NOMOR.......TAHUN............
TENTANG
....................................................................................
RUMAH SAKIT
Mengingat : 1. ........................................................................................;
2. ........................................................................................;
3. .........................................................................................
MEMUTUSKAN
Menetapkan : PERATURAN DIREKTUR RUMAH SAKIT ....
TENTANG ..........................................................................
Pasal 1
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Pasal 2
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Paraf 1
Paraf 2
Pasal 3
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Ditetapkan di
Pada tanggal
DIREKTUR
RS,
....
Paraf 1
Paraf 2