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Patbil Detail Dikonversi Dikonversi

1. This invoice is from Bandung Heart Clinic for outpatient services provided to patient Muhammad Firman Syah on December 7, 2021. 2. The total cost of services is Rp2,144,000 which includes a doctor's consultation fee of Rp150,000, an EKG for Rp90,000, registration fee of Rp20,000, and medicines totaling Rp1,884,000. 3. The patient has paid the full amount of Rp2,144,000 for the outpatient services.

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Farmasi Bandung Heart Clinic
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511 views1 page

Patbil Detail Dikonversi Dikonversi

1. This invoice is from Bandung Heart Clinic for outpatient services provided to patient Muhammad Firman Syah on December 7, 2021. 2. The total cost of services is Rp2,144,000 which includes a doctor's consultation fee of Rp150,000, an EKG for Rp90,000, registration fee of Rp20,000, and medicines totaling Rp1,884,000. 3. The patient has paid the full amount of Rp2,144,000 for the outpatient services.

Uploaded by

Farmasi Bandung Heart Clinic
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Jalan Buah Batu No 211

Bandung 40264
Bandung Heart Clinic Telp (022) 7303611

No. Form : FR/14.1/01


No. Rev 00

INVOICE
BIAYA PERAWATAN RAWAT JALAN
COST OF OUTPATIENT SERVICES
No. Reg / No. RM : 1001481 Dokter Utama : dr. H.M.Agus Thosin, , Sp.JP
Tanggal Masuk : Dec 7, 2021 4:03 PM Spesialisasi : Jantung
Nama Pasien : MUHAMAD FIRMAN SYAH Penunjang :
Tanggal Lahir : 09 Sep 1982
Penjamin Bayar : PRIBADI
Nama Instansi : PRIBADI

DETAIL TRANSAKSI RAWAT JALAN

RAWAT JALAN EPISODE : 17


BIAYA LAYANAN / COST OF SERVICES
NO RINCIAN LAYANAN TGL QTY SUBTOTAL TUNAI PRIBADI PENJAMIN

Jasa Dokter / Doctors Fee


KJT / Klinik Jantung
J-KJT-202112000261 BIAYA KONSULTASI 07/12/2021 1 150,000.00 150,000.00 0.00 0.00
dr.H.M.Agus Thosin , Sp.JP
Total Unit KJT / Klinik Jantung 150,000.00 150,000.00 0.00 0.00
Subtotal 150,000.00 150,000.00 0.00 0.00

Tindakan Medis / Measures of Medic


KJT / Klinik Jantung
J-KJT-202112000261 EKG 07/12/2021 1 90,000.00 90,000.00 0.00 0.00
dr.H.M.Agus Thosin , Sp.JP
Total Unit KJT / Klinik Jantung 90,000.00 90,000.00 0.00 0.00
Subtotal 90,000.00 90,000.00 0.00 0.00

Biaya Admin / Aministration Fee


KJT / Klinik Jantung
J-KJT-202112000261 PENDAFTARAN 07/12/2021 1 20,000.00 20,000.00 0.00 0.00
Total Unit KJT / Klinik Jantung 20,000.00 20,000.00 0.00 0.00
Subtotal 20,000.00 20,000.00 0.00 0.00

BIAYA OBAT / ALKES COST OF MEDICINES / MEDICAL SUPPLIES


NO RINCIAN LAYANAN TGL QTY SUBTOTAL TUNAI PRIBADI PENJAMIN

Farmasi / Pharmacy
DP1 / Instalasi Farmasi
J-DP1-202112000324 BISOPROLOL 5 MG TAB (HEXP) 07/12/2021 30 42,000.00 42,000.00 0.00 0.00
CLOTAIRE 90 MG TABLET (FRT) 07/12/2021 120 1,452,000.00 1,452,000.00 0.00 0.00
ATORVASTATIN 40 MG TAB (NVL) 07/12/2021 60 306,000.00 306,000.00 0.00 0.00
AMLODIPINE 5 MG TAB (HEXP) 07/12/2021 30 18,000.00 18,000.00 0.00 0.00
THROMBO ASPILETS TAB (DARIA) 07/12/2021 60 66,000.00 66,000.00 0.00 0.00
Total Unit DP1 / Instalasi Farmasi 1,884,000.00 1,884,000.00 0.00 0.00
Subtotal 1,884,000.00 1,884,000.00 0.00 0.00
Total Biaya RAWAT JALAN 2,144,000.00 2,144,000.00 0.00 0.00

Grand Total Rp. 2,144,000.00


Administrasi Rp. 0.00
Grand Total (Round Up) Rp. 2,144,000.00
Uang Muka Rp. 0.00
Yang Sudah Dibayar Pasien Rp. 2,144,000.00
Tagihan Yang Harus Dibayar Pasien Rp. 0.00

Terima Kasih Bandung, 07 Dec 2021


Thank You Manajer Klinik

NB : Tagihan tersebut belum termasuk biaya Materai Heru Cakra, SE


This Bill Not Include Legal Stamp

Page 1 of 1
30 December 2021, 17:21:32

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