PEMERINTAH KABUPATEN BONDOWOSO
DINAS KESEHATAN
PUSKESMAS GRUJUGAN
PUSKESMAS GRUJUGAN
Jl. Raya Jember No. 29
0332 !23"02 #r$%$&a' Bo'(o)o*o WebsWebsite : ite : http: // http: // www.puskewww.puskesmas-gruuga!.b"#gsp#t.$#m e-mai" : smas-gruuga!.b"#gsp#t.$#m e-mai" : puskesmasgruuga!%gmai".$#m&puskesmasgruuga!%gmai".$#m&
KE+AMATAN #RUJU#AN
' ( N ) ( W ( S (
' ( N ) ( W ( S (
PERJANJ*AN KERJASAMAAN+ARA PERJANJ*AN KERJASAMAAN+ARA PUSKESMAS GRUJUGAN PUSKESMAS GRUJUGAN )ENGAN )ENGAN RSU ,r..K(ESNAS* '(N)(W(S( RSU ,r..K(ESNAS* '(N)(W(S( +EN+ANG +EN+ANG PEAPEAANAN AUN)R RUMA ANAN AUN)R RUMA SAK*+SAK*+
Nomor , !!0- 0." -!30."0.2."3-20"/ Nomor, - -!30."".-20"/
Per%a'%a' Ker%a*ama Pelaya'a' la$'(ry r$ma1 *a4 (b$a (a' (a'(aa'&a' ( Bo'(o)o*o4 5a(a 1ar Se''4 a'&&al! Ja'$ar 20"/4 5ara 51a ya'& bera'(a a'&a' (ba)a1 ' ,
Nama , (r. Po'& Hara( S$*eyo Jabaa' , Ke5ala P$*e*ma* #r$%$&a' U' Ker%a , P$*e*ma* #r$%$&a'
Dalam 1al ' ber'(a $'$ (a' aa* 'ama P$*e*ma* #r$%$&a' *ela'%$'ya (*eb$
P*AK
P*AK PER+APER+AMAMA
Nama , (r. A&$* S$)ar(%o4 M.Ke*
Jabaa' , Dre$r RSU (r. H Koe*'a( Bo'(o)o*o U' Ker%a , RSU (r. H Koe*'a( Bo'(o)o*o
Dalam 1al ' ber'(a $'$ (a' aa* 'ama Dre$r R$ma1 Sa Um$m (r. H Koe*'a( Bo'(o)o*o*ela'%$'ya (*eb$ P*AK KE)UA P*AK KE)UA
Para P1a erleb1 (a1$l$ me'era'&a' ,
". Ba1)aP*AK PER+AMAP*AK PER+AMAa(ala1 *eb$a1 U' Pela*a'a Te'* D'a* Ke*e1aa' ( ab$5ae' Bo'(o)o*o ya'& bera'&&$'& %a)ab me'yele'&araa' 5elaya'a'
e*e1aa' 5rmer ( )laya1 er%a'ya. P*AK KE)UAP*AK KE)UAa(ala1 *$a$ R$ma1 Sa ya'& meml $*a1a ya'& (alam b(a'& 5elaya'a' e*e1aa' erma*$ %a*a 5elaya'a' 6a$'(ry.
2. Ba1)a e($a bela 1 51a *e5a a $'$ me'&a(aa' er%a*ama (alam 5elay a'a' la$'(ry R$ma1 Sa Um$m (r. H. Koe*'a( Bo'(o)o*o.
Pasa" 0 Pasa" 0 Maksu, ,a
Maksu, ,a! +u! +uua!ua!
P1a Perama aa' me'&a'ar l'e' e5a(a P1a Ke($a4 (ma'a P1a Ke($a aa' me'erma ma*$( er*eb$ (e'&a' mela*a'aa' 5e'7$7a' aa$ la$'(ry *e*$a (e'&a' 5erm'aa' P1a Perama (a' ber(a*ara' ba'ya l'e' ya'& ela1 ( *era1a' e5a(a P1a
Ke($a.
Pasa" 1 Pasa" 1
+ata 2ara Pe"aksa!aa! +ata 2ara Pe"aksa!aa!
". 6'e' ya'& ela1 (a' ar ole1 P1 a Perama e5a(a P1a Ke($a ber $5a a' l'e' aa$ *5re ya'& ela1 (&$'aa' aa$ oor.
2. 6'e' aa$ *5re ya'& ( a'ar ole1 P1a Perama 1ar$* (em5aa' e(alam b$'&$* Pla* ya'& *$(a1 (be(aa' me'%a( ($a4 ya$ l'e' ya'& '8e*$* (a' l'e' ya'& (a '8e*$*.
