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PUSKESMAS GRUJUGAN

Jl. Raya Jember No. 29 0332 !23"02 #r$%$&a'  Bo'(o)o*o Website : http: // www.puskesmas-gruuga!.b"#gsp#t.$#m e-mai" : puskesmasgruuga!%gmai".$#m&

KE+AMATAN #RUJU#AN

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PERJANJ*AN KERJASAMAAN+ARA PUSKESMAS GRUJUGAN )ENGAN RSU ,r..K(ESNAS* '(N)(W(S( +EN+ANG PEAANAN AUN)R RUMA SAK*+

Nomor , !!0- 0." -!30."0.2."3-20"/ Nomor,

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Per%a'%a' Ker%a*ama Pelaya'a' la$'(ry r$ma1 *a4 (b$a (a' (a'(aa'&a' ( Bo'(o)o*o4 5a(a 1ar Se''4 a'&&al! Ja'$ar 20"/4 5ara 51a ya'& bera'(a a'&a' (ba)a1 ' , Nama

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U' Ker%a , RSU (r. H Koe*'a( Bo'(o)o*o Dalam 1al ' ber'(a $'$ (a' aa* 'ama Dre$r R$ma1 Sa Um$m (r. H Koe*'a( Bo'(o)o*o*ela'%$'ya (*eb$ P*AK KE)UA Para P1a erleb1 (a1$l$ me'era'&a' , ". Ba1)a P*AK PER+AMAa(ala1 *eb$a1 U' Pela*a'a Te'* D'a* Ke*e1aa' ( ab$5ae' Bo'(o)o*o ya'& bera'&&$'& %a)ab me'yele'&araa' 5elaya'a'

e*e1aa' 5rmer ( )laya1 er%a'ya. P*AK KE)UA a(ala1 *$a$ R$ma1 Sa ya'& meml $*a1a ya'& (alam b(a'& 5elaya'a' e*e1aa' erma*$ %a*a 5elaya'a' 6a$'(ry. 2. Ba1)a e($a bela 1 51a *e5a a $'$ me'&a(aa' er%a*ama (alam 5elay a'a' la$'(ry R$ma1 Sa Um$m (r. H. Koe*'a( Bo'(o)o*o. Pasa" 0 Maksu, ,a! +uua!

P1a Perama aa' me'&a'ar l'e' e5a(a P1a Ke($a4 (ma'a P1a Ke($a aa' me'erma ma*$( er*eb$ (e'&a' mela*a'aa' 5e'7$7a' aa$ la$'(ry *e*$a (e'&a' 5erm'aa' P1a Perama (a' ber(a*ara' ba'ya l'e' ya'& ela1 ( *era1a' e5a(a P1a Ke($a. Pasa" 1 +ata 2ara Pe"aksa!aa!

". 6'e' ya'& ela1 (a' ar ole1 P1 a Perama e5a(a P1a Ke($a ber $5a a' l'e' aa$ *5re ya'& ela1 (&$'aa' aa$ oor. 2. 6'e' aa$ *5re ya'& ( a'ar ole1 P1a Perama 1ar$* (em5aa' e(alam b$'&$* Pla* ya'& *$(a1 (be(aa' me'%a( ($a4 ya$ l'e' ya'& '8e*$* (a' l'e' ya'& (a '8e*$*. 3. D(alam b$'&$* 5la* ya'& ( a'ar ole1 P1a Perama 1ar$* er(a5a $l*a' , Nama P$*e*ma* • J$mla1 6'e' ya'& a(a ( (alam )a(a1 • Ta'&&al (a' %am l'e' ( a'ar e P1a Ke($a • Keera'&a' '8e*$* (a' (a '8e*$* • ! A5abla 6'e' ya'& (erma ole1 P1a Ke($a (ar P1 a Perama (a meme'$1 5er*yaraa' aa$ (a le'&a54maa P1a Ke($a ber1a mela$a' 1al1al *eba&a ber$ , Mela$a' o'8rma*4 a5abla (aa ber$5a %$mla1 l'e'4 eera'&a' '8e*$* (a' (a '8e*$*4 er1a(a5 ea(aa' '. P1a Perama aa' mele'&a5 (aa ya'& 

