\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\

\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\ Catatan :
\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\ BUKTI PELAYANAN PERSALINAN
BUKTI PELAYANAN PERSALINAN PESERTA BPJS KESEHATAN
PESERTA BPJS KESEHATAN PUSKESMAS TEMBARAK
PUSKESMAS TEMBARAK

BUKTI LAYANAN NO RM BUKTI LAYANAN NO RM

Yang bertanda tangan di bawah ini : Yang bertanda tangan di bawah ini :

PENANGGUNGJAWAB/PASIEN PENANGGUNGJAWAB/PASIEN
Nama : ............................................................................... Nama : ...............................................................................

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

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

No. Telp. Pribadi/Keluarga : ............................................................................... No. Telp. Pribadi/Keluarga : ...............................................................................

No, KTP : ............................................................................... No, KTP : ...............................................................................

Adalah diri saya sendiri/ ayah/ ibu/ suami/ orang tua Adalah diri saya sendiri/ ayah/ ibu/ suami/ orang tua
Pasien : ............................................................................... Pasien : ...............................................................................

No. Kartu BPJS : ............................................................................... No. Kartu BPJS : ...............................................................................

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

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

No. Telp. : ............................................................................... No. Telp. : ...............................................................................

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

persalinan
Dengan ini menyatakan telah mendapatkan pelayanan ANC/ PNC/ KB di persalinan
Dengan ini menyatakan telah mendapatkan pelayanan ANC/ PNC/ KB di

Puskesmas Tembarak pada hari ............................. tanggal ............................... Puskesmas Tembarak pada hari ............................. tanggal ...............................

Bulan ...................................... tahun ................................. Bulan ...................................... tahun .................................

Demikian bukti pelayanan ini kami buat tanpa ada unsur terpaksa. Demikian bukti pelayanan ini kami buat tanpa ada unsur terpaksa.

Temanggung, ......................... 2019 Temanggung, ......................... 2019

Petugas Yang Menyatakan Petugas Yang Menyatakan

( ______________________ ) ( ______________________ ) ( ______________________ ) ( ______________________ )

 Catatan :
Catatan :
BUKTI PELAYANAN PERSALINAN
PESERTA BPJS KESEHATAN

BUKTI LAYANAN NO RM

Yang bertanda tangan di bawah ini :

PENANGGUNGJAWAB/PASIEN
Nama : ...............................................................................
Umur : ...............................................................................
Alamat : ...............................................................................
No. Telp. Pribadi/Keluarga : ...............................................................................
No, KTP : ...............................................................................

Adalah diri saya sendiri/ ayah/ ibu/ suami/ orang tua

Pasien : ...............................................................................
No. Kartu BPJS : ...............................................................................
Umur : ...............................................................................
Alamat : ...............................................................................
No. Telp. : ...............................................................................
Diagnosa : ...............................................................................

persalinan
Dengan ini menyatakan telah mendapatkan pelayanan ANC/ PNC/ KB di
Puskesmas Tembarak pada hari ............................. tanggal ...............................
Bulan ...................................... tahun .................................
Demikian bukti pelayanan ini kami buat tanpa ada unsur terpaksa.

Temanggung, ......................... 2017

Petugas Yang Menyatakan

( ______________________ ) ( ______________________ )