DAFTAR PENERIMAAN JASA KAPITASI

No Nama 60 40 TINDAKAN JUMLAH

1 drg. Iting Mursyidah Hanum 5,322,796 378,846 5,701,642
2 Nia Kurniasih, AM.Keb, SKM 3,591,806 255,644 3,847,450
3 drg. Ira Tantira,MKM 3,223,401 229,423 1,420,452 4,873,276
4 dr.Ilma Hitriyah 3,397,069 241,784 3,389,220 256,500 1,008,900 0 8,293,473
5 Novita Sari, Amd.Keb,SKM 3,426,678 243,891 3,670,569
6 Pipin Supartini, Amd.Kep 2,985,958 212,524 3,198,482
7 Elly Herawati, AM.Keb 2,812,860 200,203 3,013,063
8 Sri Mulyani, AM.Keb 2,488,299 177,103 2,665,402
9 Enok Komalasari, Amd.Farm 2,564,030 182,493 2,746,522
10 Sulastri, Amd.Keb,SKM 2,953,502 210,213 3,163,715
11 Erni Lisdawati, STr.Keb 3,505,256 249,484 3,754,740
12 Aan Juariah, S.Kep 2,812,860 200,203 96,786 0 3,109,849
13 Rina Rindayani, STr.Keb 2,921,047 207,904 3,443,940 6,572,890
14 Dini Suhardini, S.ST 2,975,140 211,753 3,186,894
15 Pujianti Komara,AM.Keb 2,391,500 170,213 2,561,713
16 Euis Kresna R R,Am.Keb 2,698,979 192,098 2,891,076
17 Cici Sri Haryati,AM.Keb 2,744,531 195,340 2,939,871
18 Isyeu Nurhasanah,AM.Keb 2,698,979 192,098 2,891,076
19 Vina Muharyani, Am.Keb 2,698,979 192,098 2,891,076
20 Elda Sartika, SKM 2,564,030 182,493 2,746,522
21 Diniarty S.S, AMd.Kep 2,755,919 196,150 2,952,070
22 Loudya Ulfah Y, Amd Fam 2,266,231 161,297 2,427,528
23 Kurnaedi Johansyah 1,970,141 140,223 2,110,364
24 Rinda Gandari,S.Si 2,448,441 174,266 2,622,707
25 Eka Suhesti,A.Md 2,186,514 155,623 2,342,138
26 Imas Kodariah, Ama.Kep 2,493,993 177,508 2,671,501
27 Susi Siti Rohmah, S.Kep 0 0 0
28 Desi K. Natalia, AM.Keb 1,822,095 129,686 1,951,782
29 Citra Nasopa, AM.Keb 2,357,336 167,782 2,525,117
30 Tika Kartika, AM.Keb 2,311,783 164,539 2,476,323
31 Adang Gunawan 956,600 68,085 1,024,685
32 Juariyah.H,Amd.Keb 1,571,557 111,854 1,683,412
33 Ega Desia Mataram, Amd.Kep 2,300,395 163,729 2,464,124
34 Ardi Suardi, Amd.Kep 842,719 59,980 902,699
35 Suhartini, Amd.Kep 2,289,007 162,918 2,451,926
36 Mira Mahmudah, SKM 694,674 49,443 744,117
37 Nani Sulistiani, AMd.Keb 2,277,619 162,108 2,439,727
38 Reni Anggraeni, AMd.Keb 2,243,455 159,676 2,403,131
39 Reni Nurhaeni, S.Farm 2,209,291 157,245 2,366,535
40 Mastur Solihin 1,696,826 120,770 1,817,597
41 Fitria Febriani, SE 580,793 41,337 622,130
42 M.Agung Adipura 1,935,976 137,792 2,073,768
43 Cep Rianto N,Amd.Kep 2,152,350 153,192 2,305,542
44 Yanwarrizal Ahmad, Amd.Gz 660,510 47,011 707,521
45 Gina Megawati, Amd Keb 2,038,469 145,086 2,183,556
46 Ulqia Akmalia, Amd AK 683,286 48,632 1,815,300 2,547,218
47 Taopik Hidayat,AMK 2,414,276 171,834 2,586,111
48 Eva Siti Rustini 1,195,750 85,107 1,280,857
49 dr. Beny 7,000,000 7,000,000
JUMLAH 117,133,708 7,838,683 11,431,098 136,403,489
Mengetahui :
Pimpinan BLUD Puskesmas Cimanggung
drg.Iting Mursyidah Hanum
NIP. 197706222009022001
 Daftar Rekapitulasi Jasa Pelayanan Pendapatan Pasien Umum
Nama UPT : Puskesmas Cimanggung
Kegiatan : 1.01.02.1.01.02.01.23.033 Pelayanan Kesehatan PPK BLUD Puskesmas Cimanggung
Rincian Objek : 5.1.02.02.01.14 Belanja Jasa Tenaga Kesehatan
Bulan : Oktober 2022

