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PEMERINTAH KABUPATEN MUSI BANYUASIN

DINAS KESEHATAN
PUSKESMAS TANAH ABANG
Jl. Puskesmas Dusun I Desa Tanah Abang Kec.Batanghari Leko

BUKTI PELAYANAN BPJS KESEHATAN

Telah diberikan pelayanan kesehatan berupa ............................................................ kepada nama


tersebut dibawah ini :

1. Nama : .........................................................................................................
2. Nama Suami : .........................................................................................................
3. Nomor Kartu BPJS : .........................................................................................................
4. Tanggal Pelayanan : .........................................................................................................
5. Diagnosa : .........................................................................................................
6. Alamat : .........................................................................................................
: .........................................................................................................

......................., .........................20.....
Penerima Pelayanan Kesehatan Yang Memberi Pelayanan Kesehatan

( ....................................................... ) ( ....................................................... )

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