, member of
asuransi
sinarmas formaksi
‘aed asurans hesettaninaanesa
FORMULIR XLAIM RAWAT INAP DAN RAWAT BEDAH
HOSPITAL & SURGICAL CLAIM FORM
Petunjuk Pengeluan Klsim / Guideline of Slain Sulynssin
3 Fermuir haus lengeapi ean anys Bafeku ant (1) SATU orong pasion don hare dist dengenlergkag da citrlergani olen
eset aay orang ua ka pasen cea arcane
This fom shout be earateted for ine inate ois of 1( ONE) patient only aod ma
crby Maher arent fa pati
2. Fermuirinihenisdisi dengan largkap,herer dan jee.
THis Est) Souk oe fei conety sompstey are ears
nai nctice Gueraniee lstar Claim Farm A Orginal Paget bearing tho rain 2 pion, Gate of Pesinon and wma cre
Dis clah pocerta acuraneiatou oranglue pesisn bila pasion adalah ana.
Files ty tho areipant or By he her paren form alert
DATA KARVAWAN DATA PASIEN
Tama Feaaan Tene T
Tamar Pae TemarPesara 7 |
Pot Numer Pepetoton Nobo | |
prema a Tamar ——|
Name ae Fre
Toma Fever oa = =
Tamar We Tap Taber Iie seuiouear ‘anahiGhithon
Aceress Pere i isos Netiennaae es te saci
“ike de pols asvars. Bh yang Wenn asuanel as DEaRGEN TL
Tatap arian naa PEMNSPaaG ASWTENS, Alana vo. POMS
Wanotor surance polay is covery ti ase, ices else er
ofiie Conpary, souress. era lemhone hurr
aaron a
TetalAmountet Clin
PERNVATAAN PENBERIAN KUAGA
PONES Oa TTORNEY
‘Saya monyatsican baba saya telch mombaca, mengect dan monjanab pertenyaan terciut datas dengan lengkap den benar, Oangan
in saya mentor basa hepada etiap doktor, rumah saxt Hel, puskesras, ovveahaon asucersi dan Lede huketn peor Ga ele
‘organises laity yang memounyal eatatanstau mergotaui keadasnkerehatan es) untuk erioesiahusan hopada ST: Asurarel Sra
Mas aieu mereks yang ster hues olonaya, sepals Xetoralgan mangenet ci can Kescnalan 22) Copy dar porryatssn i sama host
don esbrya ceport anys
‘resol. public heath center, suivice company. legel vistnons. parsanal cr Sitar geraaons bai hes any cords or s¥erranes on te heal
ftba pataoant nfo PT. Asser: Soar Was ts autre sl) IW ator BPC) NeaCDRBON. A DCE PY
Tempal& Tenggel/ ece & Dot
‘Tones enpan. nana Bes newman ayes
Stanaure rare clempovee ermyee any