Nama Jumlah Uang Jumlah uang

PPh Ps. 21
NO Bulan 60% 40% yang diterima
Petugas
(Rp,-) (Rp,-) (Rp,-)
1 2 3 4 5 6
1 September drg. Iting Mursyidah Hanum 8,075,400 236,717 7,838,683
dr Ilma 12,113,100 682,002 11,431,098

JUMLAH 12,113,100 8,075,400 918,719 19,269,781

20,188,500
Terbilang : Dua Puluh Juta Seratus Delapan Puluh Delapan Ribu Lima Ratus Rupiah

Mengetahui : Lunas Dibayar

Pimpinan BLUD Puskesmas Cimanggung Bendahara BLUD

drg.Iting Mursyidah Hanum Erni Lisdawati, S.Tr.Keb

NIP. 197706222009022001 NIP.19741106 200902 2 001
 7,446,000
60 4
60 4,467,600
40 2,978,400

232198

232198

20,188,500

20,188,500
 Daftar Penerimaan Jasa Pelayanan Pendapatan Pasien Umum
Nama UPT : Puskesmas Cimanggung
Kegiatan : 1.01.02.1.01.02.01.23.033 Pelayanan Kesehatan PPK BLUD Puskesmas Cimanggung
Rincian Objek : 5.1.02.02.01.14 Belanja Jasa Tenaga Kesehatan
Bulan : Oktober 2022

Nama Jumlah Uang Jumlah uang

jumlah PPh Ps. 21
NO JENIS PELAYANAN tarif Klaim yang diterima tanda tangan
Petugas gol kasus
(Rp,-) 5% 6% 15% (Rp,-)
1 2 3 4 5 6 7 8
Tindakan Rawat Jalan dr. Ilma, Dkk III 1 Paket 3,567,600 178,380 3,389,220
Tindakan Gigi drg Ira tantira, Dkk IV 1 Paket 1,671,120 250,668 1,420,452
Tindakan Emergency Aan Juariah, Dkk III 1 paket 101,880 5,094 96,786
Tindakan Laboratorium Ulqia Akmalia III 1 Paket 1,815,300 1,815,300
Tindakan KIA/Persalinan Rina Rindayani dkk III 1 paket 3,625,200 181,260 3,443,940
Keterangan Sehat dr. Ilma, Dkk III 1 Paket 270,000 13,500 256,500
Ambulance Adang, Dkk - 1 paket - -
Kesehatan Haji dr.Ilma, Dkk III 1 Paket - - -
USG dr. Ilma, Dkk III 1 Paket 1,062,000 53,100 1,008,900
Buta warna Aan Juariah, Dkk III 1 Paket - 0 -
MOU KLINIK, Penelitian dr. Ilma, Dkk III 1 Paket - 0 -
JUMLAH 12,113,100 431,334 - 250,668 11,431,098
Terbilang : Dua Belas Juta Seratus Tiga Belas Ribu Seratus Rupiah

Sumedang, 7 November 2022

Mengetahui : Lunas Dibayar
Pimpinan BLUD Puskesmas Cimanggung Bendahara BLUD

drg.Iting Mursyidah Hanum Erni Lisdawati, S.Tr.Keb

NIP. 197706222009022001 NIP.19741106 200902 2 001
 jml Jaspel Petugas DI BANK YG DIBAGIKAN

60 40 60 40
Tindakan Rawat Jalan 9,910,000 5,946,000 3,964,000 3,567,600 2,378,400
Tindakan Gigi 4,642,000 2,785,200 1,856,800 1,671,120 1,114,080
Tindakan Emergency 283,000 169,800 113,200 101,880 67,920
Tindakan Laboratorium 5,042,500 3,025,500 2,017,000 1,815,300 1,210,200
Tindakan KIA/Persalinan 10,070,000 6,042,000 4,028,000 3,625,200 2,416,800
Keterangan Sehat 750,000 450,000 300,000 270,000 180,000
Ambulance - - - -
Kesehatan Haji - - - -
usg 2,950,000 1,770,000 1,180,000 1,062,000 708,000
Buta warna - - - -
Pajak MOU KLINIK, Penelitian - - - -
682,002 33,647,500 20,188,500 13,459,000 12,113,100 8,075,400 20,188,500

4317960

11,431,098 10973100

682,002
Rp 11,431,098.00
12,113,100
 DAFTAR PENERIMAAN JASA KAPITASI

KEGIATAN : 033. - Pelayanan Kesehatan PPK BLUD Puskesmas Cimanggung

PUSKESMAS : PPK-BLUD PUSKESMAS CIMANGGUNG
BULAN : Oktober 2022
RINCIAN OBJEK/URAIAN : BELANJA JASA TENAGA KESEHATAN
KODE REKENING BLUD : 5.1.02.02.01.14
JUMLAH KAPITASI : Rp. 8,075,400