3. D(alam b$'&$* 5la* ya'& ( a'ar ole1 P1a Perama 1ar$* er(a5a $l*a' ,
• Nama P$*e*ma*
• J$mla1 6'e' ya'& a(a ( (alam )a(a1 • Ta'&&al (a' %am l'e' ( a'ar e P1a Ke($a • Keera'&a' '8e*$* (a' (a '8e*$*
! A5abla 6'e' ya'& (erma ole1 P1a Ke($a (ar P1 a Perama (a meme'$1 5er*yaraa' aa$ (a le'&a54maa P1a Ke($a ber1a mela$a' 1al1al *eba&a ber$ ,
Mela$a' o'8rma*4 a5abla (aa ber$5a %$mla1 l'e'4 eera'&a' '8e*$* (a' (a '8e*$*4 er1a(a5 ea(aa' '. P1a Perama aa' mele'&a5 (aa ya'& (b$$1a' ole1 P1a Ke($a *e7ara er$l*.
6'e' aa$ *5 re ya'& aa' (7$7 aa' ( a' ara' ole1 P1a Perama e5a(a P1a e($a ( loa* la$'(ry RSU (r. H.Koe*'a( Bo'(o)o*o
/ Wa$ 5e'ermaa' ba1a' 5emer*aa' ole1 P1a Ke($a a(ala1 *eba&a ber$ , Har Se'' *.( Sab$ : P$$l 0;.30 *.( 20.30 WIB Har M'&&$ - 6b$r , P$$l 0.00 *.( "3.00 WIB
; Ke($a bela1 51a )a%b mela*a'aa' - mema$1 ee'$a' (alam 5er%a'%a' ' (e'&a' 5e'$1 a'&&$'& %a)ab (a' ee'$a' la''ya ya'& berla$ *eba&a *a'(ar 5elaya'a' 6a$'(ry aa$5$' *a'(ar 5ro*e($r ya'& berla$.
Pasa" 3 Pasa" 3
Pe!a!ggu!g Jawab ,a! A"amat K#resp#!,e!si Pe!a!ggu!g Jawab ,a! A"amat K#resp#!,e!si
". Pe'a'&&$'& Ja)ab 1ara' P1a Perama a(ala1 ,
Nama , N*. DIAN A<U KARTIKAWATI4 S.Ke5 Jabaa' , Koor('aor Ra)a I'a5 5$*e*ma* #r$%$&a' Alama , #r$%$&a'
No.H5 , 023/22;3
2. Pe'a'&&$'& ya'& ( ea5a' ole1 P1a Ke($a a(ala1 , Nama , N*. Sa8$l Wal(4S.Ke5.M.M.Ke*
Jabaa' , Ke5ala I'*a'* +SSD (a' 6a$'(ry
Alama , Jl. Ka5e' Pere Te'(ea' No.3 Ke7amaa' Bo'(o)o*o Kab$5ae' Bo'(o)o*o4 Ja)a Tm$r 92"!
No.H5 ,
3 S$ra me'y$ra *e1$b$'&a' (e'&a' 5ela*a'aa' 5er%a'%a' ' ($%$a' e5a(a Pe'a'&&$'& Ja)ab 1ara' (a' ( a'&&a5 ela1 (erma %a (*era (e'&a' a'(a 5e'ermaa''ya.
Pasa" 4 Pasa" 4
Pemberitahua! Sete"ah Pr#ses au!,r5 Pemberitahua! Sete"ah Pr#ses au!,r5
". P1a Ke($a aa' membe ra1$a' a5a' l'e' aa$ *5re b*a ( ambl ole1 P1a Perama 5a(a *aa P1a Perama me'&a'ar l'e' aa$ *5re
2. 6'e' aa$ *5re ya' & *$(a1 ( 7$7 b*a ( ambl ole1 P1a Perama eba&a' 6a$'(ry RSU (r.H.Koe*'a( Bo'(o)o*o aa$ ( a'ar e5a(a P$*e*ma* P1a Perama (e'&a' baya ra'*5ora* ya'& ela1 ( *e5aa.
Pasa" 6 Pasa" 6
Pe!gu"a!ga! au!,r5 ,a! Pe!gga!tia! i!e! Pe!gu"a!ga! au!,r5 ,a! Pe!gga!tia! i!e!
