PT.

ASURANSI JIWA INHEALTH INDONESIA

KANTOR OPERASIONAL JAKARTA
Gedung Jaya Lt. 9 Suite 09-10
Jl. MH Thamrin No. 12 Jakarta Pusat
Telp. 021-3907037, Fax. 021-3907137
www.mandiriinhealth.co.id

Lembar Komunikasi Medik RS ....................

Bulan Pelayanan ..............................................................
TKP RJTL/ RITL/ Obat RJTL/ Obat RITL
Nama Pengaju .............................................................. Poli / RR .................................................
Nama Pasien .............................................................. P / I / S / A .................................................
No. Kartu .............................................................. BU .................................................
Diagnosis ..............................................................

KOLOM KOMUNIKASI
TANGGAL NAMA JENIS PELAYANAN
CATATAN PARAF dr.

Nama Petugas ................................................. Paraf Kasie ........................................