Jumlah
Masa Kerja Pendidikan Resiko Kerja Jabatan BLUD Kinerja % masuk
Status (10%) Nilai Jumlah Hari Kerja Pajak
(5%) (15%) (20%) (20%) Pelayanan (30%) Total(nila kerja Nilai Total x Jumlah
Jml Uang Jumlah (klm
No Nama Gol i ( klm Masuk (klm Total Kapitasi 17/16 x 15) Jml Yg Diterima Tanda Tangan
5+6+7+8 12/11x1 10 x14) Indek
tidak 00)
indek nilai indek nilai indek nilai indek nilai indek nilai indek nilai +9) H Kerja masuk masuk 5% 6% 15%

2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
1 III 5 0.37 4 0.28 9 0.36 6 0.45 8 2.98 2.9 0.91 5.35 25 23 2 92 492 9963 8,075,400 398,785 19,939 1
drg. Iting Mursyidah Hanum 378,846
2 III 5 0.37 6 0.41 6 0.24 5 0.37 4 1.49 2.8 0.88 3.77 25 22 3 88 332 9963 8,075,400 269,099 13,455 2
Nia Kurniasih, AM.Keb, SKM 255,644
3 IV 5 0.37 6 0.41 9 0.36 9 0.67 2 0.75 2.9 0.91 3.47 25 24 1 96 333 9963 8,075,400 269,909 3
drg. Ira Tantira,MKM 40,486 229,423
4 III 5 0.37 4 0.28 9 0.36 9 0.67 2 0.75 2.7 0.85 3.27 25 24 1 96 314 9963 8,075,400 254,509 12,725 4
dr.Ilma Hitriyah 241,784
5 IV 5 0.37 6 0.41 6 0.24 7 0.52 3 1.12 2.8 0.88 3.54 25 25 0 100 354 9963 8,075,400 286,931 5
Novita Sari, Amd.Keb,SKM 43,040 243,891
6 III 5 0.37 6 0.41 5 0.20 7 0.52 1 0.37 2.8 0.88 2.76 25 25 0 100 276 9963 8,075,400 223,709 11,185 6
Pipin Supartini, Amd.Kep 212,524
7 III 5 0.37 6 0.41 5 0.20 7 0.52 1 0.37 2.3 0.72 2.60 25 25 0 100 260 9963 8,075,400 210,740 10,537 7
Elly Herawati, AM.Keb 200,203
8 III 5 0.37 6 0.41 6 0.24 7 0.52 1 0.37 2.2 0.69 2.61 25 22 3 88 230 9963 8,075,400 186,424 9,321 8
Sri Mulyani, AM.Keb 177,103
9 III 5 0.37 4 0.28 6 0.24 4 0.30 1 0.37 2.6 0.82 2.37 25 25 0 100 237 9963 8,075,400 192,098 9,605 9
Enok Komalasari, Amd.Farm 182,493
10 III 5 0.37 5 0.34 6 0.24 7 0.52 1 0.37 2.8 0.88 2.73 25 25 0 100 273 9963 8,075,400 221,277 11,064 10
Sulastri, Amd.Keb,SKM 210,213
11 III 5 0.37 4 0.28 6 0.24 7 0.52 3 1.12 2.7 0.85 3.37 25 24 1 96 324 9963 8,075,400 262,615 13,131 11
Erni Lisdawati, STr.Keb 249,484
12 III 5 0.37 4 0.28 6 0.24 7 0.52 1 0.37 2.6 0.82 2.60 25 25 0 100 260 9963 8,075,400 210,740 10,537 12
Aan Juariah, S.Kep 200,203
13 III 5 0.37 5 0.34 6 0.24 7 0.52 1 0.37 2.7 0.85 2.70 25 25 0 100 270 9963 8,075,400 218,846 10,942 13
Rina Rindayani, STr.Keb 207,904
14 III 5 0.37 4 0.28 6 0.24 4 0.30 2 0.75 2.6 0.82 2.75 25 25 0 100 275 9963 8,075,400 222,898 11,145 14
Dini Suhardini, S.ST 211,753
15 II 5 0.37 4 0.28 5 0.20 7 0.52 1 0.37 2.4 0.75 2.49 25 21 4 84 210 9963 8,075,400 170,213 15
Pujianti Komara,AM.Keb 170,213
16 II 5 0.37 4 0.28 5 0.20 7 0.52 1 0.37 2 0.63 2.37 25 25 0 100 237 9963 8,075,400 192,098 16
Euis Kresna R R,Am.Keb 192,098
17 II 5 0.37 4 0.28 6 0.24 7 0.52 1 0.37 2 0.63 2.41 25 25 0 100 241 9963 8,075,400 195,340 17
Cici Sri Haryati,AM.Keb 195,340
18 II 5 0.37 4 0.28 5 0.20 7 0.52 1 0.37 2 0.63 2.37 25 25 0 100 237 9963 8,075,400 192,098 18
Isyeu Nurhasanah,AM.Keb 192,098
19 II 5 0.37 4 0.28 5 0.20 7 0.52 1 0.37 2 0.63 2.37 25 25 0 100 237 9963 8,075,400 192,098 19
Vina Muharyani, Am.Keb 192,098
20 III 5 0.37 3 0.21 6 0.24 4 0.30 1 0.37 2.8 0.88 2.37 25 25 0 100 237 9963 8,075,400 192,098 9,605 20
Elda Sartika, SKM 182,493
21 II 5 0.37 2 0.14 5 0.20 7 0.52 1 0.37 2.6 0.82 2.42 25 25 0 100 242 9963 8,075,400 196,150 21
Diniarty S.S, AMd.Kep 196,150
22 II 5 0.37 2 0.14 5 0.20 4 0.30 1 0.37 2.2 0.69 2.07 25 24 1 96 199 9963 8,075,400 161,297 22
Loudya Ulfah Y, Amd Fam 161,297
