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TANDA BUKTI PELAYANAN TANDA BUKTI PELAYANAN

Hari : ............................................................................. Hari : .............................................................................

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

Umur : ............................................................................. Umur : .............................................................................

Alamat : ............................................................................. Alamat : .............................................................................

No. Peserta BPJS : ............................................................................. No. Peserta BPJS : .............................................................................

No. Jenis Pelayanan Tarif Jumlah Keterangan No. Jenis Pelayanan Tarif Jumlah Keterangan

Petugas Pasien Petugas Pasien

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

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