FORMULIR PENGAJUAN KLAIM JAMK

UPT PUSKESMAS GULUK-GU

DANA BANTUAN SOSIAL DAERAH KABUPAT

TAHUN 2016
NAMA PENGAJU KLAIM : POLI MTBS
NO

TGL

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42

01-09-2016

NO. KARTU/SPM

NAMA PASIEN

3529096010890003

AISYAH ARFAN

01-09-2016

3529091507860011

ALIVIA PUTRI

02-09-2016

0001836745233

AHMAD MIZAN

02-09-2016

3529094107680306

BUSTANIL ARIFIN

02-09-2016

3529095501820001

MOH. ABRORI

02-09-2016

3529092709120003

MOH.LUBBUL LABIB

02-09-2016

1312016

MOHAMMAD AFIN

03-09-2016

3529131611150001

MOH. ZIYADID DIYAN

03-09-2016

3529094105140002

ROHMATUL UMMAH

05-09-2016

3529110103150001

ABDULLAH MUBAROK

05-09-2016

3529096202700002

LINATUL HOLIQOH

05-09-2016

3529092408100002

MUHAMMAD LUKMAN

05-09-2016

20102015

RAFI AZKA PUTRA

05-09-2016

3529094203130002

ROFATUL AISYAH

06-09-2016

3529090907130001

AHMAD SAIFUL ISLAM

06-09-2016

3529091201120001

MOH. IBNU HASYIM

07-09-2016

3529092511940002

MARDIYATUS SHOLIHAH

07-09-2016

3529090804090013

MUFTIYA WALIDA AL ALUF

07-09-2016

3529090611860005

ZAYYINATUS SHIFA

08-09-2016

3529090902110011

AZMI

10-09-2016

3529092909090021

DEVIANA ALFIANSYAH

10-09-2016

3529092306100006

MOH. ABDUL FANI

10-09-2016

3529091404960006

MOH. FAHRORIL ABAD

10-09-2016

3529090903130001

MOHAMMAD LUKMAN

10-09-2016

3529090401120001

NUR SYAFIYAH FAJRIYANI

14-09-2016

3529090207120001

AHMAD KHAIRUL AZAM

14-09-2016

3529090608150002

ANISA NABILATUL JANNAH

14-09-2016

3529095212890004

MOH. ZAIDAN

14-09-2016

3529090802110003

SILMA ROFIAH

15-09-2016

3529110103150001

ABDULLAH MUBAROK

15-09-2016

3529114310900003

AHMAD MASKIBATUL

15-09-2016

3529094810870004

ROFIATUL MASRUROH

15-09-2016

3529091310090022

ZARINAH AYU ROMADANIA

17-09-2016

3529090208130001

FAHAD RIJAL SYATHIR

19-09-2016

3529096202700002

LINATUL HOLIQOH

19-09-2016

3529095210860005

MOH. ADLI FAIRUZZAKI

19-09-2016

3529096003850004

MOH. SAKIB

19-09-2016

3529091109070046

SAADATUD DAROIN

22-09-2016

3529094203810004

AHMAD DARWIS

22-09-2016

3529096207890004

ANINDITA AISYAH

22-09-2016

3529136007130001

DHAIMATUS SA ADAH AL

22-09-2016

3529094312150001

LAVINA AZRA AFANI

JENIS
KELAMIN
p
p
L
L
L
L
L
L
P
L
P
L
L
P
L
L
P
P
P
L
P
L
L
L
P
L
P
L
P
L
L
P
P
L
P
L
L
L
L
P
P
P

UMUR
(Thn)

