diff --git a/app/components/app/sep/entry-form.vue b/app/components/app/sep/entry-form.vue
index b336eaf1..70e5ba7e 100644
--- a/app/components/app/sep/entry-form.vue
+++ b/app/components/app/sep/entry-form.vue
@@ -26,6 +26,7 @@ const props = defineProps<{
   doctors: any[]
   diagnoses: any[]
   facilities: any[]
+  supportCodes: any[]
   patient?: PatientEntity | null | undefined
   values?: any
 }>()
@@ -43,12 +44,6 @@ const admissionTypes = [
   { value: '2', label: 'Rujukan' },
 ]
 
-const items = [
-  { value: 'item-1', label: 'Item 1' },
-  { value: 'item-2', label: 'Item 2' },
-  { value: 'item-3', label: 'Item 3' },
-]
-
 // Validation schema (moved to shared file)
 const { handleSubmit, errors, defineField, meta } = useForm<IntegrationBpjsFormData>({
   validationSchema: toTypedSchema(IntegrationBpjsSchema),
@@ -69,8 +64,10 @@ const [attendingDoctor, attendingDoctorAttrs] = defineField('attendingDoctor')
 const [initialDiagnosis, initialDiagnosisAttrs] = defineField('initialDiagnosis')
 const [cob, cobAttrs] = defineField('cob')
 const [cataract, cataractAttrs] = defineField('cataract')
+const [clinicExcecutive, clinicExcecutiveAttrs] = defineField('clinicExcecutive')
 const [procedureType, procedureTypeAttrs] = defineField('procedureType')
 const [supportCode, supportCodeAttrs] = defineField('supportCode')
+const [note, noteAttrs] = defineField('note')
 
 // Submit handler
 const onSubmit = handleSubmit((values) => {
@@ -313,23 +310,23 @@ watch(props, (value) => {
           </Label>
           <Field :errMessage="errors.cob">
             <RadioGroup
-              v-model="cob"
+              v-model="clinicExcecutive"
+              v-bind="clinicExcecutiveAttrs"
               class="flex items-center gap-2"
-              v-bind="cobAttrs"
             >
               <div class="flex items-center space-x-2">
                 <RadioGroupItem
                   value="yes"
-                  id="cob-yes"
+                  id="clinicExcecutive-yes"
                 />
-                <Label for="cob-yes">Ya</Label>
+                <Label for="clinicExcecutive-yes">Ya</Label>
               </div>
               <div class="flex items-center space-x-2">
                 <RadioGroupItem
                   value="no"
-                  id="cob-no"
+                  id="clinicExcecutive-no"
                 />
-                <Label for="cob-no">Tidak</Label>
+                <Label for="clinicExcecutive-no">Tidak</Label>
               </div>
             </RadioGroup>
           </Field>
@@ -350,7 +347,7 @@ watch(props, (value) => {
               placeholder="Pilih DPJP"
               search-placeholder="Cari DPJP"
               empty-message="Item tidak ditemukan"
-               @update:searchText="emit('fetch', { menu: 'attendingDoctor', value: $event })"
+              @update:searchText="emit('fetch', { menu: 'attendingDoctor', value: $event })"
             />
           </Field>
         </Cell>
@@ -379,7 +376,7 @@ watch(props, (value) => {
       <Block
         labelSize="thin"
         class="!pt-0"
-        :colCount="1"
+        :colCount="2"
         :cellFlex="false"
       >
         <Cell>
@@ -387,6 +384,8 @@ watch(props, (value) => {
           <Field>
             <Textarea
               id="note"
+              v-model="note"
+              v-bind="noteAttrs"
               class="h-[200px] w-full border-gray-400 bg-white"
               placeholder="Masukkan catatan opsional"
               :disabled="isLoading || isReadonly"
@@ -402,8 +401,8 @@ watch(props, (value) => {
           <Field :errMessage="errors.cob">
             <RadioGroup
               v-model="cob"
-              class="flex items-center gap-2"
               v-bind="cobAttrs"
+              class="flex items-center gap-2"
             >
               <div class="flex items-center space-x-2">
                 <RadioGroupItem
@@ -431,8 +430,8 @@ watch(props, (value) => {
           <Field :errMessage="errors.cataract">
             <RadioGroup
               v-model="cataract"
-              class="flex items-center gap-2"
               v-bind="cataractAttrs"
+              class="flex items-center gap-2"
             >
               <div class="flex items-center space-x-2">
                 <RadioGroupItem
@@ -465,14 +464,14 @@ watch(props, (value) => {
             >
               <div class="flex items-center space-x-2">
                 <RadioGroupItem
-                  value="procedure-one"
+                  value="0"
                   id="procedure-one"
                 />
                 <Label for="procedure-one">Prosedur tidak berkelanjutan</Label>
               </div>
               <div class="flex items-center space-x-2">
                 <RadioGroupItem
-                  value="procedure-two"
+                  value="1"
                   id="procedure-two"
                 />
                 <Label for="procedure-two">Prosedur dan terapi berkelanjutan</Label>
@@ -499,7 +498,7 @@ watch(props, (value) => {
               icon-name="i-lucide-chevron-down"
               v-model="supportCode"
               v-bind="supportCodeAttrs"
-              :items="items"
+              :items="supportCodes"
               :disabled="isLoading || isReadonly"
               placeholder="Pilih Kode Penunjang"
             />
diff --git a/app/components/content/sep/entry.vue b/app/components/content/sep/entry.vue
index cc8bba0d..0a2de669 100644
--- a/app/components/content/sep/entry.vue
+++ b/app/components/content/sep/entry.vue
@@ -10,6 +10,9 @@ import type { PatientEntity } from '~/models/patient'
 import type { SepHistoryData } from '~/components/app/sep/list-cfg.history'
 import type { SepVisitData } from '~/components/app/sep/list-cfg.visit'
 
