PEMERINTAH KABUPATEN LEBAK

DINAS KESEHATAN
PUSKESMAS MANDALA
JL. MAULANA HASANUDIN TELP. ( 0252 ) 202868 KECAMATAN CIBADAK

BADAN PENYELENGGARA JAMINAN KESEHATAN (BPJS)

JAMINAN KESEHATAN NASIONAL (JKN)
BUKTI PELAYANAN PERTOLONGAN PERSALINAN
Nama ibu bersalin
:......................................................................................
Umur ibu

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

Nama kepala keluarga

:......................................................................................
Nomor kartu

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

Alamat lengkap

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

Nama paraji kemitraan

: .....................................................................................
Umur kehamilan

: ......................................................................Minggu

Faktor Resiko/ Resiko

: .....................................................................................
Data Persalinan
Hari

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

Tanggal

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

Jam

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

Data bayi
Anak ke

: ......................................(.............................................)

Keadaan

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

BB/PB

:...................................Gram/.....................................cm

Jenis Kelamin

LAKI-LAKI / PEREMPUAN
Mandala, .......................................2016
Peserta
yang menolong

petugas

..........................................
...................................
NIP/Nrptt : ...................................
Mengetahui
Kepala puskesmas Mandala

..........................

Dr. Budhi Mulyanto

NIP. 19720222 200502 1 003