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<html>
<head><link href="fileakunbayar.css" rel="stylesheet" type="text/css" /><table width='100%' border='0' align='center' cellpadding='3px' cellspacing='0' class='tbl_form'><tr class='isi2'><td valign='top' align='center'><font size='4' face='Tahoma'>RS SIMRS KHANZA</font><br>GUWOSARI, Pajangan, Bantul<br>Hp: 08562675039, 085296559963, E-mail : khanzasoftmedia@gmail.com<br><br><font size='2' face='Tahoma'>REKAP BIAYA PENDAFTARAN<br>TANGGAL 22-02-2001 s.d. 22-02-2023<br><br></font></td></tr></table>
</head>
<body>
<table width="1300px" border="0" align="left" cellpadding="3px" cellspacing="0" class="tbl_form">
<tr class="head">
<td valign="middle" bgcolor="#FFFAF8" align="center" rowspan="2" width="27px">
No.
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center" rowspan="2" width="80px">
Tgl.Periksa
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center" rowspan="2" width="170px">
Nama Pasien
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center" rowspan="2" width="110px">
NIK
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center" rowspan="2" width="250px">
Alamat
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center" rowspan="2" width="90px">
No.RM
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center" rowspan="2" width="90px">
Diagnosis
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center" colspan="3" width="300px">
Cara Bayar
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center" rowspan="2" width="90px">
Biaya
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center" rowspan="2" width="60px">
Status
</td>
</tr>
<tr class="head">
<td valign="middle" bgcolor="#FFFAF8" align="center" width="100px">
-
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center" width="100px">
Asuransi Astra Aviva Life
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center" width="100px">
UMUM
</td>
</tr>
<tr class="isi">
<td valign="middle" align="center">
1
</td>
<td valign="middle" align="center">
2022-08-09
</td>
<td valign="middle" align="left">
DEWI EKAWATI
</td>
<td valign="middle" align="center">
9201394901000008
</td>
<td valign="middle" align="left">
ALAMAT, TUNGGULREJO, GRABAG, KABUPATEN PURWOREJO, JAWA TENGAH
</td>
<td valign="middle" align="center">
000002
</td>
<td valign="middle" align="left">
I50.0 Congestive heart failure
</td>
<td valign="middle" align="center">
1
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
10,000
</td>
<td valign="middle" align="center">
Ralan
</td>
</tr>
<tr class="isi">
<td valign="middle" align="center">
2
</td>
<td valign="middle" align="center">
2022-08-10
</td>
<td valign="middle" align="left">
WINDIARTO
</td>
<td valign="middle" align="center">
9104223107000004
</td>
<td valign="middle" align="left">
123, GUWOSARI, PAJANGAN, KABUPATEN BANTUL, DI YOGYAKARTA
</td>
<td valign="middle" align="center">
1402
</td>
<td valign="middle" align="left">
</td>
<td valign="middle" align="center">
1
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
10,000
</td>
<td valign="middle" align="center">
Ralan
</td>
</tr>
<tr class="isi">
<td valign="middle" align="center">
3
</td>
<td valign="middle" align="center">
2022-08-10
</td>
<td valign="middle" align="left">
DEPIYANTO
</td>
<td valign="middle" align="center">
9104224606000005
</td>
<td valign="middle" align="left">
ALAMAT, -, -, -, -
</td>
<td valign="middle" align="center">
000004
</td>
<td valign="middle" align="left">
</td>
<td valign="middle" align="center">
1
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
0
</td>
<td valign="middle" align="center">
Ralan
</td>
</tr>
<tr class="isi">
<td valign="middle" align="center">
4
</td>
<td valign="middle" align="center">
2022-08-10
</td>
<td valign="middle" align="left">
ROBY ALAMSYAH
</td>
<td valign="middle" align="center">
9201076001000007
</td>
<td valign="middle" align="left">
ALAMAT, KROGOWANAN, SAWANGAN, KABUPATEN MAGELANG, JAWA TENGAH
</td>
<td valign="middle" align="center">
000005
</td>
<td valign="middle" align="left">
</td>
<td valign="middle" align="center">
