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  • 8/17/2019 Form Migrasi 34

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    FORMAT MIGRASI 34 KOLOM BPJS KESEHATAN

    No No KK NIK/KITAS/KITAP Nama Lengkap

    HUBKEL Tgl La!" Jen!# Kelam!n

    %%/mm/''''

    ( ) 3 4 * + , - . (

    Wajib di isi Wajib di isi Wajib di isi Wajib di isi Wajib di isi Wajib di isi Wajib d

    1 7405020000000001 7405032909670001 Adi Suriyono 1 Parepare 31/12/1952 1 2 Bacukik

    2 7405020000000001 740503450670001 #u% Su&ia'i 3 Parepare 12/05/195 2 2 Bacukik

    3 7402020000000001 740503110160003 Supriya'no 4 Parepare 30/12/1990 1 1 Bacukik

    No No KK NIK/KITAS/KITAP Nama Lengkap

    HUBKEL Tgl La!" Jen!# Kelam!n

    %%/mm/''''

    ( ) 3 4 * + , - . (

    Wajib di isi Wajib di isi Wajib di isi Wajib di isi Wajib di isi Wajib di isi Wajib d

    1 Peser'a A 1

    2 )s'ri A 3

    3 Anak A 4

    4 Anak A 4

    5 Peser'a B 1

    6 )s'ri B 3

    7 Anak B 4

    Ke0e"angan Peng!#!an1

    KOLOM KETERANGAN

    *o+o& 2 Wajib di isi ,o *ar'u *e+uar-a

    *o+o& 3 Wajib di isi ,o&or ,)*/*.P ,o&or ,)* ada ju-a pada *ar'u *e+uar-a

    *o+o& 4 Wajib di isi ,a&a 'idak bo+e% &e&akai e+ar 'anda    dan 'anda    karak'er &aksi&a

    *o+o& 5 Wajib di isi arus di isi den-an an-k ( Pe#e"0a 2P 1Angka (

    ) Sam! 2S 1 Angka )

    3 I#0"! 2I 1 Angka 3 4 Anak 2A 1 Angka 4

    * Tanggngan 2T1 Angka *

    S0a0# )a5!n

    Alama Temp T!ngg

    ( 8 P ) 8 S 3 8 I 4 8 A * 8 T

    Tempa0 La!"

    (8Lak!lak! )8Pe"empan

    (8BK9 )8K9 38:H9 48:M * 8 T&K TAU

    Wajib di isi

    Wajib di isi

    S0a0# )a5!n

    Alama Temp T!ngg

    ( 8 P ) 8 S 3 8 I

    4 8 A * 8 T

    Tempa0

    La!"

    (8Lak!lak!

    )8Pe"empan

    (8BK9 )8K9 38:H9

    48:M* 8 T&K TAU

    Wajib di isi

    Wajib di isi

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    *o+o& 6 Wajib di isi .idak bo+e% &e&akai 'anda    dan 'anda   

    *o+o& 7 Wajib di isi 12/31/1990

    *o+o&  Wajib di isi arus di isi den-an an-ka

    *o+o& 9 Wajib di isi arus di isi den-an an-k ( BK 1 Belm Ka5!n

    ) K 1 Ka5!n

    3 :H 1 :e"a! H!%p

    4 :M 1 :e"a! Ma0!

    *o+o& 10 Wajib di isi i isi den-an a+a&a' +en-kap

    *o+o& 11 Wajib di isi arus di isi den-an an-ka 3 di-i' 001

    *o+o& 12 Wajib di isi arus di isi den-an an-ka 3 di-i' 001

    *o+o& 14 Wajib di isi i isi sesuai den-an or&a' dari BP8S

    *o+o& 15 Wajib di isi i isi sesuai den-an or&a' dari BP8S

    *o+o& 16 Wajib di isi i isi sesuai den-an or&a' dari BP8S

    *o+o& 17 Wajib di isi i isi sesuai den-an or&a' dari BP8S

    *o+o& 1 Wajib di isi i isi sesuai den-an or&a' dari BP8S 1 8ika Peser'a &e&i+i% *+inik a'au Puskes&a

