840637147
Mtg Teungoh
082316463294
G1 P0 A0
4/10/14
5/12/14
3/2/15
5/4/15
50.000
200.000
4/4/15
600.000
600.000
125.000
8/4/15
12/4/15
17/4/15
75.000
75.000
875.000
981062493
Matang Baroh
085372838219
G2 P1 A0
3/10/14
4/12/14
5/2/15
4/4/15
50.000
200.000
6/4/15
600.000
600.000
125.000
10/4/15
14/4/15
19/4/15
75.000
75.000
875.000
Nuraini
1817332762
Matang Baroh
G2 P1 A0
5/10/14
4/12/14
6/2/15
7/4/15
50.000
200.000
8/4/15
600.000
600.000
125.000
14/4/15
18/4/15
23/4/15
75.000
75.000
875.000
981083955
Nurhayati
1446363573
Azizah
Khairunnisak 203987338
Matang Baroh
081376575626
G1 P0 A0
8/10/14
7/12/14
9/2/15
10/4/15
50.000
200.000
12/4/15
600.000
600.000
125.000
18/4/15
22/4/15
27/4/15
75.000
75.000
875'000
Matang Baroh
G3 P2 A0
9/10/14
8/12/14
10/2/15
12/4/15
50.000
200.000
16/4/15
600.000
600.000
125.000
18/4/15
21/4/15
26/4/15
75.000
75.000
875.000
Cibrek Tunong
10/10/14
9/12/14
11/2/15
10/4/15
50.000
200.000
16/4/15
125.000
19/4/15
23/4/15
28/4/15
75.000
13/4/15
14/4/15
50.000
50.000
50.000
200.000
200.000
17/4/15
19/4/15
200.000
20/4/15
600.000
600.000
600.000
600.000
125.000
125.000
125.000
75.000
75.000
75.000
875.000
Gp Kulam
Matang Baroh
600.000
600.000
600.000
600.000
Elyanti
Rusnawati
G2 P1 A0
G2 P1 A0
G1 P0 A0
75.000
875.000
8.750.000
6
7
8
9
1120823199
224648695
10 Marlina
1267491688
Matang Baroh
082366744700
085370574781
085315052672
11/10/14 10/12/14 12/2/15

13/10/14 12/12/14 10/2/15
G2 P1 A0 12/10/14
13/12/14 10/2/15
14/4/15
KF1
Total
Tarif
PNC
600.000
Pelayanan KB
PNC
Total
Tarif
Tindak
an Pra
Rujuka
n
20/4/15
21/4/15
22/4/15
25/4/15
27/4/15
29/4/15
22/4/15
26/4/15
30/4/15
75.000
75.000
75.000
Total
6000.000
2.000.000
Mengetahui
Klinik Mita sehat
750.000
Lapang,30 April 2014

Erlinawati,Am.Keb
Nip
Nip.19740716 200701 2 004
875.000
875.000
N DANA PELAYANAN KESEHATAN KEBIDANAN DAN NEONATAL NON KAPITASI

BADAN PENYELENGGARA JAMINAN SOSIAL)
ITAS KESEHATAN TINGKAT PERTAMA

Dasar Klaim
Kepada Yth :

