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, 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

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