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FORM MUTASI DATA PESERTA

JENIS PESERTANAMA INSTANSI/BADAN/PERUSAHAANKODE VIRTUAL ACCOUNTBANK TEMPAT PEMBAYARAN IURANTANGGAl REGISTRASINOMOR PKSKODE PKSMASA BERLAKUKODE TANGGUNGANKODE KC

KODE DATI2

No No KK NIK/KITAS/KITAP

1 2 3 5 6

No Kartu BPJSKesehatan

JenisMutasi

Tgl Aktif BerlakuMutasi

FORMULIR DAFTAR ISIAN MUTASI EKOLOM

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242

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Na a !engka"

Ko#e $u%Kel Tgl !ahir

Te "at !ahir ##/ /&&&& 1'! 2'P

( ) * 1+ 11

JenisKela in

1 ' Peserta2 ' Sua i3 ' Istri, ' Anak 5 ' Ta %ahan

LEKTRONIK (FDIME) FORMAT 37

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Ala at -o isili .T . Ko#e Pos Na a -es

12 13 1, 15 16 1( 1) 1* 2+

StatusKa0in

Ko#eKe a atan #iisi"etugas

Na aKe a atan

Ko#e-esa

#iisi"etugas

+'T-1'B4 2'K4

3'

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Na a askes Tk7I 8 ail NIP Ja%atan

Status

21 22 23 2, 25 26 2( 2) 2*

Ko#easkes

Tk7I

Ko#easkes

-okter9igi

Na aaskes

-okter9igi

No orTele"onPeserta

2'Kontrak43'Paruh0aktu,'Peneri

a

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Asuransi !ainn&a

No7 Kartu

3+ 31 32 33 3, 35 36 3(

Kelas.a0at

TMT Ker:aKar&7 Aktif

9a:i Pokok ; Tun:7Teta" Kar&7 Aktif

Ke0argaNegaraan

No7NP P

NoPass"ort1'Kelas I4

2'KelasII

1' NI42' NA

Na aAsuransi

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