Dec-14
Dengan Hormat,
Jenis
Pelayana
n
Nama Pasien
No
NO. KTP/KK
Alamat Pasien
No Hp
ANC
K1
K2
K3
K4
2/6/14
3/8/14
2/10/14
4/12/14
Rosmaniar
224746042
Matang Baroh
Nurhanifah
Suryati
981056632
Cibrek
Diah Megawati
224501152
Cibrek
Syafwati
Diana
224064257
Merbo Jurong
1108134607900001
Siti Hazanah
Juraida
5
6
7
8
Tarif
ANC
Tarif
Tindakan
Pra
Rujukan
Total Tarif
Persalinan
ANC
150.000
Tarif
Total Tarif
Tanggal
Persalinan Persalinan 125.000
INC
Normal
Normal
G1 P0 A0
G2 P1 A0
3/6/14
4/8/14
6/10/14
5/12/14
150.000
6/12/14
600.000
G2 P1 A0
4/6/14
6/8/14
5/10/14
4/12/14
150.000
7/12/14
600.000
G3 P2 A0
4/6/14
5/8/14
7/10/14
6/12/14
150.000
9/12/14
600.000
600.000
Prie
G2 P1 A0
6/6/14
8/8/14
5/10/14
7/12/14
150.000
9/12/14
600.000
981063786
Matang Baroh
6/6/14
7/8/14
6/10/14
7/12/14
150.000
1108105711900002
225032534
Dayah Aron
Meucat
G3 P2 A0
G2 P1 A0
G5 P4 A0
10/6/14
16/6/14
9/8/14 11/10/14 8/12/14

17/8/14 15/10/14 18/12/14
150.000
150.000
11/12/14 600.000
12/12/14 600.000
14/12/14 600.000
Pelayanan KB
PNC
G.P.A
Total
Tarif
Tindak
an Pra
Rujuka
n
KF1
KF2
KF3
Tarif
PNC
8/12/14
12/12/14
17/12/14
75.000
Nip
Pasang
IUD/Imp Suntik
lant
Total
Total Tarif
75.000
825.000
75.000
600.000
125.000
9/12/14
13/12/14
18/12/14
75.000
75.000
75.000
400.000
600.000
125.000
11/12/14
15/12/14
20/12/14
75.000
75.000
75.000
875.000
125.000
11/12/14
15/12/14
20/12/14
75.000
75.000
75.000
875.000
600.000
125.000
13/12/14
13/12/14
17/12/14
75.000
75.000
75.000
875.000
600.000
125.000
14//12/14
18/12/14
23/12/14
75.000
75.000
875.000
600.000
600.000
125.000
125.000
16/12/14
20/12/14
75.000
75.000
75.000
75.000
75.000
875.000
875.000
20/12/14
24/12/14
25/12/14
29/12/14
75.000
75.000
Total
600.000
1.200.000 18/12/14 600.000
Terlampir bersama ini kami sampaikan pula bukti-bukti penunjang yang sah untuk menjadi pertimbangan (Copy identitas/ partograf/Suart Keterangan Kelahiran / register kohort Ibu/Bayi/ Kartu 4.800.000
Mengetahui
Klinik Mita sehat
Total
Tarif
PNC
600.000

Erlinawati,Am.Keb
Nip.19740716 200701 2 004
600.000 6.600.000
Dasar Klaim
Kepada Yth :

