PEMERINTAH KABUPATEN LAHAT PEMERINTAH KABUPATEN LAHAT

RUMAH SAKIT UMUM DAERAH LAHAT RUMAH SAKIT UMUM DAERAH LAHAT
Jl Letjen Harun Sohar I No 28 Lahat, Kode Pos 31414, Provinsi Sumatera Selatan Jl Letjen Harun Sohar I No 28 Lahat, Kode Pos 31414, Provinsi Sumatera Selatan
Telp/ Fax.(0731) 321785/323080, Email : rsud_lahat@yahoo.co.id Telp/ Fax.(0731) 321785/323080, Email : rsud_lahat@yahoo.co.id

SURAT PENGANTAR RAWAT INAP SURAT PENGANTAR RAWAT INAP

NOMOR : / / / 20.......... RM. 01 NOMOR : / / / 20.......... RM. 01

Mohon perawatan dan pengobatan atas : Mohon perawatan dan pengobatan atas :

 Nama Penderita : .................................................................................................  Nama Penderita : .................................................................................................

 Tanggal lahir : .................................................................................................  Tanggal lahir : .................................................................................................
 Jenis kelamin : laki – laki / perempuan  Jenis kelamin : laki – laki / perempuan
 Hubungan keluarga : peserta / suami / istri / anak  Hubungan keluarga : peserta / suami / istri / anak
 Alamat : .................................................................................................  Alamat : .................................................................................................

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

 Nomor HP : .................................................................................................  Nomor HP : .................................................................................................

 Dengan Diagnosa : .................................................................................................  Dengan Diagnosa : .................................................................................................
 Therapi : .................................................................................................  Therapi : .................................................................................................

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

 Dirawat Tanggal : .........................................................................  Dirawat Tanggal : .........................................................................

Pukul : ......................................................................... Pukul : .........................................................................

Ruang : ......................................................................... Ruang : .........................................................................

Kelas : ......................................................................... Kelas : .........................................................................

DPJP : ......................................................................... DPJP : .........................................................................

 Debitur Pasien : JKN / UMUM / JAMKESDA / Lainnya ....................  Debitur Pasien : JKN / UMUM / JAMKESDA / Lainnya ....................
Atas bantuan dan perhatian saudara diucapkan terima kasih Atas bantuan dan perhatian saudara diucapkan terima kasih

Lahat, ............................ 20 ...... Lahat, ............................ 20 ......

Dokter RSUD Lahat Dokter RSUD Lahat

(_________________________) (_________________________)
Lembar I Administrasi Klaim Lembar I Administrasi Klaim
LembarIIPasien LembarIIPasien
Lembar III Arsip Lembar III Arsip