SURAT RUJUKAN PESERTA BPJS

NO. RUJUKAN :…………………………………..…

Puskesmas/Dokter Keluarga :.......................................... Kode : .........................
:Kabupaten/Kota .........
:.......................................... Kode : ..........................
: ...........

Kepada Yth. TS dr. : ................................................................................ Poli : ……………………………...

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

Mohon pemeriksaan dan penanganan lebih lanjut penderita :

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

No. Kartu : Status : …..

................................................
BPJS
:
Diagnosa ..................................................

Telah diberikan :………………………………………

Demikian atas bantuannya, diucapkan banyak terima kasih

Salam sejawat, ...................... 20

dr.............................

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - -

SURAT RUJUKAN BALIK

Teman sejawat Yth.

Mohon kontrol selanjutnya penderita :

Nama : .........................................................................................................................................

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

Terapi : .........................................................................................................................................

Tindak lanjut yang dianjurkan

Pengobatan dengan obat-obatan : Perlu rawat inap

............................................................................. Konsultasi selesai

Kontrol kembali ke RS tanggal : .........................

................................tgl .......................................
Lain-lain : ............................................................

Dokter RS,

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