23 - 1 0.07 5 0.34 2 0.08 1 0.07 1 0.37 2.5 0.78 1.73 25 25 0 100 173 9963 8,075,400 140,223 23
Kurnaedi Johansyah 140,223
24 - 1 0.07 5 0.34 6 0.24 4 0.30 1 0.37 2.6 0.82 2.15 25 25 0 100 215 9963 8,075,400 174,266 24
Rinda Gandari,S.Si 174,266
25 - 1 0.07 4 0.28 4 0.16 3 0.22 1 0.37 2.6 0.82 1.92 25 25 0 100 192 9963 8,075,400 155,623 25
Eka Suhesti,A.Md 155,623
Jumlah di pindahkan 113 8.3704 111 7.6313 145 5.87 151 11.227 42 15.661 63.1 19.80 68.56 6650 5,390,084 153,191 -
83,526 5,153,367
 Jumlah pindahan 113 8.3704 111 7.6313 145 5.87 151 11.23 42 15.661 63.1 19.80 68.56 0 0 0 0 6650 5,390,084 153,191 - 83,526 5,153,367 -
26 Imas Kodariah, Ama.Kep - 1 0.07 3 0.21 5 0.20 7 0.52 1 0.37 2.6 0.82 2.19 25 25 0 100 219 9963 8,075,400 177,508 177,508 26
27 - 0.00 0.00 0.00 0.00 0.00 0.00 0.00 25 0 25 - 0 9963 8,075,400 - 27
Susi Siti Rohmah, S.Kep 0
28 - 1 0.07 3 0.21 5 0.20 7 0.52 1 0.37 2 0.63 2.00 25 20 5 80 160 9963 8,075,400 129,686 28
Desi K. Natalia, AM.Keb 129,686
29 - 1 0.07 3 0.21 5 0.20 7 0.52 1 0.37 2.2 0.69 2.07 25 25 0 100 207 9963 8,075,400 167,782 29
Citra Nasopa, AM.Keb 167,782
30 - 1 0.07 3 0.21 5 0.20 7 0.52 1 0.37 2.1 0.66 2.03 25 25 0 100 203 9963 8,075,400 164,539 30
Tika Kartika, AM.Keb 164,539
31 - 1 0.07 3 0.21 2 0.08 1 0.07 1 0.37 2.2 0.69 1.50 25 14 11 56 84 9963 8,075,400 68,085 31
Adang Gunawan 68,085
32 - 1 0.07 3 0.21 5 0.20 7 0.52 1 0.37 2.1 0.66 2.03 25 17 8 68 138 9963 8,075,400 111,854 32
Juariyah.H,Amd.Keb 111,854
33 - 1 0.07 3 0.21 5 0.20 7 0.52 1 0.37 2.6 0.82 2.19 25 23 2 92 202 9963 8,075,400 163,729 33
Ega Desia Mataram, Amd.Kep 163,729
34 - 1 0.07 3 0.21 5 0.20 7 0.52 1 0.37 1 0.31 1.69 25 11 14 44 74 9963 8,075,400 59,980 34
Ardi Suardi, Amd.Kep 59,980
35 - 1 0.07 2 0.14 5 0.20 7 0.52 1 0.37 2.5 0.78 2.09 25 24 1 96 201 9963 8,075,400 162,918 35
Suhartini, Amd.Kep 162,918
36 - 0 0.00 1 0.07 6 0.24 4 0.30 0 0.00 0 0.00 0.61 25 25 0 100 61 9963 8,075,400 49,443 36
Mira Mahmudah, SKM 49,443
37 - 1 0.07 2 0.14 5 0.20 7 0.52 1 0.37 2.2 0.69 2.00 25 25 0 100 200 9963 8,075,400 162,108 37
Nani Sulistiani, AMd.Keb 162,108
38 - 1 0.07 2 0.14 5 0.20 7 0.52 1 0.37 2.1 0.66 1.97 25 25 0 100 197 9963 8,075,400 159,676 38
Reni Anggraeni, AMd.Keb 159,676
39 1 0.07 2 0.14 6 0.24 4 0.30 1 0.37 2.6 0.82 1.94 25 25 0 100 194 9963 8,075,400 157,245 39
Reni Nurhaeni, S.Farm 157,245
40 - 1 0.07 2 0.14 2 0.08 1 0.07 1 0.37 2.4 0.75 1.49 25 25 0 100 149 9963 8,075,400 120,770 40
Mastur Solihin 120,770
41 - 0 0.00 1 0.07 4 0.16 3 0.22 0 0.00 0.4 0.13 0.58 25 22 3 88 51 9963 8,075,400 41,337 41
Fitria Febriani, SE 41,337
42 - 1 0.07 2 0.14 2 0.08 3 0.22 1 0.37 2.6 0.82 1.70 25 25 0 100 170 9963 8,075,400 137,792 42
M.Agung Adipura 137,792
43 1 0.07 2 0.14 5 0.20 7 0.52 1 0.37 2.1 0.66 1.97 25 24 1 96 189 9963 8,075,400 153,192 43
Cep Rianto N,Amd.Kep 153,192
44 0 0.00 1 0.07 5 0.20 4 0.30 0 0.00 0.1 0.03 0.60 25 24 1 96 58 9963 8,075,400 47,011 44
Yanwarrizal Ahmad, Amd.Gz 47,011
45 - 1 0.07 2 0.14 5 0.20 3 0.22 1 0.37 2.5 0.78 1.79 25 25 0 100 179 9963 8,075,400 145,086 45
Gina Megawati, Amd Keb 145,086
46 0 0.00 1 0.07 5 0.20 4 0.30 0 0.00 0.1 0.03 0.60 25 25 0 100 60 9963 8,075,400 48,632 46
Ulqia Akmalia, Amd AK 48,632
47 5 0.37 4 0.28 5 0.20 7 0.52 1 0.37 1.5 0.47 2.21 25 24 1 96 212 9963 8,075,400 171,834 47
Taopik Hidayat,AMK 171,834
48 Eva Siti Rustini 1 0.07 1 0.07 5 0.20 7 0.52 0 0.00 0.6 0.19 1.05 25 25 0 100 105 9963 8,075,400 85,107 48
85,107 7,838,683