(b$$1a' ole1 P1a Ke($a *e7ara er$l*. 6'e' aa$ *5 re ya'& aa' (7$7 aa' ( a' ara' ole1 P1a Perama e5a(a P1a

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e($a ( loa* la$'(ry RSU (r. H.Koe*'a( Bo'(o)o*o Wa$ 5e'ermaa' ba1a' 5emer*aa' ole1 P1a Ke($a a(ala1 *eba&a ber$ , Har Se'' *.( Sab$ : P$$l 0;.30 *.( 20.30 WIB Har M'&&$ - 6b$r , P$$l 0.00 *.(

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"3.00 WIB Ke($a bela1 51a )a%b mela*a'aa' - mema$1 ee'$a' (alam 5er%a'%a' ' (e'&a' 5e'$1 a'&&$'& %a)ab (a' ee'$a' la''ya ya'& berla$ *eba&a *a'(ar 5elaya'a' 6a$'(ry aa$5$' *a'(ar 5ro*e($r ya'& berla$.

Pasa" 3 Pe!a!ggu!g Jawab ,a! A"amat K#resp#!,e!si

". Pe'a'&&$'& Ja)ab 1ara' P1a Perama a(ala1 , Nama , N*. DIAN A 5a(a l'e'-*5re Pasa" 7 +ari8 Pemeriksaa!

". Tar8 la$'(ry (e'$a' 5er lo&ram ya'& *e*$a (e'&a' ya'& ela1 (ea5a' 2. Dalam 1al P1a Ke( $a aa' mela $a' 5er$ba1a' ar84 ma a P1a Ke($a aa' memb$a *$ra 5embera1$a' e5a(a P1a Perama 5al'& lamba 30 =&a 5$l$1 > 1ar *ebel$m ar8 bar$ er*eb$ (berla$a'. 3. A5abla P1a Peram a (a me'ye$%$ 5er$ba1a' ar 8 =*eba&ama'a ( a$r (alam aya 2 5a*al ' > (a' a'ara e($a bela1 51a (a er7a5a e*e5aaa' me'&e'a 1al '4 maa 5er%a'%a' ' me'%a( 5$$* (a' bera1r (e'&a' *e'(r'ya. Pem$$*a' 5er%a'%a' er%a*ama 1al ' (a *era mera me'&1a5$* *e&ala e)a%ba' ya'& bel$m er*ele*aa'.

Pasa" 9 +ata 2ara Pemba5ara!

". P1a Perama aa' membayar *eela1 *em$a 5ro*e* la$'(ry er* eb$ *ele*a (a' l'e'-*5re *$(a1 (erma ole1 P1a Perama. 2. Har&a ya'& (e'aa' ber(a*ara' bera = 5er lo& ram> l'e' ya' & ( la$'(ry RSU (r.H.Koe*'a( Bo'(o)o*o.

Pasa" 0 Ja!gka Waktu Pera!ia!

". Per%a'%a' er%a*ama berla$ %a'&a )a$ 2 =($a> a1$'4 er1$'& *e%a ( a'(a a'&a''ya *$ra 5er%a'%a' ' (a' aa' bera1r a'&&al 02 J$' 20" 2. A5abla 5ara 51a '&' me'a1r 5er%a'%a' er %a*ama ' maa 5ara 51a bere)a%ba' $'$ membera1$a' *a$ (e'&a' ya'& la''ya 5al'& lamba 2 =($a > b$la' *ebel$m bera1r'ya ma*a 5er%a'%a' '. 3. Bera1r'ya ma*a berla$ 5er%a'%a' er% a*ama ' (a *era mera me'1 a5$*a' e)a%ba' ma*'&ma*'& er1a(a5 51a la''ya ya'& bel$m ereal*a*a'. Pasa" 00 ;#r$e maeure

". Ke($a bela1 51a *e5aa a5abla ((alam mela$a' 5e'7$7a' l'e'4 *e5er er*eb$ 5a(a 5a*al " =(aa* >4 P1a Ke($a me'&alam eerlambaa' ya'& (*ebaba' ole1 ea(a' 8or7e ma%e$re4 maa P1a Ke($a 1ar$* membera1$a'