Jun-15
Dengan Hormat,
ANC
No
Nama Pasien
NO. KTP/KK/JKN
Alamat Pasien
No Hp
G.P.A
K1
K2
K3
K4
Tarif
ANC
Total Tarif
ANC
Tarif
Tanggal
Persalina
INC
n Normal
Jenis Pelayanan
Persalinan
Tarif
Total Tarif
Total Tarif
Tindaka
Persalinan
Tindakan
n Pra
Normal
Pra Rujukan
Rujukan
Pelayanan KB
PNC
KF1
KF2
KF3
Tarif
PNC
Total Tarif
PNC
Pasang
IUD/Imp Suntik
lant
Total
Total Tarif
1858305712
Kuala Cangkoy
082370536599
G2 P1 A0
5/12/14
8/2/15
7/5/15
2/6/15
50.000
200.000
3/6/15 600.000
600.000
125.000
3/6/15
8/6/15
12/6/15 25.000
75.000
875.000
1866814391
Kuala Cangkoy
G3 P2 A0
3/12/14
7/2/15
6/5/15
4/6/15
50.000
200.000
5/6/15 600.000
600.000
125.000
5/6/15
10/6/15 14/6/15 25.000
75.000
875.000
Rohana
Indal Fitri
Raihani
1866817258
Matang Tunong
G2 P1 A0
5/12/14
7/2/15
9/5/15
7/6/15
50.000
200.000
8/6/15 600.000
600.000
125.000
8/6/15
13/6/15 17/6/15 25.000
75.000
875.000
Ramlan Isa
1816095126
Glg Baro
G1 P0 A0
8/12/14
5/2/15
10/5/15
8/6/15
50.000
200.000
9/6/15 600.000
600.000
125.000
10/6/15 14/6/15 19/6/15 25.000
75.000
875.000
Nurfauzi
Nuraini
1120753462
Kuala Cangkoy
085314046800
G2 P1 A0
3/12/14
7/2/15
10/5/15
9/6/15
50.000
200.000
10/6/15 600.000
600.000
125.000
10/6/15 15/6/15 20/6/15 25.000
75.000
875.000
Lueng Baro
Glg Baro
Kuala Cangkoy
Glg Baro
Tanjong Meunye
082161921653
G3 P2 A0 6/12/14 3/2/15
G1 P0 A0 11/12/14 9/2/15
G2 P1 A0 7/12/14 6/2/15
G2 P1 A0 13/12/14 11/2/15
G3 P2 A0 16/12/14 18/2/15
5/5/15
7/5/15
10/5/15
14/5/15
20/5/15
12/6/15
13/6/15
14/6/15
15/6/15
18/6/15
50.000
50.000
50.000
50.000
50.000
200.000
200.000
200.000
200.000
200.000
13/6/15
14/6/15
15/6/15
16/6/15
19/6/15
600.000
600.000
600.000
600.000
600.000
125.000
125.000
125.000
125.000
125.000
13/6/15
15/6/15
15/6/15
16/6/15
19/6/15
75.000
75.000
75.000
75.000
75.000
875.000
875.000
875.000
875.000
875.000
750.000
8.750.000
1
2
1866819508
7 Ti Dewi
223946651
8 Kartini S
1858307488
9 Wani Madsyam 223917355
10 Meutia
1867979676
6
082362977636
082321065136
600.000
600.000
600.000
600.000
600.000
18/6/15
19/6/15
20/6/15
21/6/15
24/6/15
22/6/15
24/6/15
24/6/15
26/6/15
28/6/15
25.000
25.000
25.000
25.000
25.000
Total
2.000.000
6.000.000
Mengetahui
Klinik Mita sehat
Nip
Lapang, 30 Juni 2015

Nurbaiti,Am.Keb
Nip. 19780521 200801 2 002
Dasar Klaim
Kepada Yth :

May-15
Dengan Hormat,
ANC
No
Nama Pasien
NO. KTP/KK/JKN
Karmila
Nuraini
Nuraini
Syarwani
5
6
Nurhayati
Siti Fatimah 224417878
Ramlani Sari
1
2
Alamat Pasien
No Hp
G.P.A
K1
K2
K3
K4
Tarif
ANC
Total Tarif
ANC
7/5/15 600.000
9/5/15 600.000
600.000 125.000
200,000
9/5/15 600.000
10/5/15 600.000
12/5/15 600.000
200,000
200,000
12/5/15 600.000
20/5/15 600.000
Matang Tunong
085260414198
G1 P0 A0
3/11/14
6/2/15
8/4/15
6/5/15
50.000
200,000
1817620795
Kuala Keureutou
082361451340
G3 P1 A0
1/11/14
4/2/15
6/4/15
7/5/15
50.000
200,000
224449334
Matang Tunong
085210953662
3/4/15
8/5/15
50.000
200,000
224460483
223836309
Kuala Cangkoy
Glg Baro
5/2/15
G10 P3 A0 3/11/14
G8 P7 A0 14/11/14 9/2/15
G4 P3 A0 7/11/14 10/2/15
13/4/15
8/5/15
50.000
200,000
6/4/15
11/5/15
50.000
7/2/15
G3 P2 A0 5/11/14
G1 P0 A0 12/11/14 13/2/15
2/4/15 9/5/15 50.000