+// Constants
+import { supportCodes } from '~/lib/constants'
+
 // Services
 import { getPatientDetail, getPatients } from '~/services/patient.service'
 import { getList as getProvinceList } from '~/services/vclaim-region-province.service'
@@ -35,6 +38,7 @@ const patients = ref<Array<{ id: string; identity: string; number: string; bpjs:
 const doctors = ref<Array<{ value: string | number; label: string }>>([])
 const diagnoses = ref<Array<{ value: string | number; label: string }>>([])
 const facilities = ref<Array<{ value: string | number; label: string }>>([])
+const supportCodesList = ref<Array<{ value: string; label: string }>>([])
 const isPatientsLoading = ref(false)
 const paginationMeta = ref<PaginationMeta>({
   recordCount: 0,
@@ -203,7 +207,7 @@ function handleSaveLetter() {
   console.log('Letter dipilih:', selectedLetter.value)
 }
 
-function handleEvent(menu: string, value: string) {
+function handleEvent(menu: string, value: any) {
   if (menu === 'admission-type') {
     console.log('service-type:', value)
     return
@@ -230,7 +234,7 @@ function handleEvent(menu: string, value: string) {
     navigateTo('/integration/bpjs/sep')
   }
   if (menu === 'save-sep') {
-    createSep(createSepPayload()).then(() => {
+    createSep(createSepPayload(value)).then(() => {
       navigateTo('/integration/bpjs/sep')
     })
   }
@@ -270,6 +274,7 @@ onMounted(async () => {
   getDiagnoseReferralList().then((value) => {
     console.log('value:', value)
   })
+  supportCodesList.value = Object.keys(supportCodes).map((item) => ({ value: item.toString(), label: supportCodes[item] })) as any
 })
 </script>
 
@@ -287,6 +292,7 @@ onMounted(async () => {
     :diagnoses="diagnoses"
     :facilities="facilities"
     :patient="selectedPatientObject"
+    :support-codes="supportCodesList"
     @fetch="handleFetch"
     @event="handleEvent"
   />
diff --git a/app/schemas/integration-bpjs.schema.ts b/app/schemas/integration-bpjs.schema.ts
index ccdaf08c..207e1783 100644
--- a/app/schemas/integration-bpjs.schema.ts
+++ b/app/schemas/integration-bpjs.schema.ts
@@ -1,3 +1,4 @@
+import { not } from "@vueuse/math"
 import { z } from 'zod'
 
 const ERROR_MESSAGES = {
@@ -16,8 +17,10 @@ const ERROR_MESSAGES = {
     initialDiagnosis: 'Diagnosa Awal wajib diisi',
     cob: 'COB wajib diisi',
     cataract: 'Katarak wajib diisi',
+    clinicExcecutive: 'Klinkik eksekutif wajib diisi',
     procedureType: 'Jenis Prosedur wajib diisi',
     supportCode: 'Kode Penunjang wajib diisi',
+    note: 'Catatan wajib diisi',
   },
 }
 
