SURAT RUJUKAN PESERTA BPJS KESEHATAN

No Rujukan : 445/ / PKM/ 201

Puskesmas : Pulau Batu Kode :...............................................

Propinsi : Jambi Kode :...............................................

Kepada Yth :.................................................. dr. Poli...............................................

Di RSU :.............................................................................................................

Mohon Pemeriksaan dan penanggulangan lebih lanjut penderita :

Nama :.................................................. Umur :......................( L/P )

No. Kartu :.................................................. Status : P / S / I / AI / A2 / A3

Diagnosa :..................................................................................................

Telah diberikan

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Demikian atas bantuannya, diucapkan terima kasih.

Salam Sejawat

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

Kantor Cabang Bungo

Jl. Teuku Umar Rimbo Tengah Muaro Bungo
Telp. +62 741 21139 Fax. +62 741 321058
www.bpjs-kesehatan.go.id