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    Surat Pernyataan

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    17 views1 page

    Surat Pernyataan

    Uploaded by

    LiesLongge
    Surat Pernyataan

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    FORMULIR PERNYATAAN PESERTA

    Saya yang bertanda tangan dibawah ini :


    Nama
    :........................................................................................................................
    Tempat/Tanggal Lahir :........................................................................................................................
    Jenis Kelamin
    :........................................................................................................................
    NIK
    :........................................................................................................................
    Nomor Telepon
    :........................................................................................................................
    Dengan sadar, terkait pemanfaatan jaminan pelayanan kesehatan BPJS Kesehatan, dengan ini menyatakan
    :
    kesediaan atas data, medis (rekam medis) diri saya untuk dipergunakan oleh Dokter/
    Rumah sakit/BPJS sesuai dengan kepentingannya

    ................................,.........................20...........
    Yang Membuat Pernyataan

    (.......................................................................)
    Peserta

    FORMULIR PERNYATAAN PESERTA


    Saya yang bertanda tangan dibawah ini :
    Nama
    :........................................................................................................................
    Tempat/Tanggal Lahir :........................................................................................................................
    Jenis Kelamin
    :........................................................................................................................
    NIK
    :........................................................................................................................
    Nomor Telepon
    :........................................................................................................................
    Dengan sadar, terkait pemanfaatan jaminan pelayanan kesehatan BPJS Kesehatan, dengan ini menyatakan
    :
    kesediaan atas data, medis (rekam medis) diri saya untuk dipergunakan oleh Dokter/
    Rumah sakit/BPJS sesuai dengan kepentingannya

    ................................,.........................20...........
    Yang Membuat Pernyataan

    (.......................................................................)
    Peserta

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