REKAPITULASI KLAIMPELAYANAN JEJARING

KLINIK NADIRA

BULAN PELAYANAN : JANUARI 2018

JENIS KLAIM : ANC,PNC,PERSALINAN, PRA RUJUKAN DAN KB

DIAJUKAN DISETUJUI
No NAMA PASIEN NAMA BIDAN NAMA BANK NO REKENING
KASUS BIAYA KASUS BIAYA
1 Martini Persalinan Rp 700,000 PERSALINAN Siti Baheram BANK BRI 3992-01-007880-53-6
2 Rauyani Persalinan Rp 700,000 PERSALINAN Siti Baheram
3 Arfina Persalinan Rp 700,000 PERSALINAN Siti Baheram
4 Mirna Fitria Persalinan Rp 700,000 PERSALINAN Siti Baheram
5 Rasnidar Persalinan Rp 700,000 PERSALINAN Siti Baheram
6 Darniati Persalinan Rp 700,000 PERSALINAN Siti Baheram
7 Darniati ANC Rp 200,000 ANC Siti Baheram
8 Asnawati ANC Rp 200,000 ANC Siti Baheram
9 Ulma Susari ANC Rp 200,000 ANC Siti Baheram
10 Rasnidar ANC Rp 200,000 ANC Siti Baheram
11 Martini ANC Rp 200,000 ANC Siti Baheram
12 Rauyani ANC Rp 200,000 ANC Siti Baheram
13 Arfina ANC Rp 200,000 ANC Siti Baheram
14 Mirna Fitria ANC Rp 200,000 ANC Siti Baheram
15 Asnawati PNC Rp 25,000 PNC Siti Baheram
16 Darniati PNC Rp 50,000 PNC Siti Baheram
17 Ulma Susari PNC Rp 25,000 PNC Siti Baheram
18 Martini PNC Rp 50,000 PNC Siti Baheram
19 Rasnidar PNC Rp 50,000 PNC Siti Baheram
20 Rauyani PNC Rp 50,000 PNC Siti Baheram
21 Arfina PNC Rp 50,000 PNC Siti Baheram
22 Mirna Fitria PNC Rp 50,000 PNC Siti Baheram
23 Saljuna PNC Rp 25,000 PNC Siti Baheram
24 Susanti Mauliza PNC Rp 25,000 PNC Siti Baheram
25 Seri Hermanila PNC Rp 25,000 PNC Siti Baheram
26 Salbiah PNC Rp 25,000 PNC Siti Baheram
27 Cut Rafnidar PNC Rp 25,000 PNC Siti Baheram
28 Azizah PNC Rp 25,000 PNC Siti Baheram
29 Nur Dewi PNC Rp 25,000 PNC Siti Baheram
30 Yulis Firdawati PNC Rp 25,000 PNC Siti Baheram
31 Syamsinar PNC Rp 25,000 PNC Siti Baheram
32 Dewi Khairani PNC Rp 25,000 PNC Siti Baheram
33 Cut Rafnidar PNC Rp 25,000 PNC Siti Baheram
34 Melva Oktayanti PNC Rp 25,000 PNC Siti Baheram
35 Lisnawati PNC Rp 50,000 PNC Siti Baheram
36 Rina Handayani PNC Rp 25,000 PNC Siti Baheram
37 Nirwana PNC Rp 25,000 PNC Siti Baheram
38 Karmila Sari PNC Rp 25,000 PNC Siti Baheram
39 Asnawati Pra Rujukan Rp 125,000 PRA RUJUKAN Siti Baheram
40 Ulma Susari Pra Rujukan Rp 125,000 PRA RUJUKAN Siti Baheram
41 Salmiati Suntik KB Rp 15,000 KB Siti Baheram
42 Nasma mariana Suntik KB Rp 15,000 KB Siti Baheram
43 Yusdiana Suntik KB Rp 15,000 KB Siti Baheram
44 Sunita Suntik KB Rp 15,000 KB Siti Baheram
45 Asmanizar Suntik KB Rp 15,000 KB Siti Baheram
46 Marhamah Suntik KB Rp 15,000 KB Siti Baheram
47 Suriati Suntik KB Rp 15,000 KB Siti Baheram
48 Arisna z Suntik KB Rp 15,000 KB Siti Baheram
49 salbiah Suntik KB Rp 15,000 KB Siti Baheram
50 Tiara Novia Yuliana Suntik KB Rp 15,000 KB Siti Baheram
51 Rusda Suntik KB Rp 15,000 KB Siti Baheram
52 Suriati Suntik KB Rp 15,000 KB Siti Baheram
54 Darnawati Suntik KB Rp 15,000 KB Siti Baheram
55 Nurul Hayati Suntik KB Rp 15,000 KB Siti Baheram
SUB TOTAL Rp 7,035,000
56 Popi Diana Persalinan Rp 700,000 Persalinan Juita Kusma BANK BRI 3992-01-006465-53-7
 BANK BRI 3992-01-006465-53-7