@@ -58,12 +61,14 @@ const IntegrationBpjsSchema = z.object({
     .min(1, ERROR_MESSAGES.required.initialDiagnosis),
   cob: z.string({ required_error: ERROR_MESSAGES.required.cob }).min(1, ERROR_MESSAGES.required.cob),
   cataract: z.string({ required_error: ERROR_MESSAGES.required.cataract }).min(1, ERROR_MESSAGES.required.cataract),
+  clinicExcecutive: z.string({ required_error: ERROR_MESSAGES.required.clinicExcecutive }).min(1, ERROR_MESSAGES.required.clinicExcecutive),
   procedureType: z
     .string({ required_error: ERROR_MESSAGES.required.procedureType })
     .min(1, ERROR_MESSAGES.required.procedureType),
   supportCode: z
     .string({ required_error: ERROR_MESSAGES.required.supportCode })
     .min(1, ERROR_MESSAGES.required.supportCode),
+  note: z.string({ required_error: ERROR_MESSAGES.required.note }).min(1, ERROR_MESSAGES.required.note).optional(),
 })
 
 type IntegrationBpjsFormData = z.infer<typeof IntegrationBpjsSchema>
diff --git a/app/services/vclaim-sep.service.ts b/app/services/vclaim-sep.service.ts
index 900aa923..293a3f76 100644
--- a/app/services/vclaim-sep.service.ts
+++ b/app/services/vclaim-sep.service.ts
@@ -8,48 +8,54 @@ export function create(data: any) {
   return base.create(path, data, name)
 }
 
-export function createPayload() {
+export function createPayload(data: any) {
+  // "nationalId": "5617213001231231",
+  // "referralLetterNumber": "12233",
+  // "referralLetterDate": "2025-10-21",
+  // "attendingDoctor": "25107",
+
+  console.log('data:', data)
   const content = {
-    noKartu: '0001116500714',
-    tglSep: '2025-08-21',
+    noKartu: data.bpjsNumber || '',
+    tglSep: data.sepDate,
     ppkPelayanan: '1323R001',
-    jnsPelayanan: '2',
+    jnsPelayanan: data.admissionType ? String(data.admissionType) : '1',
     klsRawat: {
       klsRawatHak: '2',
       klsRawatNaik: '',
       pembiayaan: '',
       penanggungJawab: '',
     },
-    noMR: 'MR9835',
+    noMR: data.med,
     rujukan: {
       asalRujukan: '1',
       tglRujukan: '2025-08-20',
       noRujukan: 'RJKMR9835001',
       ppkRujukan: '0301R011',
     },
-    catatan: 'testinsert RI',
-    diagAwal: 'E10',
+    catatan: data.note || '',
+    diagAwal: data.initialDiagnosis || '',
     poli: {
-      tujuan: '',
-      eksekutif: '0',
+      tujuan: data.destinationClinic || '',
+      eksekutif: data.clinicExcecutive === 'yes' ? '1' : '0',
     },
     cob: {
-      cob: '0',
+      cob: data.cob === 'yes' ? '1' : '0',
     },
     katarak: {
-      katarak: '0',
+      katarak: data.cataract === 'yes' ? '1' : '0',
     },
-    tujuanKunj: '0',
-    flagProcedure: '',
-    kdPenunjang: '',
+    tujuanKunj: data.destinationClinic || '',
+    flagProcedure: data.procedureType || '',
+    kdPenunjang: data.supportCode || '',
     assesmentPel: '',
     skdp: {
       noSurat: '0208R0060825K000001',
       kodeDPJP: '6546',
     },
     dpjpLayan: '000002',
-    noTelp: '081111111101',
-    user: 'Coba Ws',
+    noTelp: data.phoneNumber || '',
+    user: data.patientName || '',
     jaminan: {
       lakaLantas: '0',
       noLP: '12345',