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LAPORAN PELAYANAN DOKTER KELUARGA/KLINIK/PUSKESMAS

BPJS KESEHATAN CABANG UTAMA ........

BULAN ........................................... TAHUN .................

NAMA FASKES TK I : ................................................

KODE FASKES TK I : ................................................

JENIS PELAYANAN RUJUK

TANGGAL
NO NAMA PASIEN NO. KARTU DIAGNOSA PENUNJANG TANDA TANGAN
PELAYANAN PEMERIKSAAN TINDAKAN YA TIDAK
DIAGNOSA

Tasikmalaya, ..............................

Dr.
NIP.

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