lampiranklaim-20150302040616-1301k021031501 [1301k021].pdf
TRANSCRIPT
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PT. ASURANSI JIWA INHEALTH INDONESIA
NAMA PPK
BULAN PELAYANAN
TINGKAT PELAYANAN
NO FPK
KLINIK MEDIS BENOWO (PHC)
Februari 2015
RJTP
1301K021031501
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:
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No No SJP Noka Inhealth Nama Peserta PISA Biaya
1 1301K0210215X000001 1001011250981 DEDY RUDIJANTO, S.KOM. P 32.500
2 1301K0210215X000002 1001011268632 NY.SUMARSIH JD ABUBAKAR RODJA P 32.500
3 1301K0210215X000003 1011011277947 NY.ENDANG RATNAWATI I 32.500
4 1301K0210215X000004 1001011248663 SUDARMAN P 32.500
5 1301K0210215X000005 1001011277902 S. WAHYUDI P 32.500
6 1301K0210215X000006 1011011245841 RUSANA I 32.500
7 1301K0210215X000007 1001011270757 EFFENDI YUNUS. P 32.500
8 1301K0210215X000008 1001011269341 NY. SUJATUN P 32.500
9 1301K0210215X000009 1041011250805 ALLUFTHY SABIRIN 1 32.500
10 1301K0210215X000010 1001011253602 BAIQ NURUL HIKMAWATI, SE. MM. P 32.500
11 1301K0210215X000011 1001011253602 BAIQ NURUL HIKMAWATI, SE. MM. P 22.000
12 1301K0210215X000012 1051011250986 AIRLANGGA NIZHAR MEGANTARA 2 32.500
13 1301K0210215X000013 1051011250896 ZASKIA NAURA SURYA SAFITRI 2 132.500
14 1301K0210215X000014 1001011250891 SURYONO P 79.500
15 1301K0210215X000015 1011011246076 RUMHARTUTIK I 79.500
16 1301K0210215X000016 1041011246079 NURKHAYANI 1 39.500
17 1301K0210215X000017 1011011262535 ETI SUMARIYATI I 32.500
18 1301K0210215X000018 1051012953843 RISTY AL FITRI DAMAYANTI 2 32.500
19 1301K0210215X000019 1011011242421 DIYAH LILIK SRIYANTI I 134.000
20 1301K0210215X000020 1001011247561 DIAH UTARI, A.MD. P 32.500
21 1301K0210215X000021 1001011279566 SUNARJONO. P 32.500
22 1301K0210215X000022 1011011265224 MUJAYANAH I 110.000
23 1301K0210215X000023 1051011247195 AUDREY TAMAMAH KURNIAWAN 2 32.500
24 1301K0210215X000024 1041011247194 KAYYISAH ISNAIN KURNIAWAN 1 32.500
25 1301K0210215X000025 1041011250129 CHINDY RAMADHANI ICHSAN 1 79.500
26 1301K0210215X000026 1011011265224 MUJAYANAH I 32.500
27 1301K0210215X000027 1001011281287 NY. SITI MARIYAH JD. MOH. SOEB P 32.500
28 1301K0210215X000028 1001011279702 SUDJONO. P 32.500
29 1301K0210215X000029 1001011278306 SAIFUL IBRAHIM P 32.500
30 1301K0210215X000030 1011011252027 LIDIA NUR AININ I 49.000
31 1301K0210215X000031 1051011248714 MOHAMAD ZAKI AFANDI 2 32.500
32 1301K0210215X000032 1041011259401 BILAL ABYAN 1 32.500
LAMPIRAN FORMULIR PENGAJUAN KLAIM
Lampiran FPK; page 1 of 4; printed 3/2/2015 4:06:16 AM
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33 1301K0210215X000033 1041011250129 CHINDY RAMADHANI ICHSAN 1 32.500
34 1301K0210215X000034 1011011248675 JAMILAH JOENOES S 32.500
35 1301K0210215X000035 1001011248731 HARUN ROSID P 32.500
36 1301K0210215X000036 1011011262535 ETI SUMARIYATI I 32.500
37 1301K0210215X000037 1041011250129 CHINDY RAMADHANI ICHSAN 1 32.500
38 1301K0210215X000038 1011011247279 NINIK SRI MURYANI I 32.500
39 1301K0210215X000039 1041011250129 CHINDY RAMADHANI ICHSAN 1 87.500