57 Popi Diana ANC Rp 200,000 ANC Juita Kusma
58 Emelda Susanti ANC Rp 200,000 ANC Juita Kusma
59 Sri Devi ANC Rp 200,000 ANC Juita Kusma
60 Popi Diana PNC Rp 50,000 PNC Juita Kusma
61 Emelda Susanti PNC Rp 25,000 PNC Juita Kusma
62 Armina PNC Rp 25,000 PNC Juita Kusma
63 Hasmiati PNC Rp 25,000 PNC Juita Kusma
64 Mailisa PNC Rp 25,000 PNC Juita Kusma
65 Dewi Purwati PNC Rp 25,000 PNC Juita Kusma
66 Sri Devi PNC Rp 50,000 PNC Juita Kusma
67 Sri Devi Pra Rujukan Rp 125,000 Pra Rujukan Juita Kusma
68 Emelda Susanti Pra Rujukan Rp 125,000 Pra Rujukan Juita Kusma
69 Jamisah Suntik KB Rp 15,000 Suntik KB Juita Kusma
70 Hasmawati Suntik KB Rp 15,000 Suntik KB Juita Kusma
71 Fitriani Suntik KB Rp 15,000 Suntik KB Juita Kusma
72 Ema Lizar Suntik KB Rp 15,000 Suntik KB Juita Kusma
73 Rosnidar Suntik KB Rp 15,000 Suntik KB Juita Kusma
74 Erpita Suntik KB Rp 15,000 Suntik KB Juita Kusma
75 Farzilah Suntik KB Rp 15,000 Suntik KB Juita Kusma
SUB TOTAL Rp 1,880,000
76 Yulita Afnidar Persalinan Rp 700,000 Persalinan Hemaliniati BANK BRI 3992-01-007152-53-5
77 Aidariyah Persalinan Rp 700,000 Persalinan Hemaliniati
78 Mardiana Persalinan Rp 700,000 Persalinan Hemaliniati
79 Desi Wirna Persalinan Rp 700,000 Persalinan Hemaliniati
80 Aidariyah ANC Rp 200,000 ANC Hemaliniati
81 Mardiana ANC Rp 200,000 ANC Hemaliniati
82 Anisah ANC Rp 200,000 ANC Hemaliniati
83 Marhami ANC Rp 200,000 ANC Hemaliniati
84 Yulita Afnidar PNC Rp 50,000 PNC Hemaliniati
85 Aidariyah PNC Rp 50,000 PNC Hemaliniati
86 Mardiana PNC Rp 50,000 PNC Hemaliniati
87 Desi Wirna PNC Rp 50,000 PNC Hemaliniati
88 Marhami Pra Rujukan Rp 125,000 Pra Rujukan Hemaliniati
89 Anisah Pra Rujukan Rp 125,000 Pra Rujukan Hemaliniati
90 Rini Pra Rujukan Rp 125,000 Pra Rujukan Hemaliniati
SUB TOTAL Rp 4,175,000
91 Tuti Oktarianti Persalinan Rp 700,000 Persalinan Marlindawati BANK ACEH 124.02.03.580753-5
92 Susi Hernida ANC Rp 200,000 ANC Marlindawati
93 ELi Darni ANC Rp 200,000 ANC Marlindawati
94 Putri Yuliana ANC Rp 200,000 ANC Marlindawati
95 Tuti Oktarianti ANC Rp 200,000 ANC Marlindawati
96 Lia Afrianti PNC Rp 25,000 PNC Marlindawati
97 Yulina Ansra PNC Rp 25,000 PNC Marlindawati
98 Nur Asna PNC Rp 25,000 PNC Marlindawati
99 Eri Zani PNC Rp 25,000 PNC Marlindawati
100 Sri Widayanti PNC Rp 50,000 PNC Marlindawati
101 Susi Hernida PNC Rp 25,000 PNC Marlindawati
102 ELi Darni PNC Rp 25,000 PNC Marlindawati
103 Putri Yuliana PNC Rp 25,000 PNC Marlindawati
104 Tuti Oktarianti PNC Rp 50,000 PNC Marlindawati
105 Putri Yuliana Pra Rujukan Rp 125,000 Pra Rujukan Marlindawati
106 susi Hernida Pra Rujukan Rp 125,000 Pra Rujukan Marlindawati
SUB TOTAL Rp 2,025,000
107 Ermi Yulisma Persalinan Rp 700,000 Persalinan Yasmalizar
108 Yenni Asrika PNC Rp 25,000 PNC Yasmalizar
BANK BRI 3931-01-009836-53-1
109 Rauzatul Husna PNC Rp 25,000 PNC Yasmalizar
110 Reni PNC Rp 25,000 PNC Yasmalizar
SUB TOTAL Rp 775,000
111 Yuslinda Wati Persalinan Rp 700,000 Persalinan Haslinda BANK BPD ACEH 124.02.03.590243-1
SUB TOTAL Rp 700,000
TOTAL Rp 16,590,000

