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SURAT ELEGIBILITAS PESERTA No. SEP Tgl. SEP No.Kartu Nama Peserta Tgl.Lahir Jns.Kelamin Poli Tujuan Diagnosa Awal Catatan : : : : : : : : : Petugas BPJS Kesehatan Pasien/ Keluarga Pasien ____________ _____________ *Saya Menyetujui BPJS Kesehatan menggunakan informasi Medis Pasien jika diperlukan. *SEP bukan sebagai bukti penjaminan peserta Kls.Rawat : Jns.Rawat : COB : Asal Faskes Tk. I : Peserta :

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SURAT ELEGIBILITAS PESERTA

No. SEP

Tgl. SEP

No.Kartu

Nama Peserta

Tgl.Lahir

Jns.Kelamin

Poli Tujuan

Diagnosa Awal

Catatan

:

:

:

:

:

:

:

:

:

Petugas BPJS Kesehatan

Pasien/Keluarga Pasien

_________________________*Saya Menyetujui BPJS Kesehatan menggunakan informasi Medis Pasien jika diperlukan.*SEP bukan sebagai bukti penjaminan peserta

Kls.Rawat :

Jns.Rawat :

COB :

Asal Faskes Tk. I :

Peserta :

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