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SURAT BUKTI PELAYANAN RAWAT INAP JKN

1. Alamat : Tegal Lembut RT 08/04 Giripeni, Wates, Kulon Progo

2. Tanggal masuk : Juni 2022 Tanggal Keluar : 2022
3. Lama Dirawat : Hari
4. Cara Keluar :
5. Tarif RS : .................................................................................................................
6. ADL : .................................................................................................................
7. Spesial CMG : .................................................................................................................
a. Special Prosedur : .................................................................................................................
b. Special Drugs : .................................................................................................................
c. Special Investigation : .................................................................................................................
d. Special Prothesis : .................................................................................................................
8. Diagnosis Primer : ..............................................................................Kode...........................
Diagnosis Sekunder : ..............................................................................Kode...........................
..............................................................................Kode...........................
9. Tindakan : ..............................................................................Kode...........................
...............................................................................Kode...........................
Tanda Tangan Peserta Kulon Progo, 2022
Dokter Penanggung Jawab

( ) (dr. )

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