penanggung jawab klinik nadira

 dr. MUKHARADHI NANZA

REKAPITULASI KLAIMPELAYANAN JEJARING

KLINIK NADIRA

BULAN PELAYANAN : FEBRUARI

JENIS KLIM : ANC,PNC,PERSALINAN, PRA RUJUKAN DAN KB

DIAJUKAN DISETUJUI
No NAMA PASIEN NAMA BIDAN NAMA BANK NO REKENING
KASUS BIAYA KASUS BIAYA
1 Zurianti Persalinan Rp 700,000 Persalinan
2 Nurlaila, S.pd Persalinan Rp 700,000 Persalinan
3 Khairiyah Persalinan Rp 700,000 Persalinan
4 Yanti Persalinan Rp 700,000 Persalinan
5 Yanti ANC Rp 200,000 ANC
6 Nurmiati ANC Rp 200,000 ANC
7 Khairiyah ANC Rp 200,000 ANC
8 Zurianti ANC Rp 200,000 ANC
9 Nurlaila, S.pd ANC Rp 200,000 ANC
10 Zurianti PNC Rp 25,000 PNC
11 Nurlaila, S.pd PNC Rp 25,000 PNC
12 Khairiyah PNC Rp 50,000 PNC
13 Nurmiati PNC Rp 25,000 PNC
14 Yanti PNC Rp 25,000 PNC
15 Darniati PNC Rp 25,000 PNC
16 Ulma Susari PNC Rp 25,000 PNC
17 Martini PNC Rp 25,000 PNC
18 Rasnidar PNC Rp 25,000 PNC

Siti Baheram BANK BRI 3992-01-007880-53-6

19 Rauyani PNC Rp 25,000 PNC
20 Arfina PNC Rp 25,000 PNC
Siti Baheram BANK BRI 3992-01-007880-53-6
21 Mirna Fitria PNC Rp 25,000 PNC
22 Nurmiati Pra Rujukan Rp 125,000 Pra Rujukan
23 Masnimar Suntik KB Rp 15,000 Suntik KB
24 Hamidah Suntik KB Rp 15,000 Suntik KB
25 Kairiyah Suntik KB Rp 15,000 Suntik KB
26 Rahma Juita Suntik KB Rp 15,000 Suntik KB
27 Risnah Suntik KB Rp 15,000 Suntik KB
28 Marziah Suntik KB Rp 15,000 Suntik KB
29 Susi Susanti Suntik KB Rp 15,000 Suntik KB
30 Nurlaili Suntik KB Rp 15,000 Suntik KB
31 Agus Indra Suntik KB Rp 15,000 Suntik KB
32 Saldiana Suntik KB Rp 15,000 Suntik KB
33 Mariati Suntik KB Rp 15,000 Suntik KB
34 Siti Fazhilatul Husna Suntik KB Rp 15,000 Suntik KB
35 Nurmala Suntik KB Rp 15,000 Suntik KB
36 Eli Zakiah Suntik KB Rp 15,000 Suntik KB
37 Surya Andriani Suntik KB Rp 15,000 Suntik KB
38 Salmawati Suntik KB Rp 15,000 Suntik KB
39 Dewi Marlina Suntik KB Rp 15,000 Suntik KB
40 Mahyar Suntik KB Rp 15,000 Suntik KB
SUB TOTAL Rp 4,520,000
34 Deli Suprima Persalinan Rp 700,000 Persalinan
35 Agus Idawati Persalinan Rp 700,000 Persalinan
36 Ruswida Persalinan Rp 700,000 Persalinan
37 Deli Suprima ANC Rp 200,000 ANC
38 Agus Idawati ANC Rp 200,000 ANC
39 Ruswida ANC Rp 200,000 ANC
40 Salamiah ANC Rp 200,000 ANC
41 Deli Suprima PNC Rp 50,000 PNC
42 Agus Idawati PNC Rp 50,000 PNC
Juita Kusma BANK BRI 3992-01-006465-53-7
43 Ruswida PNC Rp 50,000 PNC
 Juita Kusma BANK BRI 3992-01-006465-53-7