1
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
10,000
</td>
<td valign="middle" align="center">
Ralan
</td>
</tr>
<tr class="isi">
<td valign="middle" align="center">
5
</td>
<td valign="middle" align="center">
2022-08-12
</td>
<td valign="middle" align="left">
WINDIARTO
</td>
<td valign="middle" align="center">
9104223107000004
</td>
<td valign="middle" align="left">
123, GUWOSARI, PAJANGAN, KABUPATEN BANTUL, DI YOGYAKARTA
</td>
<td valign="middle" align="center">
1402
</td>
<td valign="middle" align="left">
I50.1 Left ventricular failure
</td>
<td valign="middle" align="center">
1
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
0
</td>
<td valign="middle" align="center">
Ralan
</td>
</tr>
<tr class="isi">
<td valign="middle" align="center">
6
</td>
<td valign="middle" align="center">
2022-08-13
</td>
<td valign="middle" align="left">
ROBY ALAMSYAH
</td>
<td valign="middle" align="center">
9201076001000007
</td>
<td valign="middle" align="left">
ALAMAT, KROGOWANAN, SAWANGAN, KABUPATEN MAGELANG, JAWA TENGAH
</td>
<td valign="middle" align="center">
000005
</td>
<td valign="middle" align="left">
A01.0 Typhoid fever
</td>
<td valign="middle" align="center">
1
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
0
</td>
<td valign="middle" align="center">
Ralan
</td>
</tr>
<tr class="isi">
<td valign="middle" align="center">
7
</td>
<td valign="middle" align="center">
2022-08-18
</td>
<td valign="middle" align="left">
ROBY ALAMSYAH
</td>
<td valign="middle" align="center">
9201076001000007
</td>
<td valign="middle" align="left">
ALAMAT, KROGOWANAN, SAWANGAN, KABUPATEN MAGELANG, JAWA TENGAH
</td>
<td valign="middle" align="center">
000005
</td>
<td valign="middle" align="left">
</td>
<td valign="middle" align="center">
1
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
0
</td>
<td valign="middle" align="center">
Ralan
</td>
</tr>
<tr class="isi">
<td valign="middle" align="center">
8
</td>
<td valign="middle" align="center">
2022-08-24
</td>
<td valign="middle" align="left">
DEWI EKAWATI
</td>
<td valign="middle" align="center">
9201394901000008
</td>
<td valign="middle" align="left">
ALAMAT, TUNGGULREJO, GRABAG, KABUPATEN PURWOREJO, JAWA TENGAH
</td>
<td valign="middle" align="center">
000002
</td>
<td valign="middle" align="left">
K30 Dyspepsia
</td>
<td valign="middle" align="center">
1
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
10,000
</td>
<td valign="middle" align="center">
Ralan
</td>
</tr>
<tr class="isi">
<td valign="middle" align="center">
9
</td>
<td valign="middle" align="center">
2022-08-24
</td>
<td valign="middle" align="left">
ROBY ALAMSYAH
</td>
<td valign="middle" align="center">
9201076001000007
</td>
<td valign="middle" align="left">
ALAMAT, KROGOWANAN, SAWANGAN, KABUPATEN MAGELANG, JAWA TENGAH
</td>
<td valign="middle" align="center">
000005
</td>
<td valign="middle" align="left">
I50.0 Congestive heart failure
</td>
<td valign="middle" align="center">
1
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
0
</td>
<td valign="middle" align="center">
Ralan
</td>
</tr>
<tr class="isi">
<td valign="middle" align="center">
10
</td>
<td valign="middle" align="center">
2022-08-25
</td>
<td valign="middle" align="left">
DEWI EKAWATI
</td>
<td valign="middle" align="center">
9201394901000008
</td>
<td valign="middle" align="left">
ALAMAT, TUNGGULREJO, GRABAG, KABUPATEN PURWOREJO, JAWA TENGAH
</td>
<td valign="middle" align="center">
000002
</td>
<td valign="middle" align="left">
I50.0 Congestive heart failure
</td>
<td valign="middle" align="center">
1
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
0
</td>
<td valign="middle" align="center">
Ralan
</td>
</tr>
<tr class="isi">
<td valign="middle" align="center">
11
</td>
<td valign="middle" align="center">
2022-08-29
</td>
<td valign="middle" align="left">
DEWI EKAWATI
</td>
<td valign="middle" align="center">
9201394901000008
</td>
<td valign="middle" align="left">
ALAMAT, TUNGGULREJO, GRABAG, KABUPATEN PURWOREJO, JAWA TENGAH
</td>
<td valign="middle" align="center">
000002
</td>