BARU
LAMA

1 thn

1 bln

3 thn

3 thn

1 thn

1 thn

7 bln

9 bln

2 thn

1 thn

1 thn

1 bln

10 bln

3 thn

3 thn

4 thn

1 thn

10 bln

11 thn

2 bln

1 bln

27 hr

1 thn

3 thn

15 hr

4 thn

3 thn

1 thn

2 bln

1 thn

9 bln

2 bln

2 bln

3 thn

2 thn

1 bln

2 bln

3 bln

2 bln

3 bln

3 thn

9 bln

43
44
45
46
47
48
49
50
51
52
53
54
55
56
57

22-09-2016

3529094203130002

ROFATUL AISYAH

23-09-2016

3529092509080004

MOHAMMAD AUFA

24-09-2016

3529136007140001

AL KARIMATUL KHOLILAH

26-09-2016

3529093005140001

A. FAWAID FIRMANDANI

26-09-2016

3529091207160001

ACH. DENIES VICTORIA

26-09-2016

3529093107140001

AFDAN NOMAN WAFI

26-09-2016

3529096202700002

LINATUL HOLIQOH

26-09-2016

3529090603090005

MOH. AIFAN

27-09-2016

3529092408140002

MOH. DANIS AL ATTAR

27-09-2016

3529095212890004

MOH. ZAIDAN

27-09-2016

3529092509120001

MUHAMMAD ROYYAN

28-09-2016

3529132603120001

MOH. WAWAN AFANDI

28-09-2016

3529092709120003

MOH.LUBBUL LABIB

29-09-2016

3529092008090095

MOH. ISBATS BAQIH

30-09-2016

3529090804090013

MUFTIYA WALIDA AL ALUF

P
L
P
L
L
L
P
L
L
L
L
L
L
L
P
TOTAL

laki-laki
perempuan
0

3 thn

2 bln

2 thn

2 thn

2 bln

2 thn

2 thn

1 thn

2 thn

1 thn

6 bln

4 thn

1 thn

9 bln

11 bln

JUAN KLAIM JAMKESDA

MAS GULUK-GULUK

AERAH KABUPATEN SUMENEP

UN 2016
BULAN
ALAMAT

DIAGNOSA (ICD X)
TINDAKAN

j06 ISPA
GULUK TENGAH
Z23 IMUNISASI BCG
DUSUN GULUK GULUK TIMURQ20
R
BAWAAN JANTUNG
KLABAAN LAOK
j06 ISPA
DUSUN DUKO RT 05 RW 01 Z23 IMUNISASI
TALESEK
L20 DERMATITIS
DUNGDANG
j06 ISPA
MONTORNA
j06 ISPA
GULUK TENGAH

GULUK TIMUR

R05 DEMAM
B86 GATAL-GATAL
Z23 IMUNISASI

GANG ASEM

B86 GATAL-GATAL

GANG ASEM
GULUK TIMUR

j06 ISPA
GATAL-GATAL
j06 ISPA

KADIBAS

j06 ISPA

GULUK TENGAH
DUSUN BULU RT 006 RW 005

DUSUN KALABAAN DAJA RT 0 B86

BUNGKANDANG
KADIBAS
DUSUN REYANG RT 13 RW

A09 DIARE
j06 ISPA
04Z34 TINDIK TELINGA

Z23 IMUNISASI
TINDIK TELINGA
REYANG DUNDANG
j06 ISPA
TALESEK
j06 ISPA
DUSUN TALESEK RT 03 RW 1 B86 GATAL-GATAL
GULUK TENGAH
Z34 TINDIK TELINGA
KRANG SOKON TIMUR
J16 PNEUMONIA
PARSE
j06 ISPA
DUSUN BRAKAS LAOK RT 01 B86 GATAL-GATAL
PORDAPOR BARAT
Z34 TINDIK TELINGA
DUSUN BULU RT 006 RW 005 j06 ISPA
DUSUN BATU JARAN RT 04 RWj06 ISPA
BUNGKANDANG
Z23 IMUNISASI
DUKO
Z23 IMUNISASI
KADIBAS

DUSUN MASARAN RT 08 RW 0 Z34

DUSUN LENGKONG TIMUR RT R05

DEMAM
GULUK TIMUR
E44 BGM
DUSUN BANLAPAH RT 01 RW Z23 IMUNISASI
DUSUN GULUK GULUK TIMUR R
Z23 IMUNISASI
GULUK TIMUR
Z23 IMUNISASI
KETAWANG BUNGKANDANG Z23 IMUNISASI
BUNGKANDANG
j06 ISPA
PRANCAK
R05 DEMAM
DUSUN KADIBAS RT 01 RW 0 B86 GATAL-GATAL

