v
BP, s Kesehatan Surat Pernyataan Pelayanan di FTP
@isen Son eeeninen
‘No Kunjungan: 2z0303020423001202
‘Nomoe Reka Mecis ‘Tangga! Latir {a106r1996
‘Nomor Karty Peseria 0000141643844 Uru 26 tan 10 butan 12
NK '5171048406060003 ‘Tonggol Pelayanan 2604/2023
Nama NIMADE YUNITA DEW Jenis Pelayanan RuTP
Jenis Ketarin Perempuan, ‘arnt BR, PASEKAN BUDUK
Nomar HP. :
Pelayanan:
4. Pelayanan ANC
‘Pasion /Keluarga menyatekan bahwa benar, pasien telah mendapatkan pelayanan tanpa dikenalan ir bays seria memperash,
Panevan Kenads BPUS Kesehatan untuk menggunakan formas metis yang tetera oi status Kesehatan pasion sebagal ssih
‘atu syarat pengaluan klaim pelayanan program JKN.
Pasien /Keluarga
(fr
NIMADE YUNITA DEW!
[No telp yang dapat sinubung:
Dipindai dengan CamScanner ‘Tindakan (Prosedure)
Prognoes
JENIS TAGIHAN NON KAPITAS!
Playanan ANC: Pelayanan ANC 2 (Dus), sia Kehamitan: 15 mingpu
{: AYU INDAH HAPSARI
‘Bonen (Bak)
‘Tenaga Kesehatan
Biaya yang dlajukan Rp#0.000
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