<td valign="middle" align="left">
</td>
<td valign="middle" align="center">
1
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
10,000
</td>
<td valign="middle" align="center">
Ranap
</td>
</tr>
<tr class="isi">
<td valign="middle" align="center">
12
</td>
<td valign="middle" align="center">
2022-09-05
</td>
<td valign="middle" align="left">
WINDIARTO
</td>
<td valign="middle" align="center">
9104223107000004
</td>
<td valign="middle" align="left">
123, GUWOSARI, PAJANGAN, KABUPATEN BANTUL, DI YOGYAKARTA
</td>
<td valign="middle" align="center">
1402
</td>
<td valign="middle" align="left">
</td>
<td valign="middle" align="center">
1
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
0
</td>
<td valign="middle" align="center">
Ralan
</td>
</tr>
<tr class="isi">
<td valign="middle" align="center">
13
</td>
<td valign="middle" align="center">
2022-09-05
</td>
<td valign="middle" align="left">
DEPIYANTO
</td>
<td valign="middle" align="center">
9104224606000005
</td>
<td valign="middle" align="left">
ALAMAT, -, -, -, -
</td>
<td valign="middle" align="center">
000004
</td>
<td valign="middle" align="left">
</td>
<td valign="middle" align="center">
1
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
0
</td>
<td valign="middle" align="center">
Ralan
</td>
</tr>
<tr class="isi">
<td valign="middle" align="center">
14
</td>
<td valign="middle" align="center">
2022-09-05
</td>
<td valign="middle" align="left">
DEWI EKAWATI
</td>
<td valign="middle" align="center">
9201394901000008
</td>
<td valign="middle" align="left">
ALAMAT, TUNGGULREJO, GRABAG, KABUPATEN PURWOREJO, JAWA TENGAH
</td>
<td valign="middle" align="center">
000002
</td>
<td valign="middle" align="left">
I50.0 Congestive heart failure
</td>
<td valign="middle" align="center">
1
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
0
</td>
<td valign="middle" align="center">
Ralan
</td>
</tr>
<tr class="isi">
<td valign="middle" align="center">
15
</td>
<td valign="middle" align="center">
2022-09-06
</td>
<td valign="middle" align="left">
WINDIARTO
</td>
<td valign="middle" align="center">
9104223107000004
</td>
<td valign="middle" align="left">
123, GUWOSARI, PAJANGAN, KABUPATEN BANTUL, DI YOGYAKARTA
</td>
<td valign="middle" align="center">
1402
</td>
<td valign="middle" align="left">
</td>
<td valign="middle" align="center">
1
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
0
</td>
<td valign="middle" align="center">
Ralan
</td>
</tr>
<tr class="isi">
<td valign="middle" align="center">
16
</td>
<td valign="middle" align="center">
2022-09-06
</td>
<td valign="middle" align="left">
DEWI EKAWATI
</td>
<td valign="middle" align="center">
9201394901000008
</td>
<td valign="middle" align="left">
ALAMAT, TUNGGULREJO, GRABAG, KABUPATEN PURWOREJO, JAWA TENGAH
</td>
<td valign="middle" align="center">
000002
</td>
<td valign="middle" align="left">
</td>
<td valign="middle" align="center">
1
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
0
</td>
<td valign="middle" align="center">
Ralan
</td>
</tr>
<tr class="isi">
<td valign="middle" align="center">
17
</td>
<td valign="middle" align="center">
2022-09-06
</td>
<td valign="middle" align="left">
ROBY ALAMSYAH
</td>
<td valign="middle" align="center">
9201076001000007
</td>
<td valign="middle" align="left">
ALAMAT, KROGOWANAN, SAWANGAN, KABUPATEN MAGELANG, JAWA TENGAH
</td>
<td valign="middle" align="center">
000005
</td>
<td valign="middle" align="left">
</td>
<td valign="middle" align="center">
1
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
0
</td>
<td valign="middle" align="center">
Ralan
</td>
</tr>
<tr class="isi">
<td valign="middle" align="center">
18
</td>
<td valign="middle" align="center">
2022-09-08
</td>
<td valign="middle" align="left">
WINDIARTO
</td>
<td valign="middle" align="center">
9104223107000004
</td>
<td valign="middle" align="left">
123, GUWOSARI, PAJANGAN, KABUPATEN BANTUL, DI YOGYAKARTA
</td>
<td valign="middle" align="center">
1402
</td>
<td valign="middle" align="left">
</td>
<td valign="middle" align="center">
1
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