: SEPTEMBER 2016

KARCIS
MASUK
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp

7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500

BIAYA
TINDAKAN

TOTAL
BIAYA
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp

7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500

DUSUN KALABAAN DAJA RT 0 B86

GATAL-GATAL
R05 DEMAM
DUSUN TANGGULUN
A08 DEMAM TINGGI
DUSUN GRUJUGAN RT 02 RW B86 GATAL-GATAL
DUSUN GRUJUGAN RT 02 RW A09 DIARE
GULUK TENGAH
A09 DIARE
GULUK TIMUR
E44 BGM
GULUK-GULUK TIMUR
j06 ISPA
DUSUN TALANG RT 02 RW 03 A09 DIARE
DUSUN BRAKAS LAOK RT 01 R05 DEMAM
BRUMBUNG
A09 DIARE
PRANCK
R50 DISENTRI
TALESEK
B86 GATAL-GATAL
LENGKONG TIMUR
j06 ISPA
KADIBAS
j06 ISPA
TALANG

Rp
7,500
Rp
7,500
Rp
7,500
Rp
7,500
Rp
7,500
Rp
7,500
Rp
7,500
Rp
7,500
Rp
7,500
Rp
7,500
Rp
7,500
Rp
7,500
Rp
7,500
Rp
7,500
Rp
7,500
Rp 427,500

Rp
7,500
Rp
7,500
Rp
7,500
Rp
7,500
Rp
7,500
Rp
7,500
Rp
7,500
Rp
7,500
Rp
7,500
Rp
7,500
Rp
7,500
Rp
7,500
Rp
7,500
Rp
7,500
Rp
- Rp
7,500
Rp 427,500
Pengaju Klaim

ERNA SUSILOWATI, Amd.Keb

NIP. 19800412 2000312 2 003

FORMULIR PENGAJUAN KLAIM JA

UPT PUSKESMAS GULUK-G

DANA BANTUAN SOSIAL DAERAH KABUP

TAHUN 2016
NAMA PENGAJU KLAIM : POLI MTBS
NO

TGL

NO. KARTU/SPM

NAMA PASIEN

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37

01-10-2016

3529091509130001

FATIR

01-10-2016

3529092006060001

MOH RIYAN

04-10-2016

3529090804080015

MOH. ADI SYAFIK

04-10-2016

3529091201120001

MOH. IBNU HASYIM

04-10-2016

3529090903130001

MOHAMMAD LUKMAN

04-10-2016

3529092509120001

MUHAMMAD ROYYAN

06-10-2016

3529091503130003

A. ZAFANUS ZUFAR

06-10-2016

3529091502100018

ADIBATUL SAKILA

06-10-2016

3529094808880002

FAROSATUL FARODIS

06-10-2016

35290511790002

MOH. HAIKAL ROMADHAN

06-10-2016

3529092211750003

NAYYIF ARDAN GHARIZI

07-10-2016

1312016

MOHAMMAD AFIN

08-10-2016

3529090412130001

AHMAD MUZAKKI ZUBAIDI

10-10-2016

3529090710110019

BY. NY. WADIDAH

10-10-2016

3529090507100001

FARDA HAFIKOH

10-10-2016

3529090707080100

IKMAL MAULANA

10-10-2016

3529096202700002

LINATUL HOLIQOH

11-10-2016

3529132407120010

AMELIA

11-10-2016

3529090603090005

MOH. AIFAN

11-10-2016

3529101108130001

MOHAMMAD NABIL

11-10-2016

3529095011110001

NAOROTUL QOLBIYAH

12-10-2016

3529090907130001

AHMAD SAIFUL ISLAM

12-10-2016

3529096608100002

AHWAZIYA NADIYANI

12-10-2016

3529091107080002

ANNISWA KHUMAIRO

12-10-2016

3529096503100001

FREZY DINDA NIDIA.