44 Salamiah PNC Rp 25,000 PNC

45 Emelda Susanti PNC Rp 25,000 PNC
46 Popi Diana PNC Rp 25,000 PNC
47 Sri Devi PNC Rp 25,000 PNC
48 Salamiah Pra Rujukan Rp 125,000 Pra Rujukan
50 Rusmina Suntik KB Rp 15,000 Suntik KB
51 Qhasanah Suntik KB Rp 15,000 Suntik KB
52 Nurima Suntik KB Rp 15,000 Suntik KB
SUB TOTAL Rp 3,320,000
53 Suryani Persalinan Rp 700,000 Persalinan Hemaliniati BANK BRI 3992-01-007152-53-5
54 Hawarni Persalinan Rp 700,000 Persalinan
55 Nurul Hidayati ANC Rp 200,000 ANC
56 Irma Liana Novita ANC Rp 200,000 ANC
57 Hawarni PNC Rp 50,000 PNC
58 Suryani PNC Rp 50,000 PNC
59 Nurul Hidayati Pra Rujukan Rp 125,000 Pra Rujukan
60 Irma Liana Novita Pra Rujukan Rp 125,000 Pra Rujukan
SUB TOTAL Rp 2,150,000
61 Susi Hernida PNC Rp 25,000 PNC Marlindawati BANK ACEH 124.02.03.580753-5
62 ELi Darni PNC Rp 25,000 PNC
63 Putri Yuliana PNC Rp 25,000 PNC
64 Tuti Oktarianti PNC Rp 25,000 PNC
SUB TOTAL Rp 100,000
65 Isra Mirana Persalinan Rp 700,000 Persalinan Yasmalizar BANK BRI 3931-01-009836-53-1
66 Lasmuati Persalinan Rp 700,000 Persalinan
67 Nur Azizah ANC Rp 200,000 ANC
68 Pariawati ANC Rp 200,000 ANC
69 Putri Maya Sari ANC Rp 200,000 ANC
70 Deli Maita ANC Rp 200,000 ANC
71 Isra Mirana PNC Rp 50,000 PNC
72 Lasmuati PNC Rp 50,000 PNC
SUB TOTAL Rp 2,300,000
73 Siti Nuria Persalinan Rp 700,000 Persalinan
Haslinda BANK BPD ACEH 124.02.03.590243-1
74 Siti Nuria ANC Rp 200,000 ANC Haslinda BANK BPD ACEH 124.02.03.590243-1
75 Siti Nuria PNC Rp 50,000 PNC
SUB TOTAL Rp 950,000
76 Erna Persalinan Rp 700,000 Persalinan Asmanidar BANK BPD ACEH 122.02.05.600007-3
77 Masriati Persalinan Rp 700,000 Persalinan
78 Fatimah Persalinan Rp 700,000 Persalinan
79 Mellisa Persalinan Rp 700,000 Persalinan
80 Dewi Sartika Persalinan Rp 700,000 Persalinan
81 Eka Fauziah Persalinan Rp 700,000 Persalinan
82 Sri Mulyana Persalinan Rp 700,000 Persalinan
83 Erna ANC Rp 200,000 ANC
84 Masriati ANC Rp 200,000 ANC
85 Fatimah ANC Rp 200,000 ANC
86 Mellisa ANC Rp 200,000 ANC
87 Dewi Sartika ANC Rp 200,000 ANC
88 Eka Fauziah ANC Rp 200,000 ANC
89 Sri Mulyana ANC Rp 200,000 ANC
90 Erna PNC Rp 50,000 PNC
91 Masriati PNC Rp 50,000 PNC
92 Fatimah PNC Rp 50,000 PNC
93 Mellisa PNC Rp 50,000 PNC
94 Dewi Sartika PNC Rp 50,000 PNC
96 Sri Mulyana PNC Rp 50,000 PNC
SUP TOTAL Rp 6,600,000
TOTAL