10,000
</td>
<td valign="middle" align="center">
Ralan
</td>
</tr>
<tr class="isi">
<td valign="middle" align="center">
19
</td>
<td valign="middle" align="center">
2022-09-08
</td>
<td valign="middle" align="left">
ROBY ALAMSYAH
</td>
<td valign="middle" align="center">
9201076001000007
</td>
<td valign="middle" align="left">
ALAMAT, KROGOWANAN, SAWANGAN, KABUPATEN MAGELANG, JAWA TENGAH
</td>
<td valign="middle" align="center">
000005
</td>
<td valign="middle" align="left">
</td>
<td valign="middle" align="center">
1
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
10,000
</td>
<td valign="middle" align="center">
Ralan
</td>
</tr>
<tr class="isi">
<td valign="middle" align="center">
20
</td>
<td valign="middle" align="center">
2022-09-09
</td>
<td valign="middle" align="left">
WINDIARTO
</td>
<td valign="middle" align="center">
9104223107000004
</td>
<td valign="middle" align="left">
123, GUWOSARI, PAJANGAN, KABUPATEN BANTUL, DI YOGYAKARTA
</td>
<td valign="middle" align="center">
1402
</td>
<td valign="middle" align="left">
</td>
<td valign="middle" align="center">
1
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
10,000
</td>
<td valign="middle" align="center">
Ralan
</td>
</tr>
<tr class="isi">
<td valign="middle" align="center">
21
</td>
<td valign="middle" align="center">
2022-09-09
</td>
<td valign="middle" align="left">
ROBY ALAMSYAH
</td>
<td valign="middle" align="center">
9201076001000007
</td>
<td valign="middle" align="left">
ALAMAT, KROGOWANAN, SAWANGAN, KABUPATEN MAGELANG, JAWA TENGAH
</td>
<td valign="middle" align="center">
000005
</td>
<td valign="middle" align="left">
</td>
<td valign="middle" align="center">
1
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
10,000
</td>
<td valign="middle" align="center">
Ralan
</td>
</tr>
<tr class="isi">
<td valign="middle" align="center">
22
</td>
<td valign="middle" align="center">
2022-09-13
</td>
<td valign="middle" align="left">
ROBY ALAMSYAH
</td>
<td valign="middle" align="center">
9201076001000007
</td>
<td valign="middle" align="left">
ALAMAT, KROGOWANAN, SAWANGAN, KABUPATEN MAGELANG, JAWA TENGAH
</td>
<td valign="middle" align="center">
000005
</td>
<td valign="middle" align="left">
I50.0 Congestive heart failure
</td>
<td valign="middle" align="center">
1
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
0
</td>
<td valign="middle" align="center">
Ralan
</td>
</tr>
<tr class="isi">
<td valign="middle" align="center">
23
</td>
<td valign="middle" align="center">
2022-09-13
</td>
<td valign="middle" align="left">
DEPIYANTO
</td>
<td valign="middle" align="center">
9104224606000005
</td>
<td valign="middle" align="left">
ALAMAT, -, -, -, -
</td>
<td valign="middle" align="center">
000004
</td>
<td valign="middle" align="left">
</td>
<td valign="middle" align="center">
1
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
0
</td>
<td valign="middle" align="center">
Ralan
</td>
</tr>
<tr class="isi">
<td valign="middle" align="center">
24
</td>
<td valign="middle" align="center">
2022-09-13
</td>
<td valign="middle" align="left">
WINDIARTO
</td>
<td valign="middle" align="center">
9104223107000004
</td>
<td valign="middle" align="left">
123, GUWOSARI, PAJANGAN, KABUPATEN BANTUL, DI YOGYAKARTA
</td>
<td valign="middle" align="center">
1402
</td>
<td valign="middle" align="left">
</td>
<td valign="middle" align="center">
1
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
0
</td>
<td valign="middle" align="center">
Ralan
</td>
</tr>
<tr class="isi">
<td valign="middle" align="center">
25
</td>
<td valign="middle" align="center">
2022-09-17
</td>
<td valign="middle" align="left">
ROBY ALAMSYAH
</td>
<td valign="middle" align="center">
9201076001000007
</td>
<td valign="middle" align="left">
ALAMAT, KROGOWANAN, SAWANGAN, KABUPATEN MAGELANG, JAWA TENGAH
</td>
<td valign="middle" align="center">
000005
</td>
<td valign="middle" align="left">
</td>
<td valign="middle" align="center">
1
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
0
</td>
<td valign="middle" align="center">
Ralan
</td>
</tr>
<tr class="isi">