12-10-2016

3529090601130002

HIDAYATULLAH

12-10-2016

3529095512800006

MAFAZA KHOLIDAY

12-10-2016

3529095202920006

MOH. MUSAFFAK

12-10-2016

3529094712740002

MOHAMMAD AIFAN

12-10-2016

3529092806130003

MUHAMMAD AUFAL AMAL

12-10-2016

3529092801140001

MUHAMMAD NIZAM

12-10-2016

3529095011110001

NAOROTUL QOLBIYAH

12-10-2016

3529092509910001

SOBIHAH MAULIDA

12-10-2016

3529094207120001

WASILATUN NAJAHAH

13-10-2016

3529090101110003

ALI MAKKI

13-10-2016

3529090308100005

KHOIROTUN NAQIYAH

13-10-2016

3529093012080006

MOH .FAKIH

JENIS
KELAMIN
L
L
L
L
L
L
L
P
L
L
L
L
L
P
P
L
P
P
L
L
P
L
P
P
P
P
P
L
L
L
L
P
P
P
L
P
L

UMUR BARU
(Thn) LAMA
5 thn

10 thn

11 bln

4 thn

3 thn

6 bln

3 thn

1 bln

3 bln

4 thn

1 bln

8 bln

2 thn

1 bln

10 bln

2 thn

2 thn

4 thn

1 thn

3 thn

4 thn

3 thn

6 thn

1 thn

6 thn

3 thn

1 thn

3 thn

1 thn

3 thn

2 thn

4 thn

4 thn

4 thn

5 thn

4 thn

10 bln

38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83

13-10-2016

3529091301150001

MUHAMMAD FATIH ZAKY

13-10-2016

3529096808130001

NADIA AULIA ISTIQOMAH

13-10-2016

3529094701120002

SITI SHAFA

14-10-2016

3529095212890004

MOH. ZAIDAN

15-10-2016

3529091603760002

ANISATUL JANNAH

17-10-2016

3529093005120019

AMIR

17-10-2016

3529091501090001

GHINA GHINANA

17-10-2016

3529096202700002

LINATUL HOLIQOH

17-10-2016

3529093012080006

MOH .FAKIH

17-10-2016

3529090203100003

MOH. ZADA

17-10-2016

3529104904130001

NAIFAH SALSA AFRIYANI

17-10-2016

3529094810870004

ROFIATUL MASRUROH

17-10-2016

3529091109070046

SAADATUD DAROIN

17-10-2016

3529095008130001

WASILATUR RAHMAH

17-10-2016

3529091808100020

ZAMZMILATUL JAMILAH

17-10-2016

3529094404940004

ZULFAN NADA

18-10-2016

3529135304670001

MOH KAFI AZAM

18-10-2016

3529090309730004

MOH. ROIZAL FAKIH

20-10-2016

3529093107130001

ANDI RAHMAT

20-10-2016

3529090804080015

MOH. ADI SYAFIK

20-10-2016

3529095412120001

MUZAWWAQATUN

20-10-2016

3529091310090022

ZARINAH AYU ROMADANIA

21-10-2016

3529094107680306

BUSTANIL ARIFIN

21-10-2016

352910016006810

NIKMATUL KAMELIA

22-10-2016

3529092010100005

BAMBANG HERMAWAN

22-10-2016

3529090804090013

MUFTIYA WALIDA AL ALUF

22-10-2016

3529096505130001

ZAHROTUL ROJABIYAH

24-10-2016

3529091109110001

AKMAL MAULANA

24-10-2016

3529090608120002

IBNU FAJAR ROMADHANI

24-10-2016

3529097108140001

ISTYI HILYATAL FARAHAH

24-10-2016

3529096202700002

LINATUL HOLIQOH

24-10-2016

3529092206120002

MOH LUTFI

24-10-2016

3529092805110001

MOH. AT TUFAN AL

24-10-2016

3529090908120001

MOH. MUFID JUNAIDI

24-10-2016

3529081508120002

MOH. ROZIKI HASAN

24-10-2016

3529096003850004

MOH. SAKIB

24-10-2016

3529090310120001

MOHAMMAD FATIHUR

24-10-2016

3529091311100001

MUHAMMAD BUSRO LANA

24-10-2016

3529096004110001

NAILUN ALIYAH

24-10-2016

3529096312150001

REVATUS SADIYAH

24-10-2016

3529097107120001

ROZANATIN KAMILAH

25-10-2016

3529094308130001

HUSNUL FITRIYAH

26-10-2016

3529090611110002

ALIB AKBAR

27-10-2016

3529093005120019

AMIR

27-10-2016

3529096207890004

ANINDITA AISYAH

27-10-2016

