JASINDO {agen sroneno a 3 tarts 28
HEALTH CARE ‘Mohandas Sone one SMe Ondee om
FORMULIR KLAIM
(leasnuess* [7] reimBursement* — *(Pith sesuai kebutuhan)
Nara Kananee a Pas gat “iehasse = pac 2) ths
Na Peseta Neva Ponsaban
Seusescin —(] pogtasi svi) Ak
PUTTS EINE
fas nk Frees see aon; ris) Wave
“apo “epar
ene Peeaen ae :(C] Rota | JOedeum, (10: Spete (LG | Raat
FRR | ren alee, |e
RESUME MEDIS
4. anaes 4 Diagnose Tembahan (ha és)
2) Runa aa
4) Pengobatan‘Tindakan|
2) Kluhan Taman
b)Pembedahan (ka ada)
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