SURAT JAMINAN PELAYANAN

RAWAT INAP/JALAN PESERTA BPJS

1. Nomor Kartu BPJS :.............................................................................

2. Nama Pasien :.............................................................................
3. Status :.............................................................................
4. Jenis Kelamin :.............................................................................
5. MR. :.............................................................................
6. Diagnosa Awal :.............................................................................
7. Hak. Kls Rawat :.............................................................................
8. Tgl SJP :.............................................................................
Catatan Khusus :.............................................................................

Peserta/Keluarga Legalisator BPJS

Pasien

(……………………..) (………………………)

SURAT JAMINAN PELAYANAN

RAWAT INAP/JALAN PESERTA BPJS

1. Nomor Kartu BPJS :.............................................................................

2. Nama Pasien :.............................................................................
3. Status :.............................................................................
4. Jenis Kelamin :.............................................................................
5. MR. :.............................................................................
6. Diagnosa Awal :.............................................................................
7. Hak. Kls Rawat :.............................................................................
8. Tgl SJP :.............................................................................
Catatan Khusus :.............................................................................

Peserta/Keluarga Legalisator BPJS

Pasien

(……………………..) (………………………)