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  • Surat Jaminan Pelayanan Peserta BPJS Rawat Jalan

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    SURAT JAMINAN PELAYANAN PESERTA BPJS RAWAT JALAN

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    10 views1 page

    Surat Jaminan Pelayanan Peserta BPJS Rawat Jalan

    Uploaded by

    riana yoseferta

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    No.

    RM :
    Nama :
    Tanggal Lahir :
    DINAS KESEHATAN (Mohon diisi atau tempelkan stiker jika ada)
    UPT RSUD SOLOK SELATAN
    Jl. Raya Km. 1 Muara Labuh.
    Telpon. Fax (0755) 70462

    SURAT JAMINAN PELAYANAN PESERTA BPJS RAWAT JALAN


    POLIKLINIK …………………………………..
    NO. BPJS :
    DIAGNOSA : ………………………………………………………………………………………………………………………………….
    ………………………………………………………………………………………………………………………………….
    ………………………………………………………………………………………………………………………………….
    TINDAKAN : ………………………………………………………………………………………………………………………………….
    ………………………………………………………………………………………………………………………………….
    ………………………………………………………………………………………………………………………………….

    PENERIMA PELAYANAN MUARA LABUH,………………………………….


    DPJP

    ………………………………………………… ………………………………………………

    No.RM :
    Nama :
    Tanggal Lahir :
    DINAS KESEHATAN (Mohon diisi atau tempelkan stiker jika ada)
    UPT RSUD SOLOK SELATAN
    Jl. Raya Km. 1 Muara Labuh.
    Telpon. Fax (0755) 70462

    SURAT JAMINAN PELAYANAN PESERTA BPJS RAWAT JALAN


    POLIKLINIK …………………………………..
    NO. BPJS :
    DIAGNOSA : ………………………………………………………………………………………………………………………………….
    ………………………………………………………………………………………………………………………………….
    ………………………………………………………………………………………………………………………………….
    TINDAKAN : ………………………………………………………………………………………………………………………………….
    ………………………………………………………………………………………………………………………………….
    ………………………………………………………………………………………………………………………………….

    PENERIMA PELAYANAN MUARA LABUH,………………………………….


    DPJP

    ………………………………………………… ………………………………………………

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