PEMERINTAH KABUPATEN CIAMIS

DINAS KESEHATAN
PUSKESMAS SADANANYA
Jln. Raya Sadananya No.477 Telp. (0265) 775690 Sadananya – Ciamis - 46256

BUKTI PELAYANAN
ANC, PERSALINAN, PNC, KB PASCA PERSALINAN, RUJUKAN

Menerangkan bahwa :
Nama : ......................................................................................................................
Alamat : ......................................................................................................................
No. Kartu JKN / BPJS : ......................................................................................................................

Telah mendapatkan pelayanan :

1. Tanggal ANC : ............................................................................................
2. Tanggal Persalinan : ............................................................................................
3. Tanggal PNC : ............................................................................................
4. Tanggal Pemasangan KB Pasca Salin : ............................................................................................
5. Tanggal Rujukan : ............................................................................................

Keterangan ini dibuat untuk dipergunakan sebagai bukti pengajuan klaim JKN-BPJS.

Sadananya, 2021
Pengguna BPJS Bidan Pelaksana

( ..................................... ) Hj. Oo Ida Hodijah, Am.Keb

NIP : 19720410 199202 2 003

Mengetahui,
Kepala UPTD Kesehatan Puskesmas Sadananya

HAMLAN, SKM.,MM
NIP. 19670808 198901 1 002
 PEMERINTAH KABUPATEN CIAMIS
DINAS KESEHATAN
PUSKESMAS SADANANYA
Jln. Raya Sadananya No.477 Telp. (0265) 775690 Sadananya – Ciamis - 46256

RESUME MEDIS / PELAYANAN

Nama : ......................................................................................................................
Alamat : ......................................................................................................................
No. Kartu JKN / BPJS : ......................................................................................................................

a. Pasien datang jam ....... Tanggal ........ Dengan keluhan .......................................................................

...............................................................................................................................................................
b. Dilakukan pemeriksaan dengan hasil :
................................................................................................................................................................
................................................................................................................................................................
c. Tindakan / pelayanan yang diberikan meliputi :
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
d. Hasil dari tindakan / pelayanan yang di berikan :
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
Resume ini dibuat untuk dipergunakan sebagai bukti pengajuan klaim JKN-BPJS

Sadananya, 2021
Pengguna BPJS Bidan Pelaksana

( ..................................... ) Hj. Oo Ida Hodijah, Am.Keb

NIP : 19720410 199202 2 003

Mengetahui,
Kepala UPTD Kesehatan Puskesmas Sadananya

HAMLAN, SKM.,MM
NIP. 19670808 198901 1 002
 PEMERINTAHAN KABUPATEN CIAMIS
DINAS KESEHATAN
PUSKESMAS SADANANYA
Alamat : Jl. Raya Sadananya No. 477 Telp. (0265) 775690 Sadananya

KETERANGAN PERSALINAN

Menerangkan bahwa yang ditolong persalinan adalah :

Nama pasien : .....................................................................................
Jenis kelamin : .....................................................................................
Nomor Kartu : ..................................................................................
Umur : ....................................................................................
Alamat Rumah : Dusun...............................Rt......../ Rw.......................
Desa............................................................................
Kecamatan..................................................................
Persalinan tanggal : .....................................................................................
Demikian surat keterangan persalinan ini dibuat agar dipergunakan sebagaimana mestinya.

Sadananya, ...................... 2021

Peserta JKN Yang Menolong Kepala UPTD Kesehatan
Persalinan Puskesmas Sadananya

................................... Hj. Oo Ida H, Am.Keb HAMLAN, SKM.,MM

NIP : 19720410 199202 2 003 NIP. 19670808 198901 1 002