Rekapitulasi Pelayanan.docx
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REKAPITULASI PELAYANAN PROTHESA GIGI PUSKESMAS JETIS II BULAN...........TAHUN...........
NO
NAMA PASIEN
NOMOR PESERTA
ALAMAT
NO.TELEPON
TGL PELAYANAN
JUMLAH GIGI
BESARAN TARIF PAKET
TOTAL
Catatan: Pengajuan klaim non kapitasi disertai: 1. Kwitansi bermeterai 2. Form Pengajuan klaim
Jetis,......./......../.......... Kepala Puskesmas Jetis II
( )
NO
NAMA PASIEN
NOMOR PESERTA
ALAMAT
NO.TELEPON
TGL PELAYANAN
JUMLAH GIGI
BESARAN TARIF PAKET
TOTAL
Catatan: Pengajuan klaim non kapitasi disertai: 1. Kwitansi bermeterai 2. Form Pengajuan klaim
Jetis,......./......../.......... Kepala Puskesmas Jetis II
( )
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