penanggung jawab klinik nadira

dr. MUKHARADHI NANZA

 REKAPITULASI KLAIMPELAYANAN JEJARING
KLINIK NADIRA
BULAN PELAYANAN : MARET
JENIS KLIM : ANC,PNC,PERSALINAN, PRA RUJUKAN DAN KB

DIAJUKAN DISETUJUI
No NAMA PASIEN NAMA BIDAN NAMA BANK NO REKENING
KASUS BIAYA KASUS BIAYA
1 Masdiana Persalinan Rp 700,000 Persalinan Siti Baheram BANK BRI 3992-01-007880-53-6
2 Masnijar Persalinan Rp 700,000 Persalinan
3 Nurhabibah Persalinan Rp 700,000 Persalinan
4 Kasnilawati Persalinan Rp 700,000 Persalinan
5 Merida Persalinan Rp 700,000 Persalinan
6 Fitriana Persalinan Rp 700,000 Persalinan
7 Ainar R Persalinan Rp 700,000 Persalinan
8 Kasri Persalinan Rp 700,000 Persalinan
9 Liernita Persalinan Rp 700,000 Persalinan
10 Hernalia.s.TH Persalinan Rp 700,000 Persalinan
11 Jaswita Persalinan Rp 700,000 Persalinan
12 Rima Wati Persalinan Rp 700,000 Persalinan
13 Rofika Asmara Persalinan Rp 700,000 Persalinan
14 Darhayati Persalinan Rp 700,000 Persalinan
15 Masdiana ANC Rp 200,000 ANC
16 Masnijar ANC Rp 200,000 ANC
17 Nurhabibah ANC Rp 200,000 ANC
18 Kasnilawati ANC Rp 200,000 ANC
19 Merida ANC Rp 200,000 ANC
20 Fitriana ANC Rp 200,000 ANC
21 Ainar R ANC Rp 200,000 ANC
22 Kasri ANC Rp 200,000 ANC
23 Liernita ANC Rp 200,000 ANC
24 Hernalia.s.TH ANC Rp 200,000 ANC
25 Jaswita ANC Rp 200,000 ANC
26 Rima Wati ANC Rp 200,000 ANC
27 Rofika Asmara ANC Rp 200,000 ANC
28 Darhayati ANC Rp 200,000 ANC
29 Masdiana PNC Rp 50,000 PNC
30 Masnijar PNC Rp 50,000 PNC
31 Nurhabibah PNC Rp 50,000 PNC
32 Kasnilawati PNC Rp 50,000 PNC
33 Merida PNC Rp 50,000 PNC
34 Fitriana PNC Rp 50,000 PNC
35 Ainar R PNC Rp 50,000 PNC
36 Kasri PNC Rp 50,000 PNC
37 Liernita PNC Rp 25,000 PNC
38 Hernalia.s.TH PNC Rp 50,000 PNC
39 Jaswita PNC Rp 25,000 PNC
40 Rima Wati PNC Rp 25,000 PNC
41 Rofika Asmara PNC Rp 50,000 PNC
42 Darhayati PNC Rp 50,000 PNC
43 Zurianti PNC Rp 50,000 PNC
44 Nurlaila, S.pd PNC Rp 50,000 PNC
45 Khairiyah PNC Rp 25,000 PNC
46 Nurmiati PNC Rp 50,000 PNC
47 Yanti PNC Rp 50,000 PNC
48 Arisna. Z Suntik KB Rp 15,000 Suntik KB
49 Nurhayati Suntik KB Rp 15,000 Suntik KB
50 Rosdiana Suntik KB Rp 15,000 Suntik KB
51 Yusdiana Suntik KB Rp 15,000 Suntik KB
52 Eka Darwita Suntik KB Rp 15,000 Suntik KB
53 Zulhaidar Suntik KB Rp 15,000 Suntik KB
54 Zulaidar Suntik KB Rp 15,000 Suntik KB
SUB TOTAL Rp 13,555,000
55 Deli Suprima PNC Rp 25,000 PNC Juita Kusma BANK BRI 3992-01-006465-53-7
56 Agus Idawati PNC Rp 25,000 PNC
57 Ruswida PNC Rp 25,000 PNC
 Juita Kusma BANK BRI 3992-01-006465-53-7