14/4/15 19/5/15 50.000
1858298466
085260289160
Tarif
Tanggal
Persalina
INC
n Normal
Jenis Pelayanan
Persalinan
Tarif
Total Tarif
Total Tarif
Tindaka
Persalinan
Tindakan
n Pra
Normal
Pra Rujukan
Rujukan
Pelayanan KB
PNC
KF1
KF2
KF3
Tarif
PNC
Nip
Pasang
IUD/Imp Suntik
lant
Total
Total Tarif
7/5/15
12/5/15 17/5/15 25.000
75,000
75,000
875,000
13/5/15 17/5/15 25.000
50,000
50,000
375,000
600.000 125.000
9/5/15
14/5/15 19/5/15 25.000
10/5/15 15/5/15 20/5/15 25.000
75,000
75,000
875,000
600.000 125.000
75,000
75,000
600.000 125.000
13/5/15 18/5/15 22/5/15 25.000
75,000
75,000
875,000
600.000 125.000
600.000 125.000
13/5/15 17/5/15 22/5/15 25.000

21/5/15 25/5/15 29/5/15 25.000
75,000
75,000
75,000
75,000
875,000
875,000
500,000
500,000
5,625,000
- 125.000
125,000
Total
1,400,000
3,600.000
125,000
Mengetahui
Klinik Mita sehat
Total Tarif
PNC
Lapang, 30 April 2015

Nurbaiti,Am.Keb
Nip. 19780521 200801 2 002
875,000
Dasar Klaim
Kepada Yth :

Sep-15
Dengan Hormat,
ANC
No
Nama Pasien
NO. KTP/KK/JKN
Alamat Pasien
No Hp
G.P.A
K1
1
2
3
4
5
6
7
8
9
K2
K3
K4
Tarif
ANC
Total Tarif
ANC
Tarif
Tanggal
Persalina
INC
n Normal
Maryani R
Ratna Ali
Musnaini
0001892237545
Kuala Cangkoy
G1 P0 A0
2/3/15
5/5/15
7/8/15
1/9/15
50.000
200,000
000224465242
Kuala Cangkoy
G4 P3 A0
6/3/15
10/5/15
12/8/15
2/9/15
50.000
200,000
0000223280774
Geulanggang Baro
10/3/15
7/5/15
4/8/15
3/9/15
50.000
200,000
Nurasiah
Nurdiana
0001884390614
0000225148296
0000225175465
Matang Tunong
Tanjong Dama
Matang Tunong
085207473512
-
G1 P0 A0
G1 P0 A0
G3 P2 A0
11/3/15
5/3/15
16/5/15
7/5/15
8/8/15
9/8/15
4/9/15 50.000
10/9/15 50.000
200,000
200,000
G1 P0 A0
9/3/15
15/5/15
17/5/15 11/9/15
50.000
200,000
Kuala Cangkoy
081270637391
G2 P1 A0
12/3/15
15/5/15
10/8/15 11/9/15
50.000
200,000
Gp. Pande
085270724684
G3 P2 A0
15/3/15
18/5/15
20/8/15 13/9/15 50.000
200,000
12/9/15 600.000
14/9/15 600.000
085370299449
085277673995
G1 P0 A0
G3 P2 A0
13/3/15
10/3/15
17/5/15
12/5/15
19/8/15 15/9/15 50.000

11/8/15 16/9/15 50.000
200,000
200,000
16/9/15 600.000
17/9/15 600.000
Lindawati
Nurdahlina 0001875156952
Irma suryani0001785123933
Raliyah
0000224534081
10 Nurhayati
0000225144898
Cibrek
Tanjong Dama
2/9/15 600.000
3/9/15 600.000
4/9/15 600.000
10/9/15 600.000
11/9/15 600.000
12/9/15 600.000
Jenis Pelayanan
Persalinan
Tarif
Total Tarif
Total Tarif
Tindaka
Persalinan
Tindakan
n Pra
Normal
Pra Rujukan
Rujukan
Nip
KF3
Tarif
PNC
Total Tarif
PNC
Pasang
IUD/Imp Suntik
lant
Total
KF1
KF2
600.000 125.000
3/9/15
7/9/15
12/9/15 25.000
75,000
75,000
875,000
600.000 125.000
600.000 125.000
3/9/15
8/9/15
13/9/15 25.000
50,000
75,000
875,000
4/9/15
9/9/15
14/9/15 25.000
10/9/15 15/9/15 19/9/15 25.000