40 1301K0210215X000040 1041011247273 KINENGGAR RARAS SELASIH 1 32.500
41 1301K0210215X000041 1011011265224 MUJAYANAH I 86.500
42 1301K0210215X000042 1001011265223 BONIRIN P 74.500
43 1301K0210215X000043 1011014210979 SITI NAFSIYAH I 39.500
44 1301K0210215X000044 1051011248714 MOHAMAD ZAKI AFANDI 2 32.500
45 1301K0210215X000045 1041011242424 PRIMO RAJENDRA PRAYOGA 1 32.500
46 1301K0210215X000046 1011011242421 DIYAH LILIK SRIYANTI I 32.500
47 1301K0210215X000047 1011011252027 LIDIA NUR AININ I 32.500
48 1301K0210215X000048 1041011246676 ZAHRA ATHIRAH M. 1 32.500
49 1301K0210215X000049 1001011265223 BONIRIN P 32.500
50 1301K0210215X000050 1001011251868 ERNAWATI, SH. P 32.500
51 1301K0210215X000051 1051011251864 JHANTER ANNAS SIMORANGKIR 2 32.500
52 1301K0210215X000052 1011011249924 MUNTIANI I 32.500
53 1301K0210215X000053 1001014016624 SITI CHOLIFAH P 127.500
54 1301K0210215X000054 1061011242292 KARINA DIARAFITA TONDANG 3 32.500
55 1301K0210215X000055 1001011281287 NY. SITI MARIYAH JD. MOH. SOEB P 74.500
56 1301K0210215X000056 1001011281287 NY. SITI MARIYAH JD. MOH. SOEB P 116.500
57 1301K0210215X000057 1011011265224 MUJAYANAH I 210.000
58 1301K0210215X000058 1001011277902 S. WAHYUDI P 32.500
59 1301K0210215X000059 1041011253663 NAFISA ALSYAFANI 1 32.500
60 1301K0210215X000060 1011011248708 ISTIANAH I 32.500
61 1301K0210215X000061 1001011280286 CHURIYATI P 32.500
62 1301K0210215X000062 1051011248714 MOHAMAD ZAKI AFANDI 2 32.500
63 1301K0210215X000063 1001013786696 SUPRIYATI P 32.500
64 1301K0210215X000064 1011014210979 SITI NAFSIYAH I 79.500
65 1301K0210215X000065 1051011248692 IQBAL ANDITHO 2 32.500
66 1301K0210215X000066 1061011242292 KARINA DIARAFITA TONDANG 3 32.500
67 1301K0210215X000067 1001011249923 SUGIYANTO P 32.500
68 1301K0210215X000068 1001011246029 ARIES MOCHAMAD HASAN P 32.500
69 1301K0210215X000069 1051011248736 SEPTINA DWI WIJAYANTI 2 32.500
70 1301K0210215X000070 1051011253664 ALISHA AYUNINDYA 2 32.500
71 1301K0210215X000071 1051011248714 MOHAMAD ZAKI AFANDI 2 32.500
72 1301K0210215X000072 1041013894882 ANANDA HENDI PRATAMA S 1 32.500
73 1301K0210215X000073 1001013894887 HENDRIK MARTHEN SIAHAILATUA P 32.500
74 1301K0210215X000074 1051011250986 AIRLANGGA NIZHAR MEGANTARA 2 32.500
Lampiran FPK; page 2 of 4; printed 3/2/2015 4:06:16 AM
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75 1301K0210215X000075 1041011247273 KINENGGAR RARAS SELASIH 1 32.500
76 1301K0210215X000076 1051011250896 ZASKIA NAURA SURYA SAFITRI 2 32.500
77 1301K0210215X000077 1001011250891 SURYONO P 132.500
78 1301K0210215X000078 1011011269059 SITI LAIYINAH I 210.000
79 1301K0210215X000079 1001011269058 MUCHAMAD ARIF P 32.500
80 1301K0210215X000080 1051011261494 DINI SETYA NUR RIZKI 2 32.500
81 1301K0210215X000081 1001011250632 SLAMET RIYANTO, SE. P 32.500
82 1301K0210215X000082 1001011248663 SUDARMAN P 32.500
83 1301K0210215X000083 1001011280837 DJUWONO. P 32.500
84 1301K0210215X000084 1041011248746 EVAN FAROS SALFATAH 1 32.500
85 1301K0210215X000085 1011011268969 DJUWARNING I 32.500
86 1301K0210215X000086 1001011265223 BONIRIN P 32.500
87 1301K0210215X000087 1011011272659 RIYANTO S 32.500