58 Salamiah PNC Rp 25,000 PNC

59 Jalina Suntik KB Rp 15,000 Suntik KB
60 Riva desita Suntik KB Rp 15,000 Suntik KB
61 Siska Permata Sari Suntik KB Rp 15,000 Suntik KB
62 Muslida Wati Suntik KB Rp 15,000 Suntik KB
63 Siti zahara Suntik KB Rp 15,000 Suntik KB
64 Erna Juita Suntik KB Rp 15,000 Suntik KB
65 Ani Aswita Suntik KB Rp 15,000 Suntik KB
66 Ati Rianti Suntik KB Rp 15,000 Suntik KB
67 Khairumi Suntik KB Rp 15,000 Suntik KB
68 Suprina Suntik KB Rp 15,000 Suntik KB
69 Emelda Susanti Suntik KB Rp 15,000 Suntik KB
70 Aslima Suntik KB Rp 15,000 Suntik KB
SUB TOTAL Rp 280,000
71 Rini Kusmayani Persalinan Rp 700,000 Persalinan Hemaliniati BANK BRI 3992-01-007152-53-5
72 Reni Furza Persalinan Rp 700,000 Persalinan
73 Ira Wati Persalinan Rp 700,000 Persalinan
74 Zuriati Persalinan Rp 700,000 Persalinan
75 Eka Safria Persalinan Rp 700,000 Persalinan
76 Reni Furza ANC Rp 200,000 ANC
77 Ira Wati ANC Rp 200,000 ANC
78 Zuriati ANC Rp 200,000 ANC
79 Eka Safria ANC Rp 200,000 ANC
80 Fitri Sakdah ANC Rp 200,000 ANC
81 Rini Kusmayani ANC Rp 200,000 ANC
82 Reni Furza PNC Rp 50,000 PNC
83 Ira Wati PNC Rp 50,000 PNC
84 Zuriati PNC Rp 50,000 PNC
85 Eka Safria PNC Rp 25,000 PNC
86 Fitri Sakdah Pra Rujukan Rp 125,000 Pra Rujukan
SUB TOTAL Rp 5,000,000
87 Hasnidar Persalinan Rp 700,000 Persalinan Marlindawati BANK ACEH 124.02.03.580753-5
88 Arfah ANC Rp 200,000 ANC
89 Riska Yuni Shara ANC Rp 200,000 ANC
 Marlindawati BANK ACEH 124.02.03.580753-5

90 Hasnidar ANC Rp 200,000 ANC

91 Arfah PNC Rp 25,000 PNC
92 Riska Yuni Shara PNC Rp 25,000 PNC
93 Hasnidar PNC Rp 25,000 PNC
94 Arfah Pra Rujukan Rp 125,000 Pra Rujukan
95 Riska Yuni Shara Pra Rujukan Rp 125,000 Pra Rujukan
SUB TOTAL Rp 1,625,000
96 Mardiati Persalinan Rp 700,000 Persalinan Yasmalizar BANK BRI 3931-01-009836-53-1
97 Ratna Wita ANC Rp 200,000 ANC
98 Amitra ANC Rp 200,000 ANC
99 Mardiati PNC Rp 50,000 PNC
100 Lasmuati PNC Rp 25,000 PNC
101 Isra Mirana PNC Rp 25,000 PNC
SUB TOTAL Rp 1,200,000
102 Nurul Tasmin Persalinan Rp 700,000 Persalinan Haslinda BANK BPD ACEH 124.02.03.590243-1
103 Nurul Tasmin ANC Rp 200,000 ANC
104 Nurul Tasmin PNC Rp 50,000 PNC
SUB TOTAL Rp 950,000
105 Nurhadisah ANC Rp 200,000 ANC Asmanidar BANK BPD ACEH 122.02.05.600007-3
106 Eka Fauziah PNC Rp 75,000 PNC
107 Erna PNC Rp 25,000 PNC
108 Masriati PNC Rp 50,000 PNC
109 Fatimah PNC Rp 50,000 PNC
110 Mellisa PNC Rp 25,000 PNC
111 Dewi Sartika PNC Rp 25,000 PNC
112 Sri Mulyana PNC Rp 25,000 PNC
SUB TOTAL Rp 475,000
TOTAL

