BUKTI PELAYANAN RAWAT INAP

Yang bertanda tangan di bawah ini :

Nama dokter : ................................................................................................

Nama FKTP : ................................................................................................

Menyatakan bahwa pasien :

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

Nomor Kartu JKN : ................................................................................................

Nomor RM : ................................................................................................

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

Nomor telp./HP : ................................................................................................

Membutuhkan rawat inap pada :

Tanggal masuk : ................................................................................................

Tanggal keluar : ................................................................................................

Diagnosa : ................................................................................................

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Pasien/Penanggungjawab Dokter yang memerintahkan

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 BUKTI PELAYANAN AMBULAN

Yang bertanda tangan di bawah ini :

Nama dokter : ................................................................................................
Nama FKTP : ................................................................................................
Menyatakan bahwa pasien :
Nama : ................................................................................................
Nomor Kartu JKN : ................................................................................................
Nomor RM : ................................................................................................
Alamat : ................................................................................................
Nomor telp./HP : ................................................................................................
Membutuhkan pelayanan ambulan guna penatalaksanaan lebih lanjut di :
Tujuan Rujukan : ................................................................................................
Jarak tempuh (km) : ................................................................................................
Jam berangkat : ................................................................................................
Jam tiba : ................................................................................................
Diagnosa : ................................................................................................
Pengemudi ambulan : ................................................................................................
Plat Nomor Kendaraan : ................................................................................................

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Pasien/Penanggungjawab Dokter yang merujuk

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Penerima Rujukan

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