    *o+o& 19 Wajib di isi i isi sesuai den-an or&a' dari BP8S

    *o+o& 20 Wajib di isi i isi sesuai den-an or&a' dari BP8S 2 8ika Peser'a &e&i+i% ok'er *e+uar-a *o+

    *o+o& 21 Wajib di isi i isi sesuai den-an or&a' dari BP8S

    a'a peser'a diisi beruru'an : peser'a is'ri/sua&i anak 1 anak 2 anak 3 +a+u di+anju'kan d peser'a +ain dan an--o'a ke+uar-anya dan se'erusnya

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    Ema!l NPP Ja;a0an S0a0#

    (. ) )( )) )3 )4 )* )+ ), )- ). 3

    !akessi

    !akessi

    !akessi

    Ema!l NPP Ja;a0an

    S0a0#

    (. ) )( )) )3 )4 )* )+ ), )- ). 3

    Nama Fa#ke#

    Tk7I

    Ko%e Fa#ke# &ok0e"

    G!g!

    Nama Fa#ke# &ok0e"

    G!g!

    Nomo" Telepon Pe#e"0a

    Kela# Ra5a0

    TMT Ke"

    Ga

    Tn

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    FORM MIGRASI PESERTA

     JENIS PESERTA

    NAMA INSTANSI/BA&AN/PERUSAHAAN

    KO&E ?IRTUAL A::OUNT

    BANK TEMPAT PEMBA@ARAN IURAN

    TANGGAl REGISTRASI

    NOMOR PKS

    KO&E PKS

    MASA BERLAKU

    KO&E TANGGUNGAN

    KO&E K:

    KO&E &ATI)

    No No KK NIK/KITAS/KITAP Nama Lengkap

    ( ) 3 4

    1 7311020701100004 7311020603380001 ABD RASUL

    2 7311020701100004 7311024712430002 I DIMENG

    3 7311021511100032 7311024308760002 YUSRIANI

    4 7311021511100032 7311023107010003 MUH IKHSAN M

    5 7311021511100032 7311026612020003 SUCI RAMADANI M

    6 7311021511100032 7311024412120002 ADINDA BALQIS SYAM

    7 7311020808150001 7311025810900001 NURUL AZIZAH 8 7311022901052855 7311025209870005 RAFIKA

    9 7311022901052855 7311027004060002 NAURA KEYZA ALSAHARA

    10 7311021809100006 7311026311930001 EKA LESTARIY ANAR

    11 7311020201120005 7311021506980002 SAIDUL

    12 7311020412140003 7311024611660001 ST FATIMAH

    13 7311020412140003 7311025305850003 ARFIAH YUNUS

    14 7311021904110005 7311021108700001 AMIRUDDIN

    15 7311021904110005 7311026512730002 SYAMSINAR ARSYAD

    16 7311021904110005 7311022809990001 MUHAMMAD FADHIL

    17 7311021904110005 7311020104010002 MUHAMMAD FARID

    18 7311021904110005 7311021903080001 HAIRUL MUNZIL

    19 7311022901055364 7311021212770006 AHMAD

    20 7311022901055364 7311024707780001 RAHMAATI

    21 7311022901055364 7311020510970002 ADE FAHRUL

    22 7311022901055364 7311025508020001 !UTRI AULIA

    23 7311022901055364 7311024308080001 NABILA ALZAHRA

    24 7311021106120001 7311020107640001 K"MB"NG

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    25 7311021106120001 7311025508730002 RUSMIATI