12/9/15 16/9/15 21/9/15 25.000
75,000
75,000
75,000
875,000
600.000 125.000
600.000 125.000
75,000
75,000
75,000
600.000 125.000
13/9/15 17/9/15 22/9/15 25.000
75,000
75,000
875,000
600.000 125.000
12/9/15 17/9/15 22/9/15 25.000
75,000
75,000
875,000
600.000 125.000
600.000 125.000
600.000 125.000
14/9/15 15/9/15 24/9/15 25.000
75,000
75,000
875,000
17/9/15 21/9/15 26/9/15 25.000

17/9/15 22/9/15 27/9/15 25.000
75,000
75,000
75,000
75,000
875,000
875,000
725,000
750,000
8,750,000
Total
2,000,000
6,000.000
Mengetahui
Klinik Mita sehat
Pelayanan KB
PNC
Lapang, 30 September 2015

Nurbaiti,Am.Keb
Nip. 19780521 200801 2 002
Total Tarif
875,000
875,000
Dasar Klaim
Kepada Yth :

Februari 2016
Dengan Hormat,
ANC
No
Nama Pasien
NO. KTP/KK/JKN
Alamat Pasien
No Hp
G.P.A
K1
K2
K3
K4
Tarif
ANC
Total Tarif
ANC
981069254
Kuala Cangkoy
G4 P3 A0
8/7/15
10/10/15
5/1/16
2/2/16
50.000
200,000
1962199462
Kuala Cangkoy
082272276718
G1 P0 A0
2/7/15
13/10/15 10/1/16
5/2/16
50.000
200,000
Irma Yanti
Lindawati
Suriana
223285432
Geulanggang Baro
10/7/15 13/10/15
8/1/16
4/2/16
50.000
200,000
Mariani
224453215
Buket Linteung
G1 P0 A0
G1 P0 A0
15/10/15 11/1/16
2/2/16
50.000
200,000
1
2
7/7/15
Tarif
Tanggal
Persalina
INC
n Normal
13/2/16 600.000
15/2/16 600.000
17/2/16 600.000
19/2/16 600.000
Jenis Pelayanan
Persalinan
Tarif
Total Tarif
Total Tarif
Tindaka
Persalinan
Tindakan
n Pra
Normal
Pra Rujukan
Rujukan
Nip
KF3
Tarif
PNC
Total Tarif
PNC
Pasang
IUD/Imp Suntik
lant
Total
KF1
KF2
600.000 125.000
3/9/15
7/9/15
12/9/15 25.000
75,000
75,000
875,000
600.000 125.000
600.000 125.000
3/9/15
8/9/15
13/9/15 25.000
75,000
75,000
875,000
4/9/15
9/9/15
14/9/15 25.000
10/9/15 15/9/15 19/9/15 25.000
75,000
75,000
875,000
600.000 125.000
75,000
75,000
300,000
300,000
3,500,000
Total
800,000
2,400.000
Mengetahui
Klinik Mita sehat
Pelayanan KB
PNC
Lapang, 30 September 2015

Nurbaiti,Am.Keb
Nip. 19780521 200801 2 002
Total Tarif
875,000

Dasar Klaim
Kepada Yth :