236,717
135 10 160 11 247 10 269 20 59 22 102 32 105 9963 8,075,400 153,191 - 83,526 7,838,683
Jumlah
Terbilang Delapan Juta Tujuh Puluh Lima Ribu Empat Ratus Rupiah
7,922,209

-
Mengetahui Sumedang, 7 November 2022 7,922,209 7,922,209 153,191
Pimpinan BLUD Puskesmas Cimanggung Bendahara BLUD 7,922,209

7,838,683

drg.Iting Mursyidah Hanum Erni Lisdawati, S.Tr.Keb

NIP. 197706222009022001 NIP.19741106 200902 2 001
24

az
 16

-
 DAFTAR PENERIMAAN JASA KAPITASI

KEGIATAN : 033. - Pelayanan Kesehatan PPK BLUD Puskesmas Cimanggung

PUSKESMAS : PPK-BLUD PUSKESMAS CIMANGGUNG
BULAN : Oktober 2022
RINCIAN OBJEK/URAIAN : BELANJA JASA TENAGA KESEHATAN
KODE REKENING BLUD : 5.1.02.02.01.14
JUMLAH KAPITASI : Rp. 120,459,600

Jumlah
Masa Kerja Pendidikan Resiko Kerja Jabatan BLUD Kinerja Nilai % masuk
Status (10%) Jumlah Hari Kerja Nilai Total x Jumlah Pajak
(5%) (15%) (20%) (20%) Pelayanan (30%) Total(nila kerja ( klm Jml Uang Jumlah (klm
No Nama Gol Jml Yg Diterima Tanda Tangan
i 12/11x10 Masuk (klm Total Kapitasi 17/16 x 15)
10 x14) Indek
5+6+7+8 0)
indek nilai indek nilai indek nilai indek nilai indek nilai indek nilai +9) H Kerja masuk tidak 5% 6% 15%
masuk

