Rumah Sakit Umum Kertayasa

Jl. Ngurah Rai No. 143 Negara 82217

Telp. (0365) 41248, 4501243 Fax. (0365) 44378
Email : rsukertayasa@gmail.com

FORMULIR BUKTI PELAYANAN (KLAIM BPJS)

Negara, …../……/……….
Nama Pasien : ................................................................................... Jenis Kelamin : L/P
Tanggal Lahir/Umur : .................................................................................../ ……. tahun
Riwayat Penyakit : Kasus Baru Kontrol ……………………………………
Anamnesis :

Pemeriksaan Fisik : .................................................................................................................

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Diagnosis : .................................................................................................................
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Tindakan : .................................................................................................................
Terapi dan penunjang : Medikamentosa

Laboratorium ...................................................................................
CT Scan USG ………………………….
MRI Rontgent ……………………..
EEG / EKG/ Fisioterapi Lainnya ………………………
Masuk Rawat Inap Rujuk …………………………

Hormat Kami, Tandai (tanda kotak) dengan cek list (v)

Lembar 1 : Klaim penjamin pertama
Lembar 2 : Arsip /klaim penjamin kedua
(………………..)