88 1301K0210215X000088 1001011272658 SUHARTATI P 32.500
89 1301K0210215X000089 1051011251122 FINAHARI RAHMADANYA 2 79.500
90 1301K0210215X000090 1001011248742 TJATUR RACHMAN SALFATAH, A.MD P 79.500
91 1301K0210215X000091 1051011251752 MUHAMMAD RAHLIL AMARDI KORO 2 39.500
92 1301K0210215X000092 1051011248466 NADINE AURARELA MARSHA OWENA 2 32.500
93 1301K0210215X000093 1011011248462 AULANA SANARIKO S 32.500
94 1301K0210215X000094 1051011248714 MOHAMAD ZAKI AFANDI 2 32.500
95 1301K0210215X000095 1001011278723 H.R. SABARUDIN P 32.500
96 1301K0210215X000096 1011011278724 NY. INDAH SUWARTI I 32.500
97 1301K0210215X000097 1041011251863 SALSABILA MUSTIKA ANNAS. 1 32.500
98 1301K0210215X000098 1041011250985 ASTRIED NADIA MAYASARI 1 32.500
99 1301K0210215X000099 1041011253988 AMALIA MUTIARA RACHMA 1 32.500
100 1301K0210215X000100 1001011247561 DIAH UTARI, A.MD. P 32.500
101 1301K0210215X000101 1011011247562 BENNI EKO ARIBOWO, A.MD. S 32.500
102 1301K0210215X000102 1041011246079 NURKHAYANI 1 32.500
103 1301K0210215X000103 1001011279702 SUDJONO. P 32.500
104 1301K0210215X000105 1011011248719 SUTARTI I 49.000
105 1301K0210215X000106 1051011251122 FINAHARI RAHMADANYA 2 111.500
106 1301K0210215X000107 1001011251058 SUPRAYITNO P 32.500
107 1301K0210215X000108 1011011279703 NY.UMAIYAH I 32.500
108 1301K0210215X000109 1011011268969 DJUWARNING I 32.500
109 1301K0210215X000110 1011014210979 SITI NAFSIYAH I 39.500
110 1301K0210215X000111 1001011280286 CHURIYATI P 32.500
111 1301K0210215X000112 1011011267171 YULIANI I 15.000
112 1301K0210215X000113 1001011250891 SURYONO P 32.500
113 1301K0210215X000114 1041011252021 NAUFAL ZAYD ABDURRAHMAN 1 32.500
114 1301K0210215X000115 1061011248737 KARISMA TRI WAHYUNI 3 32.500
115 1301K0210215X000116 1001011248461 UMU FAROKHAH, SE P 32.500
116 1301K0210215X000117 1011011248708 ISTIANAH I 32.500
Lampiran FPK; page 3 of 4; printed 3/2/2015 4:06:16 AM
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117 1301K0210215X000118 1011011267171 YULIANI I 79.500
118 1301K0210215X000119 1051011246677 SHABINA M. 2 32.500
119 1301K0210215X000120 1001011278958 SANTOSO, SH. P 32.500
120 1301K0210215X000121 1051011242302 ANNISA AGUSTI ANDINI 2 32.500
121 1301K0210215X000122 1051011246025 ARYA PUTRA KURNIAWAN 2 32.500
122 1301K0210215X000123 1051011259402 KHANAN AYESHA 2 79.500
123 1301K0210215X000124 1011011259407 RATNA FAUSIAH I 32.500
124 1301K0210215X000125 1051011253664 ALISHA AYUNINDYA 2 32.500
125 1301K0210215X000126 1041011253663 NAFISA ALSYAFANI 1 32.500
126 1301K0210215X000127 1051011250615 LOUIS YOSEPHIN SANTOSO 2 32.500
127 1301K0210215X000128 1011011250611 DWI HARIJANTI I 32.500
128 1301K0210215X000129 1011011265224 MUJAYANAH I 74.500
129 1301K0210215X000130 1001011248742 TJATUR RACHMAN SALFATAH, A.MD P 79.500
130 1301K0210215X000131 1041011242424 PRIMO RAJENDRA PRAYOGA 1 32.500
131 1301K0210215X000132 1051011249928 VIRA FIRNANDA 1 32.500
132 1301K0210215X000133 1011011249924 MUNTIANI I 32.500
133 1301K0210215X000134 1001011250801 LASIARA, SE P 32.500
Total 6.005.500
Lampiran FPK; page 4 of 4; printed 3/2/2015 4:06:16 AM