penanggung jawab klinik nadira

dr. MUKHARADHI NANZA

 REKAPITULASI KLAIMPELAYANAN JEJARING
KLINIK NADIRA
BULAN PELAYANAN : APRIL
JENIS KLIM : ANC,PNC,PERSALINAN, PRA RUJUKAN DAN KB

DIAJUKAN DISETUJUI
No NAMA PASIEN NAMA BIDAN NAMA BANK NO REKENING
KASUS BIAYA KASUS BIAYA
1 Helmiati Persalinan Rp 700,000 Persalinan Siti Baheram BANK BRI 3992-01-007880-53-6
2 Nena Fitriani Persalinan Rp 700,000 Persalinan
3 Eni Triana Persalinan Rp 700,000 Persalinan
4 Suryanti Persalinan Rp 700,000 Persalinan
5 Munawarah Persalinan Rp 700,000 Persalinan
6 Yulita yani Persalinan Rp 700,000 Persalinan
7 Desi Lidia Persalinan Rp 700,000 Persalinan
8 Desi Herlita Persalinan Rp 700,000 Persalinan
9 Satri Yanis Persalinan Rp 700,000 Persalinan
10 Emelia Suryani Persalinan Rp 700,000 Persalinan
11 Kasma Wati Persalinan Rp 700,000 Persalinan
12 Nur Fatimah Persalinan Rp 700,000 Persalinan
13 Marni Persalinan Rp 700,000 Persalinan
14 Nurul Qamari Persalinan Rp 700,000 Persalinan
15 Silvia Persalinan Rp 700,000 Persalinan
16 Tia Zahara Persalinan Rp 700,000 Persalinan
17 Yulita ANC Rp 200,000 ANC
18 Helmiati ANC Rp 200,000 ANC
19 Nena Fitriani ANC Rp 200,000 ANC
20 Eni Triana ANC Rp 200,000 ANC
21 Suryanti ANC Rp 200,000 ANC
22 Munawarah ANC Rp 200,000 ANC
23 Yulita yani ANC Rp 200,000 ANC
24 Desi Lidia ANC Rp 200,000 ANC
25 Desi Herlita ANC Rp 200,000 ANC
26 Satri Yanis ANC Rp 200,000 ANC
27 Emelia Suryani ANC Rp 200,000 ANC
28 Kasma Wati ANC Rp 200,000 ANC
29 Nur Fatimah ANC Rp 200,000 ANC
30 Marni ANC Rp 200,000 ANC
31 Nurul Qamari ANC Rp 200,000 ANC
32 Silvia ANC Rp 200,000 ANC
33 Tia Zahara ANC Rp 200,000 ANC
34 Yulita PNC Rp 25,000 PNC
35 Helmiati PNC Rp 25,000 PNC
36 Nena Fitriani PNC Rp 50,000 PNC
37 Eni Triana PNC Rp 50,000 PNC
38 Suryanti PNC Rp 50,000 PNC
39 Munawarah PNC Rp 50,000 PNC
40 Yulita yani PNC Rp 50,000 PNC
41 Desi Lidia PNC Rp 50,000 PNC
42 Desi Herlita PNC Rp 50,000 PNC
43 Satri Yanis PNC Rp 50,000 PNC
44 Emelia Suryani PNC Rp 50,000 PNC
45 Kasma Wati PNC Rp 50,000 PNC
46 Nur Fatimah PNC Rp 50,000 PNC
47 Marni PNC Rp 50,000 PNC
48 Nurul Qamari PNC Rp 50,000 PNC
49 Silvia PNC Rp 25,000 PNC
50 Tia Zahara PNC Rp 50,000 PNC
51 Yulita Pra Rujukan Rp 125,000 Pra rujukan
SUB TOTAL Rp 15,500,000
52 Fatimah Persalinan Rp 700,000 Persalinan Juita Kusma BANK BRI 3992-01-006465-53-7
53 Nurhafsah Persalinan Rp 700,000 Persalinan
