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SURAT BUKTI PERAWATAN PRA RUJUKAN DI FASKES TK I

PESERTA BPJS KESEHATAN ERA JKN


Yang bertanda tangan di bawah ini , menerangkan dengan benar bahwa :
Nama

: ...................................................................................................

Nomor Kartu

: ...................................................................................................

Alamat dan No telp / Hp Pasien

: ...................................................................................................

Telah dirawat pada tanggal

: ............s/d.............Selama ...... (..............................) Jam / hari

Diagnosa Penyakit

: ...................................................................................................

Faskes Tujuan Rujukan

: ...................................................................................................

Alasan dirujuk

: ...................................................................................................
: ...................................................................................................

Jumlah Biaya yang harus ditanggung Rp ..............................................................................................


( ......................................................................................................................................................)
Dokter / Bidan Peruujuk

RS Penerima Rujukan

Peserta BPJS Kesehatan

(..........................................)
( ............................................)
( ............................................)
...........................................................................................................................................................
SURAT BUKTI PERAWATAN PRA RUJUKAN DI FASKES TK I
PESERTA BPJS KESEHATAN ERA JKN
Yang bertanda tangan di bawah ini , menerangkan dengan benar bahwa :
Nama

: ...................................................................................................

Nomor Kartu

: ...................................................................................................

Alamat dan No telp / Hp Pasien

: ...................................................................................................

Telah dirawat pada tanggal

: ............s/d.............Selama ...... (..............................) Jam / hari

Diagnosa Penyakit

: ...................................................................................................

Faskes Tujuan Rujukan

: ...................................................................................................

Alasan dirujuk

: ...................................................................................................
: ...................................................................................................

Jumlah Biaya yang harus ditanggung Rp ..............................................................................................


( ......................................................................................................................................................)
Dokter / Bidan Peruujuk
(..........................................)

RS Penerima Rujukan
( ............................................)

Peserta BPJS Kesehatan


( ............................................)