3529094204880006

ARDANIATUF

L
P
P
L
P
L
P
P
L
L
P
P
P
P
P
P
L
L
L
L
P
P
L
P
L
P
P
L
L
P
P
L
L
L
L
L
L
L
P
P
P
P
L
L
P
L

1 thn

3 thn

4 thn

1 thn

1 bln

4 thn

4 bln

2 thn

10 bln

10 bln

3 thn

3 bln

4 bln

3 thn

2 thn

2 bln

8 bln

1 thn

3 thn

11 bln

4 thn

3 bln

3 thn

5 thn

1 thn

1 thn

3 thn

5 thn

4 thn

2 thn

2 thn

9 bln

5 thn

4 thn

4 thn

3 bln

4 thn

6 thn

5 thn

1 thn

4 thn

3 thn

4 thn

4 thn

4 bln

6 bln

84
85
86
87
88
89

27-10-2016

3529095409120002

KHALWANI

27-10-2016

3529092408140000

MOH. DANIS AL ATTAR

27-10-2016

3529092010090029

MUHAMMAD NUR AL

28-10-2016

3529132603120001

MOH. WAWAN AFANDI

10/29/2016

3529096812150000

RIFATUL MAGFIRAH

10/29/2016

3529111108150000

DELFAN HADIK

L
L
L
L
P
L
TOTAL

laki-laki
perempuan

54
35
89

4 thn

2 thn

10 bln

4 thn

10 bln

16 bln

NGAJUAN KLAIM JAMKESDA

ESMAS GULUK-GULUK

AL DAERAH KABUPATEN SUMENEP

TAHUN 2016
BULAN
ALAMAT

DIAGNOSA (ICD X)TINDAKAN

KLABAAN
KLABAAN LAOK

A08

J06.9

DUSUN GULUK TENGAH

A08.5

KADIBAS

A08.5

DUSUN TALESEK RT 03 RW
BRUMBUNG
LENGKONG TIMUR

B86
J06.9
B86

KLABAAN DAJA

Z23

GULUK TENGAH

Z23

PARSANGA
DUSUN GULUK GULUK TENGA
DUNGDANG
DUSUN GULUK GULUK TIMUR

L08

Z23
R50.1
J06.9

GULUK TIMUR

Z23
Z23
J06.9
E44

MONTORNAH

J06.9

GULUK-GULUK TIMUR

Z23

DUSUN TALAGA BARAT RT 0

R50.1

DUSUN KADIBAS RT 04 RW

J06.9

LEGUNG
TALANG KETAWANG LAOK
DUSUN KLABAAN

GULUK TIMUR

Z41.9

GULUK TENGAH

Z41.9

GULUK TIMUR

Z41.9

DUSUN GULUK TENGAH RT

Z41.9

DUSUN GULUK GULUK TIMUR

Z41.9

GANG ASEM

Z41.9

PAYUDAN DUNDANG

Z41.9

DUSUN GULUK GULUK TIMUR

Z41.9

GULUK TENGAH

Z41.9

DUSUN GULUK GULUK TENGA

DUSUN KADIBAS RT 04 RW

R50
Z41.9

DUSUN GULUK GULUK TENGA

Z41.9

GULUK TENGAH

Z41.9

DUSUN GULUK-GULUK TENGA

Z41.9

DUSUN GULUK GULUK TENGA

J06.9
J06.9

BIRSA

: OKTOBER 2016

KARCIS
MASUK
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp

7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500

BIAYA
TINDAKAN

TOTAL
BIAYA
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp

7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500

GULUK GULUK TIMUR RT 02

Z41.9

DUSUN TALESEK RT 001 RW

Z41.9

JL SURAU AT TAQWA RT 02

J06.9

DUSUN BRAKAS LAOK RT 01

J06.9

DUSUN LENGKONG BARAT RT

Z41.2

GULUK TIMUR
GULUK TENGAH

Z41.9
Z23.6

GULUK TIMUR

E44

BIRSA

Z23.8

JL. PELABUHAN KERTASADA

Z23.8

KETAWANG DALEMAN GAND

R05

BUNGKANDANG

Z23.6

GULUK TIMUR

Z23.6

DUSUN GULUK GULUK TENGA

R50.0

DUSUN GULUK-GULUK TENG

R05

DUSUN BUNGKANDANG RT 0

Z23.2

DUSUN KOMES RT 03 RW 0

J06.9

TIMUR LEKE

L30.9

DUSUN LENGKONG TIMUR RT

DUSUN GULUK TENGAH
DUSUN GULUK GULUK TENGA

L02
Z23.6
Z41

DUKO

Z41

KLABAAN LAOK

J45.9

GULUK TENGAH

Z41.9

KADIBAS

K12

KADIBAS

J06.9

DUSUN KLABAAN LAOK RT 0

L02.9

BUNGKANDANG

L23.9

DUSUN KADIBAS RT 02 RW

Z41.2

DUSUN KANDIBAS RT 02 RW

Z41.2

GULUK TIMUR

E44

DUSUN DUKO KETAWANG L

Z23.6

DUSUN KADIBAS RT 02 RW

Z41.2

DUSUN KADIBAS RT 01 RW

Z41.2

GULUK-GULUK

Z41.2

DUSUN GULUK GULUK TIMUR

Z23.6

DUSUN KADIBAS RT 01 RW

J06.9

DUSUN KADIBAS RT 02 RW

Z41.2

DUSUN KADIBAS RT 02 RW