*e7ara er$l* me'&e'a ea(aa' er*eb$ e5a(a P1a Ke($a *elambalamba'ya 2 ? 2! %am *eela1 er%a('ya 8or7e ma%e$re er*eb$. 2. Kea(aa' 8or7e ma%e$re *e5er er*eb$ 5a(a aya " =*a$> (aa* erma*$ ea5 (a erbaa* 5a(a 1al1al *eba&a ber$ , 5e5era'&a'4 1$r$ 1ara4 $'%$ ra*a ma**a4 5erombaa'4 r** 'a*o'al4 ebaara'4 *aboa*e4 e5(em74 be'7a'a alam *e5er ba'%r4 &em5a b$m. 3. A5abla er%a( ea( a' 8or7e ma%e$r e *e5er (aa *4 *e1'&&a (a mem$' &'a' P1a Perama (a' P1a Ke($a mela'%$a' 5er%a'%a' er%a*ama '4 maa Ke($a bela1 51a *e5aa $'$ me'yele*aa' *e&ala *e*$a$'ya *e7ara m$*ya)ara1. Pasa" 01 Pe!5e"esaia! Perse"isiha! ". Ja er%a( 5er*e l*1a' *eba&a ab a (ar 5ela*a'aa' 5er%a' %a' '4 ma a Ke($a bela1 51a *e5aa $'$ me'yele*aa' 5erma*ala1a' er*eb$ *e7ara m$*ya)ara1 2.

&$'a me'7a5a m$8aa. A5abla (e'&a' m$*ya)ara1 (a er7a5a m$8aa maa Ke($a bela1 51a *e5aa $'$ me'yele*aa' 5erma*ala1a' Pe'&a(la' Ne&er Bo'(o)o*o. Pasa" 03 Pemutusa! / Pembata"a! Pera!ia!

". Per%a'%a' ' me'%a( baal (em 1$ $m aa$ (a5a ( 5$$ *a' *ea5 *aa  *ebel$ m )a$'ya4 (e'&a' erleb1 (a1$l$ me'yam5aa' *$ra 5embera1$a' - 5er'&aa'4 a5abla er%a( 1al1al *e5er ber$ ' , a. Dalam 1al 5ara 51 a (a (a5 a meme'$1 e)a%ba''ya (a' aa$ mel a$a' 5ela'&&ara' er1a(a5 ee'$a'ee'$a' (alam 5er%a'%a' '. b. Dalam 1al er%a('ya 8or7e ma%e$re *eba&ama'a (ma*$( (alam 5a*al "". 7. Para P1a ber1 a me'&a1r 5er%a'%a' ' *ebe l$m )a$'ya a5abla ( (alam 5el*a'aa' 5er%a'%a' *al1 *a$ aa$ e($a bela1 51a (a mam5$ meme'$1 ee'$a' ya'& ela1 ( a$r ((alam 5er%a'%a' ' berla'&*$'& membera' eera'&a' 5al*$ aa$ (5al*$a'. 2. Hal ' (la$a' *e7ara er$l* ole1 ma*'&ma*'& 51a 30 =T&a P$l$1> 1ar *ebel$m 5er%a'%a' ' ('yaaa' (a1r. Pasa" 04 ai! < "ai!

Selama berla'&*$'&'ya er%a*ama '4 1al @1al ya'& m$'&' mb$l *e1$b$'&a' 5ela*a'aa' 5er%a'%a' (a' bel$m ( a$r (alam S$ra Per%a'%a' Ker%a*ama ' aa' (

*ele*aa' (a' ( a$r aa* (a*ar 5er*e$%$a' ber*ama (alam *eb$a1 a((e'($m ya'& mer$5aa' ba&a' ya'& me'&a *era (a er5*a1a' (ar 5er%a'%a' '.

Pasa" 06 Pe!utup

". S$ra 5er%a'%a' ' (b$a ra'&a5 2 =($a> (a'(aa'&a' ( aa* maera ya'& 7$$5 (a' mem5$'ya e$aa' 1$$m ya'& *ama $a'ya4 ma*'&  ma*'& $'$ P1a Perama (a' P1a Ke($a *era (a5a ( 5erba'ya *e*$a eb$$1a'. 2. S$ra Per%a'%a' Ker%a*ma ' ( b$a (a' (a'(aa'&a' ( Bo'(o)o*o 5a(a a'&&al er*eb$ ( aa*.

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