2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
1 III 5 0.37 4 0.28 9 0.36 6 0.45 8 2.98 2.9 0.91 5.35 25 23 2 92 492 9963 113,459,600 5,602,943 280,147 1
drg. Iting Mursyidah Hanum 5,322,796
2 III 5 0.37 6 0.41 6 0.24 5 0.37 4 1.49 2.8 0.88 3.77 25 22 3 88 332 9963 113,459,600 3,780,848 189,042 2
Nia Kurniasih, AM.Keb, SKM 3,591,806
3 IV 5 0.37 6 0.41 9 0.36 9 0.67 2 0.75 2.9 0.91 3.47 25 24 1 96 333 9963 113,459,600 3,792,236 3
drg. Ira Tantira,MKM 568,835 3,223,401
4 III 5 0.37 4 0.28 9 0.36 9 0.67 2 0.75 2.7 0.85 3.27 25 24 1 96 314 9963 113,459,600 3,575,862 178,793 4
dr.Ilma Hitriyah 3,397,069
5 IV 5 0.37 6 0.41 6 0.24 7 0.52 3 1.12 2.8 0.88 3.54 25 25 0 100 354 9963 113,459,600 4,031,386 5
Novita Sari, Amd.Keb,SKM 604,708 3,426,678
6 III 5 0.37 6 0.41 5 0.20 7 0.52 1 0.37 2.8 0.88 2.76 25 25 0 100 276 9963 113,459,600 3,143,114 157,156 6
Pipin Supartini, Amd.Kep 2,985,958
7 III 5 0.37 6 0.41 5 0.20 7 0.52 1 0.37 2.3 0.72 2.60 25 25 0 100 260 9963 113,459,600 2,960,905 148,045 7
Elly Herawati, AM.Keb 2,812,860
8 III 5 0.37 6 0.41 6 0.24 7 0.52 1 0.37 2.2 0.69 2.61 25 22 3 88 230 9963 113,459,600 2,619,262 130,963 8
Sri Mulyani, AM.Keb 2,488,299
9 III 5 0.37 4 0.28 6 0.24 4 0.30 1 0.37 2.6 0.82 2.37 25 25 0 100 237 9963 113,459,600 2,698,979 134,949 9
Enok Komalasari, Amd.Farm 2,564,030
10 III 5 0.37 5 0.34 6 0.24 7 0.52 1 0.37 2.8 0.88 2.73 25 25 0 100 273 9963 113,459,600 3,108,950 155,448 10
Sulastri, Amd.Keb,SKM 2,953,502 24
11 III 5 0.37 4 0.28 6 0.24 7 0.52 3 1.12 2.7 0.85 3.37 25 24 1 96 324 9963 113,459,600 3,689,743 184,487 11
Erni Lisdawati, STr.Keb 3,505,256
12 III 5 0.37 4 0.28 6 0.24 7 0.52 1 0.37 2.6 0.82 2.60 25 25 0 100 260 9963 113,459,600 2,960,905 148,045 12
Aan Juariah, S.Kep 2,812,860
13 III 5 0.37 5 0.34 6 0.24 7 0.52 1 0.37 2.7 0.85 2.70 25 25 0 100 270 9963 113,459,600 3,074,786 153,739 13
Rina Rindayani, STr.Keb 2,921,047
14 III 5 0.37 4 0.28 6 0.24 4 0.30 2 0.75 2.6 0.82 2.75 25 25 0 100 275 9963 113,459,600 3,131,726 156,586 14
Dini Suhardini, S.ST 2,975,140
15 II 5 0.37 4 0.28 5 0.20 7 0.52 1 0.37 2.4 0.75 2.49 25 21 4 84 210 9963 113,459,600 2,391,500 15
Pujianti Komara,AM.Keb 2,391,500
16 II 5 0.37 4 0.28 5 0.20 7 0.52 1 0.37 2 0.63 2.37 25 25 0 100 237 9963 113,459,600 2,698,979 16
Euis Kresna R R,Am.Keb 2,698,979
17 II 5 0.37 4 0.28 6 0.24 7 0.52 1 0.37 2 0.63 2.41 25 25 0 100 241 9963 113,459,600 2,744,531 17
Cici Sri Haryati,AM.Keb 2,744,531
18 II 5 0.37 4 0.28 5 0.20 7 0.52 1 0.37 2 0.63 2.37 25 25 0 100 237 9963 113,459,600 2,698,979 18
Isyeu Nurhasanah,AM.Keb 2,698,979
19 II 5 0.37 4 0.28 5 0.20 7 0.52 1 0.37 2 0.63 2.37 25 25 0 100 237 9963 113,459,600 2,698,979 19
Vina Muharyani, Am.Keb 2,698,979
20 III 5 0.37 3 0.21 6 0.24 4 0.30 1 0.37 2.8 0.88 2.37 25 25 0 100 237 9963 113,459,600 2,698,979 134,949 20
Elda Sartika, SKM 2,564,030
21 II 5 0.37 2 0.14 5 0.20 7 0.52 1 0.37 2.6 0.82 2.42 25 25 0 100 242 9963 113,459,600 2,755,919 21
Diniarty S.S, AMd.Kep 2,755,919
22 II 5 0.37 2 0.14 5 0.20 4 0.30 1 0.37 2.2 0.69 2.07 25 24 1 96 199 9963 113,459,600 2,266,231 22
Loudya Ulfah Y, Amd Fam 2,266,231
23 - 1 0.07 5 0.34 2 0.08 1 0.07 1 0.37 2.5 0.78 1.73 25 25 0 100 173 9963 113,459,600 1,970,141 23
Kurnaedi Johansyah 1,970,141
24 - 1 0.07 5 0.34 6 0.24 4 0.30 1 0.37 2.6 0.82 2.15 25 25 0 100 215 9963 113,459,600 2,448,441 24
Rinda Gandari,S.Si 2,448,441