Jun-15
Dengan Hormat,
Jenis Pelayanan
Persalinan
ANC
No
Nama Pasien
NO. KTP/KK
Alamat Pasien
No Hp
G.P.A
K1
K2
K3
K4
G4 P3 A0
1/12/14
2/2/15
4/4/15
1/6/15
50.000
200.000
2/6/15
600.000
600.000 125.000
G1 P0 A0
2/12/14
4/2/15
3/4/15
1/6/15
50.000
200.000
3/6/15
600.000
600.000 125.000
G4 P1 A2
2/12/14
3/2/15
1/4/15
2/6/15
50.000
200.000
4/6/15
600.000
4/12/14
3/2/15
5/4/15
2/6/15
50.000
200.000
6/6/15
600.000
4/2/15
6/4/15
5/6/2015
50.000
200.000
9/6/15
600.000
5/6/15
6/6/15
8/6/15
50.000
200.000
50.000
50.000
200.000
200.000
Nurlina
Nurlianti
Sukmawati
224532088
cibrek
1121218659
kd.Jratmanyang
1853731247
kd.Jratmanyang
Mahzalena
224718726
Matang Baroh
G1 P0 A0
981064629
Diana
Eight Gusna Ningr 1093610158
Matang Baroh
G4 P2 A1
2/12/14
7
8
Wardhani
Ana Erlinawati
G1 P0 A0
G1 P0 A0
G3 P2 A0
'7/12/14 6/12/15 8/4/15

6/12/14 7/2/15 8/4/15
9/12/14 10/2/15 12/4/15
1
2
1269502817
224758337
Kp Jawa
Matang Baroh
Matang Baroh
10/6/15 600.000
11/6/15 600.000
15/6/15 600.000
Pelayanan KB
PNC
Total
Tarif
Tarif
Total Tarif
Tarif
Total Tarif Tanggal
Tindakan
Tindaka
Tarif ANC
ANC
INC
Pra
Normal n Normal
n Pra
Rujukan
Rujukan
KF1
KF3
KF4
Nip
Total
8/6/15
12/6/15
75.000
75.000
875.000
9/6/15
14/6/15
75.000
75.000
875.000
9/6/15
12/6/15 16/6/15
75.000
75.000
400.000
8/6/15
12/6/15 17/6/15
75.000
75.000
875.000
125.000
125.000 14/6/15 17/6/15 20/6/15
75.000
75.000
400.000
600.000 125.000
12/6/15 16/6/15 21/6/15

13/6/15 17/6/15 22/6/15
17/6/15 21/6/15 26/6/15
75.000
75.000
875.000
75.000
75.000
75.000
75.000
875.000
875.000
600.000
6.050.000
125.000
125.000
600.000 125.000
-
600.000 125.000
600.000 125.000
Total
1.600.000
'3.600.000
250.000
Mengetahui
Klinik Mita sehat
Total
Tarif
5/6/15
4/6/15
KF2
Pasang
lant
Lapang,30 Juni 2015

Erlinawati,Am.Keb
Nip.19740716 200701 2 004
Ket
LEMBARAN KLAIM

Dasar Klaim
Kepada Yth :
Dengan Hormat,
Bersama ini kami ajukan klaim/ pertanggungjawaban dana Pelayanan Kesehatan Kebidanan dan Neo
No
Nama
Pasien
NO. KTP/KK
Mariana 224493939
Husniah 261514372
1963128813
Ratna
Megawati
Rahmiyant1438386287
Salboiti 1892245836
Nurlina 1120322339
1
2
6
7
8
9
10
11
12
13
Ninining Y
Asnidar
Nuraini
Rohana
Sabian
Nurlailatul J
224661789
1120800295
981040498
1964631071
1964627289
1898736579
1120750986
Alamat Pasien
No HP
G.P.A
K.Keureuto
G3 P2 A0
Kd.mtg Panyang
G5 P4 A0
Kuala Cangkoy
085261859900
G1 P0 A0
Kuala Cangkoy
cibrek
082363635153
G2 P1 A0
085260748544
G1 P0 A0
Kuala Keureuto
G3 P2 A0
Ara
Cibrek tunong
Cibrek Baroh
Matang Baroh
Kuala Keureuto
Kuala Cangkoy
Meuria Aron
G3 P2 A0
G4 P3 A0
G3 P2 A0
G1 P0 A0
G3 P2 A0
G3 P2 A0
G6 P5 A0
'''085370771026
-
Total
Terlampir bersama ini kami sampaikan pula bukti-bukti penunjang yang sah untuk menjadi pertimbanga
Mengetahui
Klinik Mita seh
Nip
MBARAN KLAIM/ PERTANGGUNG JAWABAN DANA PELAYANAN KESEHATAN