    26 7311021106120001 7311022505990002 ANUGRAHA EGI !RATAMA

    27 7311022506120024 7311023112500045 ARSYAD

    28 7311022506120024 7311027112560017 NASRI

    29 7311022411140003 7311072608820001 SYAIFUDDIN

    30 7311022411140003 7311026308800001 SADRIANI

    31 7311022411140003 7311026107150001 SAMIRAH SA#IDAH

    32 7311022907110005 7311025005470001 FATIMAH

    33 7311022907110005 7311025703700001 #UHAENA

    34 7311022907110005 7311020511810001 MASKUR

    35 7311022907110005 7311024912900001 NURLINA

    36 7311022907110005 7311024107560009 MASIA

    37 7311022901055622 7311022707550001 LA D"L"

    38 7311022901055622 7311027112550032 #UNAEDA

    39 7311020109120021 7311020101460001 SA!!E

    40 7311020109120021 7311026104560002 #AARIAH

    41 7311020109120021 7311024510990001 SEL!IANA

    42 7311020109120021 7311024508620002 MATAHARI

    43 7311022901055626 7311023112270005 SAMADE

    44 7311022901055626 7311027108300001 NAISA

    45 7311022901055626 7311024107480019 I MASE

    46 7311022901055626 7311026001700001 #UMAEDAH

    47 7311022901055626 7311021112850002 BAHRI

    48 7311022901053658 7311021504570001 ZAINUDDIN

    49 7311022901053658 7311026005580001 ST RILLAH

    50 7311022901053658 7311022610930002 IRHAMSYAH 51 7311022209120029 7311023112550035 ABD KADIR

    52 7311022209120029 7311025611620001 HALIMA

    53 7311022209120029 7311025903910001 SALMIAH

    54 7311022209120029 7311022110920001 ISMAIL

    55 7311022901052225 7311023112580017 M KASIM

    56 7311022901052225 7311027112680039 !AASIAH

    57 7311022901052225 7311023112700038 AGUSTAN

    58 7311022901052225 7311020102920002 KAMARUDDIN

    59 7311022901052225 7311026004980002 MUSFIRA

    60 7311022901052228 7311020112600001 MASSERE

    61 7311022901052228 7311025710640001 ATI

    62 7311022901052228 7311022308920004 AGUS

    63 7311022901052228 7311022110050001 SAHRUL

    64 7311022901052228 7311026108070001 II AGUSTINA

    65 7311022901052228 7311023112450017 DALLU

    66 7311020703120003 7311020507450002 ALIMIN

    67 7311020703120003 7311026008120001 SAKINAH

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    68 7311022901053577 7311022112080003 SYAIFUL

    69 7311021910150002 7311031603920005 SYAALUDDIN

    70 7311021004120007 7311023012820001 HERMAN

    71 7311021004120007 7311025010880005 NUR HIKMAH

    72 7311021004120007 7311024207110002 HERMALIA !UTRI

    73 7311021910150002 7311021009150001 AL FIRSYAH

    74 7311021607140001 7311020505710008 AMIR

    75 7311021607140001 7311024307830001 MASTURA

    76 7311021607140001 7311021807020001 ASAR

    77 7311021607140001 7311022403080002 RAYHAN

    78 7311022812130005 7604040512880001 RISAL

    79 7311022812130005 7311022004130001 MUHAMMAD RIFQI

    80 7311020511100010 7311025801060002 RIKA

    81 7311022906100020 7311024508700007 ARTATI

    82 7311022901053081 7311023112660019 SYAMSUL

    83 7311022901053081 7311027112650035 HABIBA

    84 7311022901053081 7311020909920002 ERIN

    85 7311022901053081 7311022911940001 SYAHRIL

    86 7311021710110015 7311020201670005 ISMAIL

    87 7311021710110015 7311024112740001 MARDIANA

    88 7311021710110015 7311020112960001 ISHAK

    89 7311021710110015 7311021903000001 ILHAM

    90 7311021710110015 7311026307110001 ISYAHRINI

    91 7311021711150005 7310090107940092 U!I

    92 7311021105100005 7311023112120001 AHMAD GUNADI UMAR

    93 7311022901