25 - 1 0.07 4 0.28 4 0.16 3 0.22 1 0.37 2.6 0.82 1.92 25 25 0 100 192 9963 113,459,600 2,186,514 25
Eka Suhesti,A.Md 2,186,514
Jumlah di pindahkan 113 8.37 111 7.631 145 5.87 151 11.23 42 15.66 63.1 19.80 68.56 6650 75,730,838 2,152,349
- 1,173,543 72,404,946
 Jumlah pindahan 113 8.37 111 7.631 145 5.87 151 11.23 42 15.66 63.1 19.80 68.56 0 0 0 0 6650 75,730,838 2,152,349 - 1,173,543 72,404,946
26 - 1 0.07 3 0.21 5 0.20 7 0.52 1 0.37 2.6 0.82 2.19 25 25 0 100 219 9963 113,459,600 2,493,993 26
Imas Kodariah, Ama.Kep 2,493,993
27 - 0.00 0.00 0.00 0.00 0.00 0.00 0.00 25 0 25 - 0 9963 113,459,600 - 27
Susi Siti Rohmah, S.Kep 0
28 - 1 0.07 3 0.21 5 0.20 7 0.52 1 0.37 2 0.63 2.00 25 20 5 80 160 9963 113,459,600 1,822,095 28
Desi K. Natalia, AM.Keb 1,822,095
29 - 1 0.07 3 0.21 5 0.20 7 0.52 1 0.37 2.2 0.69 2.07 25 25 0 100 207 9963 113,459,600 2,357,336 29
Citra Nasopa, AM.Keb 2,357,336
30 - 1 0.07 3 0.21 5 0.20 7 0.52 1 0.37 2.1 0.66 2.03 25 25 0 100 203 9963 113,459,600 2,311,783 30
Tika Kartika, AM.Keb 2,311,783
31 - 1 0.07 3 0.21 2 0.08 1 0.07 1 0.37 2.2 0.69 1.50 25 14 11 56 84 9963 113,459,600 956,600 31
Adang Gunawan 956,600
32 - 1 0.07 3 0.21 5 0.20 7 0.52 1 0.37 2.1 0.66 2.03 25 17 8 68 138 9963 113,459,600 1,571,557 32
Juariyah.H,Amd.Keb 1,571,557
33 - 1 0.07 3 0.21 5 0.20 7 0.52 1 0.37 2.6 0.82 2.19 25 23 2 92 202 9963 113,459,600 2,300,395 33
Ega Desia Mataram, Amd.Kep 2,300,395
34 - 1 0.07 3 0.21 5 0.20 7 0.52 1 0.37 1 0.31 1.69 25 11 14 44 74 9963 113,459,600 842,719 34
Ardi Suardi, Amd.Kep 842,719
35 - 1 0.07 2 0.14 5 0.20 7 0.52 1 0.37 2.5 0.78 2.09 25 24 1 96 201 9963 113,459,600 2,289,007 35
Suhartini, Amd.Kep 2,289,007
36 - 0 0.00 1 0.07 6 0.24 4 0.30 0 0.00 0 0.00 0.61 25 25 0 100 61 9963 113,459,600 694,674 36
Mira Mahmudah, SKM 694,674
37 - 1 0.07 2 0.14 5 0.20 7 0.52 1 0.37 2.2 0.69 2.00 25 25 0 100 200 9963 113,459,600 2,277,619 37
Nani Sulistiani, AMd.Keb 2,277,619
38 - 1 0.07 2 0.14 5 0.20 7 0.52 1 0.37 2.1 0.66 1.97 25 25 0 100 197 9963 113,459,600 2,243,455 38
Reni Anggraeni, AMd.Keb 2,243,455
39 1 0.07 2 0.14 6 0.24 4 0.30 1 0.37 2.6 0.82 1.94 25 25 0 100 194 9963 113,459,600 2,209,291 39
Reni Nurhaeni, S.Farm 2,209,291
40 - 1 0.07 2 0.14 2 0.08 1 0.07 1 0.37 2.4 0.75 1.49 25 25 0 100 149 9963 113,459,600 1,696,826 40
Mastur Solihin 1,696,826
41 - 0 0.00 1 0.07 4 0.16 3 0.22 0 0.00 0.4 0.13 0.58 25 22 3 88 51 9963 113,459,600 580,793 41
Fitria Febriani, SE 580,793
42 - 1 0.07 2 0.14 2 0.08 3 0.22 1 0.37 2.6 0.82 1.70 25 25 0 100 170 9963 113,459,600 1,935,976 42
M.Agung Adipura 1,935,976
43 1 0.07 2 0.14 5 0.20 7 0.52 1 0.37 2.1 0.66 1.97 25 24 1 96 189 9963 113,459,600 2,152,350 43
Cep Rianto N,Amd.Kep 2,152,350
44 0 0.00 1 0.07 5 0.20 4 0.30 0 0.00 0.1 0.03 0.60 25 24 1 96 58 9963 113,459,600 660,510 44
Yanwarrizal Ahmad, Amd.Gz 660,510 120,459,600
45 - 1 0.07 2 0.14 5 0.20 3 0.22 1 0.37 2.5 0.78 1.79 25 25 0 100 179 9963 113,459,600 2,038,469 45
Gina Megawati, Amd Keb 2,038,469
46 0 0.00 1 0.07 5 0.20 4 0.30 0 0.00 0.1 0.03 0.60 25 25 0 100 60 9963 113,459,600 683,286 46
Ulqia Akmalia, Amd AK 683,286
47 5 0.37 4 0.28 5 0.20 7 0.52 1 0.37 1.5 0.47 2.21 25 24 1 96 212 9963 113,459,600 2,414,276 47
Taopik Hidayat,AMK 2,414,276
48 Eva Siti Rustini 1 0.07 1 0.07 5 0.20 7 0.52 0 0.00 0.6 0.19 1.05 25 25 0 100 105 9963 113,459,600 1,195,750 1,195,750 48