54 Putri Helma Lena ANC Rp 200,000 ANC
55 Maulizar ANC Rp 200,000 ANC
56 Fatimah ANC Rp 200,000 ANC
57 Titin Kasandra ANC Rp 200,000 ANC
58 Nurhafsah ANC Rp 200,000 ANC
59 Yuli Priyani ANC Rp 200,000 ANC
60 Putri Helma Lena PNC Rp 25,000 PNC
61 Maulizar PNC Rp 25,000 PNC
62 Fatimah PNC Rp 50,000 PNC
63 Zulma Harwita PNC Rp 25,000 PNC
64 Nurhafsah PNC Rp 50,000 PNC
65 Yuli Priyani PNC Rp 50,000 PNC
66 Putri Helma Lena Pra Rujukan Rp 125,000 Pra Rujukan
67 Maulizar Pra Rujukan Rp 125,000 Pra Rujukan
68 Sri Wahyuni Suntik KB Rp 15,000 Suntik KB
69 Erpita Suntik KB Rp 15,000 Suntik KB
70 Hasmawati Suntik KB Rp 15,000 Suntik KB
71 Ernita Suntik KB Rp 15,000 Suntik KB
72 Qhasanah Suntik KB Rp 15,000 Suntik KB
73 Rosnidar Suntik KB Rp 15,000 Suntik KB
74 Emalizar Suntik KB Rp 15,000 Suntik KB
75 Nur Asmah Suntik KB Rp 15,000 Suntik KB
76 Jaswati Suntik KB Rp 15,000 Suntik KB
77 Farzila Suntik KB Rp 15,000 Suntik KB
78 Jamisah Suntik KB Rp 15,000 Suntik KB
SUB TOTAL Rp 3,240,000
79 Erna Wati Persalinan Rp 700,000 Persalinan Hemaliniati BANK BRI 3992-01-007152-53-5
80 Erna Wati ANC Rp 200,000 ANC
81 Maidella Julian Tari ANC Rp 200,000 ANC
82 Rini Kusmayani PNC Rp 75,000 PNC
83 Erna Wati PNC Rp 50,000 PNC
84 Maidella Julian Tari Pra Rujukan Rp 125,000 Pra Rujukan
SUB TOTAL Rp 1,350,000
85 Elvida ANC Rp 200,000 ANC Marlindawati BANK ACEH 124.02.03.580753-5
 Marlindawati BANK ACEH 124.02.03.580753-5
86 Nosita Viamika ANC Rp 200,000 ANC
87 Arfah PNC Rp 25,000 PNC
88 Hasnidar PNC Rp 50,000 PNC
89 Riska Yuni Shara PNC Rp 25,000 PNC
90 Nosita Viamika PNC Rp 25,000 PNC
91 Elvida Pra Rujukan Rp 125,000 Pra Rujukan
92 Nosita Viamika Pra Rujukan Rp 125,001 Pra Rujukan
SUB TOTAL Rp 775,001
93 Arnidah ANC Rp 200,000 ANC Yasmalizar BANK BRI 3931-01-009836-53-1
94 Fadhilah yusra ANC Rp 200,000 ANC
95 Mardiati PNC Rp 25,000 PNC
SUB TOTAL Rp 425,000
96 Zulma Harwita ANC Rp 200,000 ANC Haslinda BANK BPD ACEH 124.02.03.590243-1
97 Yuliati ANC Rp 200,000 ANC
98 Julisna ANC Rp 200,000 ANC
99 Yuliati PNC Rp 50,000 PNC
100 Yuliati Pra Rujukan Rp 125,000 Pra Rujukan
SUB TOTAL Rp 775,000
101 Rini Persalinan Rp 700,000 Persalinan Asmanidar BANK BPD ACEH 122.02.05.600007-3
102 Nurhadisah Persalinan Rp 700,000 Persalinan
103 Rini ANC Rp 200,000 ANC
104 Rini PNC Rp 50,000 PNC
105 Nurhadisah PNC Rp 25,000 PNC
SUB TOTAL Rp 1,675,000
TOTAL

penanggung jawab klinik nadira

dr. MUKHARADHI NANZA