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    This document is a legalization letter from BPJS Kesehatan Cab. BANYUWANGI for Nila Gayatri regarding eyeglasses. It specifies her patient information including name, BPJS card number, date of birth, gender, prescription details for both eyes, SJP number from RSU Al Rohmah, and is dated February 21, 2019 with the legalizator's signature. The letter legalizes her eyeglasses treatment covered under the BPJS health insurance program.

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    This document is a legalization letter from BPJS Kesehatan Cab. BANYUWANGI for Nila Gayatri regarding eyeglasses. It specifies her patient information including name, BPJS card number, date of birth, gender, prescription details for both eyes, SJP number from RSU Al Rohmah, and is dated February 21, 2019 with the legalizator's signature. The letter legalizes her eyeglasses treatment covered under the BPJS health insurance program.

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    © All Rights Reserved
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    0 views1 page

    Print Out

    Uploaded by

    rs al rohmah
    This document is a legalization letter from BPJS Kesehatan Cab. BANYUWANGI for Nila Gayatri regarding eyeglasses. It specifies her patient information including name, BPJS card number, date of birth, gender, prescription details for both eyes, SJP number from RSU Al Rohmah, and is dated February 21, 2019 with the legalizator's signature. The letter legalizes her eyeglasses treatment covered under the BPJS health insurance program.

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    BPJS Kesehatan Cab.

    BANYUWANGI
    SURAT LEGALISASI PELAYANAN
    Nomor Legalisasi : 19020094904
    Jenis Legalisasi : Kacamata

    Nama Pasien : NILA GAYATRI X Kacamata


    No.Kartu BPJS : 0001731571839 X Lensa Lensa Kiri Kanan

    Tgl. Lahir : 21 August 2001 Spheris -1.50 -1.00


    Jenis Kelamin : Perempuan
    Cylindris -0.50 0.00

    No SJP : 0190R0200219V000127 Keterangan : acc RS alrohmah

    PPK Asal SJP : RSU Al Rohmah


    Tanggal SJP : 19 February 2019 Tanggal, 21 February 2019
    Legalisator Rumah Sakit

    21/02/2019 07.33.08 ( didik rahmudi )

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