A5abla me'$r P1a Perama er(a5a 1a*l 5e'7$7a' l'e' ya'& (a mem$a*a' aa$ e1la'&a' aa$ er%a( er$*aa' *5re-l'e' *e1'&&a (5erl$a' 5e'7$7a' $la'& aa$ 5e'&&a'a' l'e'4 maa P1a Perama $'$ mela$a' 5e'7$7'a $la'& aa$ 5e'&&a'a'
l'e' (e'&a' ee'$a' ,
• 6'e' aa$ *5re ya'& ela1 (7$7 er'yaa ma*1 oor aa$5$' ba$
• J$mla1 l'e' ya'& ela1 melal$ 5ro*e* la$'(ry embal (e'&a' %$mla1 ya'& $ra'&
(ar %$mla1 l'e' ya'& ( a'ar ole1 P1a Perama (a' ela1 ( $l* *e7ara %ela* 5a(a era*
•
A5abla er%a( er$*aa' =robe4&o*o'&4ber$ba1 )ar'a> 5a(a l'e'-*5re
Pasa" 7 Pasa" 7 +ari8 Pemeriksaa! +ari8 Pemeriksaa!
". Tar8 la$'(ry (e'$a' 5er lo&ram ya'& *e*$a (e'&a' ya'& ela1 (ea5a' 2. Dalam 1al P1a Ke( $a aa' mela $a' 5er$ba1a' ar84 ma a P1a Ke($a aa'
memb$a *$ra 5embera1$a' e5a(a P1a Perama 5al'& lamba 30 =&a 5$l$1 > 1ar *ebel$m ar8 bar$ er*eb$ (berla$a'.
3. A5abla P1a Peram a (a me'ye$%$ 5er$ba1a' ar 8 =*eba&ama'a ( a$r (alam aya 2 5a*al ' > (a' a'ara e($a bela1 51a (a er7a5a e*e5aaa' me'&e'a 1al '4 maa 5er%a'%a' ' me'%a( 5$$* (a' bera1r (e'&a' *e'(r'ya. Pem$$*a' 5er%a'%a' er%a*ama 1al ' (a *era mera me'&1a5$* *e&ala e)a%ba' ya'& bel$m
er*ele*aa'.
Pasa" 9 Pasa" 9
+ata 2ara Pemba5ara! +ata 2ara Pemba5ara!
". P1a Perama aa' membayar *eela1 *em$a 5ro*e* la$'(ry er* eb$ *ele*a (a' l'e'-*5re *$(a1 (erma ole1 P1a Perama.
2. Har&a ya'& (e'aa' ber(a*ara' bera = 5er lo& ram> l'e' ya' & ( la$'(ry RSU (r.H.Koe*'a( Bo'(o)o*o.
Pasa" 0 Pasa" 0
Ja!gka Waktu Pera!ia! Ja!gka Waktu Pera!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' aa' bera1r a'&&al 02 J$' 20"
2. A5abla 5ara 51a '&' me'a1r 5er%a'%a' er %a*ama ' maa 5ara 51a bere)a%ba' $'$ membera1$a' *a$ (e'&a' ya'& la''ya 5al'& lamba 2 =($a > b$la' *ebel$m bera1r'ya ma*a 5er%a'%a' '.
3. Bera1r'ya ma*a berla$ 5er%a'%a' er% a*ama ' (a *era mera me'1 a5$*a' e)a%ba' ma*'&ma*'& er1a(a5 51a la''ya ya'& bel$m ereal*a*a'.
Pasa" 00 Pasa" 00 ;#r$e maeure ;#r$e maeure
". Ke($a bela1 51a *e5aa a5abla ((alam mela$a' 5e'7$7a' l'e'4 *e5er er*eb$ 5a(a 5a*al " =(aa* >4 P1a Ke($a me'&alam eerlambaa' ya'& (*ebaba' ole1 ea(a' 8or7e ma%e$re4 maa P1a Ke($a 1ar$* membera1$a'
*e7ara er$l* me'&e'a ea(aa' er*eb$ e5a(a P1a Ke($a *elambalamba'ya 2 ? 2! %am *eela1 er%a('ya 8or7e ma%e$re er*eb$.
2. Kea(aa' 8or7e ma%e$re *e5er er*eb$ 5a(a aya " =*a$> (aa* erma*$ ea5 (a erbaa* 5a(a 1al1al *eba&a ber$ , 5e5era'&a'4 1$r$ 1ara4 $'%$ ra*a ma**a4 5erombaa'4 r** 'a*o'al4 ebaara'4 *aboa*e4 e5(em74 be'7a'a alam *e5er ba'%r4 &em5a b$m.
3. A5abla er%a( ea( a' 8or7e ma%e$r e *e5er (aa *4 *e1'&&a (a mem$' &'a' P1a Perama (a' P1a Ke($a mela'%$a' 5er%a'%a' er%a*ama '4 maa Ke($a bela1 51a *e5aa $'$ me'yele*aa' *e&ala *e*$a$'ya *e7ara m$*ya)ara1.