49 7,000,000 49
dr. Beny 7,000,000
135 10 160 11 247 10 269 20 59 22 102 32 105 9963 120,459,600 2,152,349 - 1,173,543 117,133,708
Jumlah
Terbilang Seratus Dua Puluh Juta Empat Ratus Lima Puluh Sembilan Ribu Enam Ratus Rupiah
3,325,892 120,459,600

117,133,708
Mengetahui Sumedang, 7 November 2022 3,325,892 3,325,892 117,133,708
Pimpinan BLUD Puskesmas Cimanggung Bendahara BLUD 120,459,600

120,459,600

drg.Iting Mursyidah Hanum Erni Lisdawati, S.Tr.Keb

NIP. 197706222009022001 NIP.19741106 200902 2 001
az
16
 DAFTAR PENERIMAAN JASA KAPITASI
No Nama Libur Kerja
1 drg. Iting Mursyidah Hanum
2 Nia Kurniasih, AM.Keb, SKM
3 drg. Ira Tantira,MKM
4 dr.Ilma Hitriyah
5 Novita Sari, Amd.Keb,SKM
6 Pipin Supartini, Amd.Kep
7 Elly Herawati, AM.Keb
8 Sri Mulyani, AM.Keb
9 Enok Komalasari, Amd.Farm
10 Sulastri, Amd.Keb,SKM
11 Erni Lisdawati, STr.Keb
12 Aan Juariah, S.Kep
13 Rina Rindayani, STr.Keb
14 Dini Suhardini, S.ST
15 Pujianti Komara,AM.Keb
16 Euis Kresna R R,Am.Keb
17 Cici Sri Haryati,AM.Keb
18 Isyeu Nurhasanah,AM.Keb
19 Vina Muharyani, Am.Keb
20 Elda Sartika, SKM
21 Diniarty S.S, AMd.Kep
22 Loudya Ulfah Y, Amd Fam
23 Kurnaedi Johansyah
24 Rinda Gandari,S.Si
25 Eka Suhesti,A.Md
26 Imas Kodariah, Ama.Kep
27 Susi Siti Rohmah, S.Kep
28 Desi K. Natalia, AM.Keb
29 Citra Nasopa, AM.Keb
30 Tika Kartika, AM.Keb
31 Juariyah.H,Amd.Keb
32 Ega Desia Mataram, Amd.Kep
33 Ardi Suardi, Amd.Kep
34 Suhartini, Amd.Kep
35 Mira Mahmudah, SKM
36 Nani Sulistiani, AMd.Keb
37 Reni Anggraeni, AMd.Keb
38 Reni Nurhaeni, S.Farm
39 Mastur Solihin
40 Fitria Febriani, SE
41 M.Agung Adipura
42 Cep Rianto N,Amd.Kep
43 Yanwarrizal Ahmad, Amd.Gz
44 Gina Megawati, Amd Keb
45 Ulqia Akmalia, Amd AK
46 Taopik Hidayat,AMK
47 Eva Siti Rustini
JUMLAH
Mengetahui :
Pimpinan BLUD Puskesmas Cimanggung

drg.Iting Mursyidah Hanum

NIP. 197706222009022001