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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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