Pasa" 01 Pasa" 01
Pe!5e"esaia! Perse"isiha! Pe!5e"esaia! Perse"isiha!
". Ja er%a( 5er*e l*1a' *eba&a ab a (ar 5ela*a'aa' 5er%a' %a' '4 ma a Ke($a bela1 51a *e5aa $'$ me'yele*aa' 5erma*ala1a' er*eb$ *e7ara m$*ya)ara1
&$'a me'7a5a m$8aa.
2. A5abla (e'&a' m$*ya)ara1 (a er7a5a m$8aa maa Ke($a bela1 51a *e5aa $'$ me'yele*aa' 5erma*ala1a' Pe'&a(la' Ne&er Bo'(o)o*o.
Pasa" 03 Pasa" 03
Pemutusa! / Pembata"a! Pera!ia! Pemutusa! / Pembata"a! Pera!ia!
". Per%a'%a' ' me'%a( baal (em 1$ $m aa$ (a5a ( 5$$ *a' *ea5 *aa *ebel$ m )a$'ya4 (e'&a' erleb1 (a1$l$ me'yam5aa' *$ra 5embera1$a' - 5er'&aa'4 a5abla er%a( 1al1al *e5er ber$ ' ,
a. Dalam 1al 5ara 51 a (a (a5 a meme'$1 e)a%ba''ya (a' aa$ mel a$a' 5ela'&&ara' er1a(a5 ee'$a'ee'$a' (alam 5er%a'%a' '.
b. Dalam 1al er%a('ya 8or7e ma%e$re *eba&ama'a (ma*$( (alam 5a*al "". 7. Para P1a ber1 a me'&a1r 5er%a'%a' ' *ebe l$m )a$'ya a5abla ( (alam
5el*a'aa' 5er%a'%a' *al1 *a$ aa$ e($a bela1 51a (a mam5$ meme'$1 ee'$a' ya'& ela1 ( a$r ((alam 5er%a'%a' ' berla'&*$'& membera' eera'&a' 5al*$ aa$ (5al*$a'.
2. Hal ' (la$a' *e7ara er$l* ole1 ma*'&ma*'& 51a 30 =T&a P$l$1> 1ar *ebel$m 5er%a'%a' ' ('yaaa' (a1r.
Pasa" 04 Pasa" 04 ai! < "ai! 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 ' aa' (
*ele*aa' (a' ( a$r aa* (a*ar 5er*e$%$a' ber*ama (alam *eb$a1 a((e'($m ya'& mer$5aa' ba&a' ya'& me'&a *era (a er5*a1a' (ar 5er%a'%a' '.
Pasa" 06 Pasa" 06 Pe!utup Pe!utup
". S$ra 5er%a'%a' ' (b$a ra'&a5 2 =($a> (a'(aa'&a' ( aa* maera ya'& 7$$5 (a' mem5$'ya e$aa' 1$$m ya'& *ama $a'ya4 ma*'& ma*'& $'$ P1a Perama (a' P1a Ke($a *era (a5a ( 5erba'ya *e*$a eb$$1a'.
2. S$ra Per%a'%a' Ker%a*ma ' ( b$a (a' (a'(aa'&a' ( Bo'(o)o*o 5a(a a'&&al er*eb$ ( aa*.
P*AK
P*AK PER+APER+AMAMA K##r,i!at#r Rawat *!ap K##r,i!at#r Rawat *!ap
Puskesmas Gruuga! Puskesmas Gruuga!
Ns.)*AN AU KAR+*KAWA+*&S.Kep Ns.)*AN AU KAR+*KAWA+*&S.Kep
NIP."920;" 2000" 2 00 P*AK KE)UA P*AK KE)UA )irektur )irektur RSU ,r..K#es!a,i '#!,#w#s# RSU ,r..K#es!a,i '#!,#w#s# ,r
,r.. A AGUS GUS SUWAR)JSUWAR)J*+( *+( & M& M.K.Keses. NIP. "9/!0920 "990"" " 002 Me!getahui Me!getahui Kepa"a Puskesmas Kepa"a Puskesmas Gruuga! Gruuga! ,r. P(NG A
,r. P(NG AR*A)R*A)* SUS* SUSE+(E+(
NIP."9;;0920 200/0! " 0"2
)irektur RSU ,r..K#es!a,i )irektur RSU ,r..K#es!a,i
'#!,#w#s# '#!,#w#s#
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,r. AGU AGUS SUS SUWAWARJ*)RJ*)+(.M.+(.M.KesKes
