Digital Claim System

OUTPATIENT REGISTRATION

Card Number : 8887770001831857 Cashier ID : Kemangmc

Polis Number : BUKA01 Transaction Date : 20/8/2019 18:59:53
Member Name : NOURA SALIMA Marchant ID : FP08646
Company Name : PT BUKALAPAK.COM Trace No : 2019720218594920
Card Expired Date : 12/2019

BENEFIT LIST

NO BENEFIT LIMIT NO BENEFIT LIMIT

1 Admin SP IDR 928.973.700 19 Vac - Basic Package IDR 928.973.700
2 Admin GP IDR 928.973.700 20 Vac - HepA IDR 928.973.700
3 Pharmacy IDR 928.973.700 21 Vac - HepB IDR 928.973.700
4 Diagnostic - ECG IDR 928.973.700 22 Vac - Herpes IDR 928.973.700
5 Diagnostic - USG IDR 928.973.700 23 Vac - HIB IDR 928.973.700
6 Specialist IDR 928.973.700 24 Vac - HPV IDR 928.973.700
7 General Physician IDR 928.973.700 25 Vac - Basic - Infantrix IDR 928.973.700
8 General Physician + Prescribed Drugs IDR 928.973.700 26 Vac - Influenza IDR 928.973.700
9 Physiotherapy IDR 928.973.700 27 Vac - Meningococcal IDR 928.973.700
10 Family Planning - Implant KB IDR 928.973.700 28 Vac - MMR IDR 928.973.700
11 Family Planning - IUD IDR 928.973.700 29 Vac - Rabies IDR 928.973.700
12 Family Planning - Pill IDR 928.973.700 30 Vac - Rotavirus IDR 928.973.700
13 Family Planning - Sterilization IDR 928.973.700 31 Vac - Salmonella IDR 928.973.700
14 Family Planning - Injection IDR 928.973.700 32 Vac - Smallpox IDR 928.973.700
15 Lab IDR 928.973.700 33 Vac - Streptococcal IDR 928.973.700
16 Radiology IDR 928.973.700 34 Vac - Tetanus IDR 928.973.700
17 Supplement IDR 928.973.700 35 Vac - TwinRix IDR 928.973.700
18 Vaccination Combo IDR 928.973.700 36 Vac - Varicella IDR 928.973.700

Excess Internal

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Cibis Nine Building, 5th Floor

Jalan TB. Simatupang No. 2, Cilandak, Pasar Minggu, RT.13/RW.5, Cilandak Timur
Ps. Minggu, Kota Jakarta Selatan, Daerah Khusus Ibukota Jakarta 12560