PADA BPJS (BADAN PENYELENGGARA JAMIN
FASILITAS KESEHATAN TINGKAT PERTAM

Dec-15
an Kebidanan dan Neonatal Non Kapitasi yang telah kami berikan (dalam Rupiah)dengan perincian sebagai berik
Jenis Pelayanan
ANC
K3
Persalinan
K4
Tarif
ANC
Total
Tarif
ANC
Total
Tarif
Tarif
Tanggal Persalin
Persalin
INC
an
an
Normal
Normal
K1
K2
2/6/15
1/8/15
3/10/15 1/12/15 50.000 200.000 5/12/15 600.000 600.000
2/6/15
3/8/15
4/10/15 1/12/15 50.000 200.000 6/12/15 600.000 600.000
4/6/15
3/8/15
2/10/15 3/12/15 50.000 200.000 8/12/15 600.000 600.000
5/6/15
4/8/15
6/10/15 3/12/15 50.000 200.000 8/12/15 600.000 600.000
5/6/15
4/8/15
3/10/15 2/12/15 50.000 200.000 9/12/15 600.000 600.000
6/6/15
5/8/15
4/12/15 3/12/15 50.000 200.000 10/12/15 600.000 600.000
5/6/15 6/8/15 7/10/15 4/12/15

6/6/15 5/8/15 7/10/15 5/12/15
7/6/15 6/8/15 8/10/15 5/12/15
8/6/15 9/8/15 10/10/15 7/12/15
12/6/15 11/8/15 10/10/15 11/12/15
16/6/15 15/8/15 18/10/15 9/12/15
14/6/15 15/8/15 13/10/15 12/12/15
50.000 200.000 12/12/15

50.000 200.000 12/12/15
50.000 200.000 13/12/15
50.000 200.000 14/12/15
50.000 200.000 16/12/15
50.000 200.000 16/12/15
50.000 200.000 18/12/15
600.000
600.000
600.000
600.000
600.000
600.000
600.000
600.000
600.000
600.000
600.000
600.000
600.000
600.000
2.600,000
7.800.000
uk menjadi pertimbangan (Copy identitas/ partograf/Suart Keterangan Kelahiran / register kohort Ibu/Bayi/ Kartu Ib
ANAN KESEHATAN KEBIDANAN DAN NEONATAL NON KAPITASI

ELENGGARA JAMINAN SOSIAL)
TINGKAT PERTAMA
gan perincian sebagai berikut :

Jenis Pelayanan
Persalinan
Total
Tarif
Tarif
Tindaka
Tindaka
n Pra
n Pra
Rujukan
Rujukan
Pelayanan KB
PNC
KF1
KF2
KF3
KF4
Tarif
PNC
Total
Tarif
PNC
125.000
'7/12/15 11/12/15 14/12/15
75.000
75.000
125.000
8/12/15 10/12/15 13/12/15
75.000
75.000
125.000
10/12/15 14/12/15 17/12/15
75.000
75.000
125.000
10/12/15 14/12/15 17/12/15
75.000
75.000
125.000
11/12/15 15/12/15 18/12/15
75.000
75.000
125.000
12/12/15 16/12/15 19/12/15
75.000
75.000
125.000
14/12/15 18/12/15 21/12/15

