PT.

ASURANSI JIWA INHEALTH INDONESIA

LAMPIRAN PENGAJUAN TAGIHAN (DATA YANG SUDAH DIVERIF)

NAMA PROVIDER :
TINGKAT :
PELAYANAN
NOMOR REGISTER :

NOMOR FPK :

NO TGL NOSJP / REF SJP NOR NOKA PESERTA NAMA PESERTA R/NR NAMA OBAT NAMA OBAT VER JM JM HARGA HARG SUB SUB TOTAL VER
PELAYANAN ESE L L AJU A TOTAL
P AJ VE VER AJU
U R
1 24 Mar 2016 1824A0010416X000001 | 1824R0020316X000001 01 1001004079004 SYAMSIAR NY N NOFOI.1 | Amlodipin - KIFA - Tab 10 mg NOFOI.1 | Amlodipin - KIFA - Tab 10 mg 30 30 11,700 11,700 183,600 183,600

N NOFOI.2 | Canderin 16 - DEXA - Tab. 16mg NOFOI.2 | Canderin 16 - DEXA - Tab. 16mg 30 30 162,000 162,00
0
N NOFOI.3 | Neurodex - DEXA - Tab. Salut Selaput NOFOI.3 | Neurodex - DEXA - Tab. Salut Selaput 30 30 9,900 9,900
2 16 Mar 2016 1824A0010416X000002 | 1824R0020316X000002 02 1061001081516 APRIANTO PALAWA N NOFOI.1 | Cefadroxil 500 Mg Kapsul - MBFA - 500 mg NOFOI.1 | Cefadroxil 500 Mg Kapsul - MBFA - 500 mg 10 10 7,200 7,200 9,864 9,864

N NOFOI.2 | Meloxicam - KIFA - Tab 15 mg NOFOI.2 | Meloxicam - KIFA - Tab 15 mg 6 6 2,664 2,664
3 03 Mar 2016 1824A0010416X000005 | 1824R0020316X000005 05 1011008062214 ANDI AMALIYAH N NOFOI.1 | Ciprofloxacin - IKAP - 200 NOFOI.1 | Ciprofloxacin - IKAP - 200 15 15 7,920 7,920 25,110 25,110
N NOFOI.2 | Tremenza - SANB - Tab 62,5mg NOFOI.2 | Tremenza - SANB - Tab 62,5mg 15 15 12,870 12,870

N NOFOI.3 | Methylprednisolone - HEXP - 4 mg NOFOI.3 | Methylprednisolone - HEXP - 4 mg 15 15 4,320 4,320

218,5 218,574
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..........., 29-Apr-
2016
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