Z41.2

GULUK-GULUK

Z41.2

DUSUN KADIBAS RT 03 RW

Z41.2

TANODUNG DAJA
LENGKONG TIMUR

Z41.2
R05

GULUK TIMUR

Z41.2

BUNGKANDANG

Z23.6

DUSUN BIRSA RT 02 RW 01

Z23.6

Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp

7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500

Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp

7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500

GANG ASEM

R50

DUSUN TALANG RT 02 RW

A09

GULUK TIMUR

R05

PRANCK
TANUDUNG LAOK
KLABAAN

R50
R50
B86

Rp
7,500
Rp
7,500
Rp
7,500
Rp
7,500
Rp
7,500
Rp
7,500
Rp 667,500

Rp
7,500
Rp
7,500
Rp
7,500
Rp
7,500
Rp
7,500
Rp
7,500
Rp 667,500
Pengaju Klaim

ERNA SUSILOWATI, Amd.Keb

NIP. 19800412 2000312 2 003

FORMULIR PENGAJUAN KL

UPT PUSKESMAS GUL

DANA BANTUAN SOSIAL DAERAH K

TAHUN 2016
NAMA PENGAJU KLAIM : POLI MTBS
NO
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36

TGL

NO. KARTU/SPM

NAMA PASIEN

JENIS
KELAMIN

UMUR
(Thn)

37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
TOTAL

ORMULIR PENGAJUAN KLAIM JAMKESDA

UPT PUSKESMAS GULUK-GULUK

NTUAN SOSIAL DAERAH KABUPATEN SUMENEP

TAHUN 2016
BULAN
BARU
LAMA

ALAMAT

DIAGNOSA (ICD X)

TINDAKAN

KARCIS
MASUK
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp

7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500

Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp

TOTAL

7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500

Rp
7,500
Rp
7,500
Rp
7,500
Rp 427,500
Pengaju Klaim

ERNA SUSILOWATI, Amd.Keb

NIP. 19800412 2000312 2 003

: NOVEMBER 2016
BIAYA
TINDAKAN

TOTAL
BIAYA
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp

7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500

Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp

7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500

Rp
7,500
Rp
7,500
Rp
- Rp
7,500
Rp 427,500
Pengaju Klaim

ERNA SUSILOWATI, Amd.Keb

NIP. 19800412 2000312 2 003

FORMULIR PENGAJUAN KLA

UPT PUSKESMAS GUL

DANA BANTUAN SOSIAL DAERAH K

TAHUN 2016
NAMA PENGAJU KLAIM : POLI MTBS
NO
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36

TGL

NO. KARTU/SPM

NAMA PASIEN

JENIS
KELAMIN

UMUR
(Thn)

37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
TOTAL

RMULIR PENGAJUAN KLAIM JAMKESDA

UPT PUSKESMAS GULUK-GULUK

TUAN SOSIAL DAERAH KABUPATEN SUMENEP

TAHUN 2016
BULAN
BARU
LAMA

ALAMAT

DIAGNOSA (ICD X)

TINDAKAN

: DESEMBER 2016

KARCIS
MASUK
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp

7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500

BIAYA
TINDAKAN

TOTAL

Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp

7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500

Rp
7,500
Rp
7,500
Rp
7,500 Rp
Rp 427,500
Pengaju Klaim

ERNA SUSILOWATI, Amd.Keb

NIP. 19800412 2000312 2 003

DESEMBER 2016
TOTAL
BIAYA
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp

7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500

Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp

7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500

Rp
7,500
Rp
7,500
Rp
7,500
Rp 427,500
gaju Klaim

LOWATI, Amd.Keb
412 2000312 2 003