14/12/15 18/12/15 21/12/15
15/12/15 19/12/15 22/12/15
16/12/15 20/12/15 23/12/15
18/12/15 22/12/15 25/12/15
18/12/15 22/12/15 27/12/15
20/12/15 24/12/15 29/12/15
75.000
75.000
75.000
75.000
75.000
75.000
75.000
75.000
125.000
125.000
125.00
125.000
125.000
125.000
ster kohort Ibu/Bayi/ Kartu Ibu/ Kartu Nifas dll))
75.000
75.000
75.000
75.000
75.000
75.000
975.000
Pasang
IUD/Imp
lant

Erlinawati,Am.Keb
Nip.19740716 200701 2 004
PITASI
Ket
Pelayanan KB
Suntik
Total
Tarif
Total
75.000
875.000
75.000
875.000
75.000
875.000
75.000
875.000
75.000
875.000
75.000
875.000
75.000
875.000
75.000
75.000
75.000
75.000
75.000
75.000
875.000
875.000
875.000
875.000
875.000
875.000
11.375.000

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LEMBARAN KLAIM/ PERTANGGUNG JAWABAN DANA PELAYANAN KESEHATAN KEBIDANAN DAN NEONATAL NON KAPITASI

PADA BPJS (BADAN PENYELENGGARA JAMINAN SOSIAL)

Nama Klinik/Bidan Jejaring

Mita Sehat / BPM Erlinawati.Am.Keb

Lapang,30 September 2015

Nama Klinik/Bidan Jejaring

Mita Sehat / BPM Erlinawati.Am.Keb

3/11/15 7/11/2015 10/11/15

Lapang,30 Oktober 2015

Nama Klinik/Bidan Jejaring

Mita Sehat / BPM Erlinawati.Am.Keb

Matang Sijuek Barat

1108136603890001 Geulanggang Baro

Lapang, 30 Januari 2014

Nama Klinik/Bidan Jejaring

Mita Sehat / BPM Erlinawati.Am.Keb

Matang Sijuek Barat

10/8/13 12/10/13 10/12/13 13/2/14

15/8/13 16/10/13 14/12/13 17/2/14

18/8/13 17/10/13 19/12/13 20/2/14

13/1/14 16/1/14 21/1/14

Lapang, 28 Februari 2014

Nama Klinik/Bidan Jejaring

Mita Sehat / BPM Erlinawati.Am.Keb

1108134107650188 Kuala Keureutou

1108134107810196 Matang Baroh

Lapang, 31 Maret 2014

Nama Klinik/Bidan Jejaring

Mita Sehat / BPM Erlinawati.Am.Keb

Surat Edaran Kemenkes HK/ MENKES/31/I/2014

Nurhayati 1108134107790175 Matang Baroh

1108134105830002 Kuala Keureuto

12/5/14 17/5/14 75.000

15/5/14 20/5/14 75.000

22/5/14 27/5/14 75.000

14/5/14 100.000 100.000

24/5/14 28/5/14 75.000

Lapang, 30 Mei 2014

Nama Klinik/Bidan Jejaring

Mita Sehat / BPM Erlinawati.Am.Keb

1108134107750191 Kuala Cangkoy

1108135101780002 Matang Baroh

1108134107830250 Matang Baroh

11/10/13 10/12/13 12/2/14 9//4/14

1108235807950001 Kuala Kereuto

1108135606930001 Matang Baroh

19/4/14 23/4/14 28/4/14

Lapang,30 Juni 2014

Nama Klinik/Bidan Jejaring

Mita Sehat / BPM Erlinawati.Am.Keb

1108134203930002 Matang Baroh

1108235410890001 Cot Jabet

1108104107720140 Desa Ampeh

21/6/14 25/6/14 29/6/14 75.000

Lapang,30 Juni 2014

Nama Klinik/Bidan Jejaring

Mita Sehat / BPM Erlinawati.Am.Keb

Yeni Yuslin 1108134307800001 Kuala Keureuto

1108236103940001 Matang Baroh

Lapang,31 Juli 2014

Nama Klinik/Bidan Jejaring

Mita Sehat / BPM Nurbaiti.Am.Keb

1108134107720095 Tanjong Dama

1108234303900001 Merbo Jurong