364 lines
12 KiB
PHP
364 lines
12 KiB
PHP
<html>
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<head>
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<meta http-equiv=Content-Type content="text/html; charset=windows-1252">
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<meta name=ProgId content=Excel.Sheet>
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<meta name=Generator content="Microsoft Excel 15">
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<style id="Surat Pernyataan_8298_Styles">
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@page {
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margin: 1cm;
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}
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<!--table
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.xl158298
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{padding-top:1px;
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mso-ignore:padding;
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font-size:12.0pt;
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{padding-top:1px;
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mso-ignore:padding;
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font-size:12.0pt;
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font-weight:400;
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font-style:normal;
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text-decoration:none;
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font-family:Arial, sans-serif;
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{padding-top:1px;
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padding-right:1px;
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font-size:12.0pt;
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font-weight:400;
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text-decoration:none;
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font-family:Arial, sans-serif;
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{padding-top:1px;
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mso-ignore:padding;
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font-size:12.0pt;
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font-weight:700;
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font-style:normal;
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text-decoration:none;
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font-family:"Arial Black", sans-serif;
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mso-font-charset:0;
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{padding-top:1px;
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mso-ignore:padding;
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font-size:12.0pt;
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text-decoration:none;
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font-family:Arial, sans-serif;
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white-space:normal;}
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-->
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</style>
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</head>
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<body>
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<div id="Surat Pernyataan_8298" align=center x:publishsource="Excel">
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<table border=0 cellpadding=0 cellspacing=0 width=588 style='border-collapse:
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collapse;table-layout:fixed;width:440pt'>
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<col width=123 style='mso-width-source:userset;mso-width-alt:4498;width:92pt'>
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<col width=75 style='mso-width-source:userset;mso-width-alt:2742;width:56pt'>
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<col width=16 style='mso-width-source:userset;mso-width-alt:585;width:12pt'>
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<col width=179 style='mso-width-source:userset;mso-width-alt:6546;width:134pt'>
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<col width=195 style='mso-width-source:userset;mso-width-alt:7131;width:146pt'>
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<tr height=26 style='height:19.5pt'>
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<td colspan=5 height=26 class=xl678298 width=588 style='height:19.5pt;
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width:440pt'>
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<img src="<?php echo _BASE_.'assets/images/'.$_SESSION['kop_surat']; ?>" style="width:440pt">
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</td>
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</tr>
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<tr height=26 style='height:19.5pt'>
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<td colspan=5 height=26 class=xl678298 width=588 style='height:19.5pt;
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width:440pt'><a name="RANGE!A1:E36">SURAT PERNYATAAN</a></td>
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</tr>
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<tr height=20 style='height:15.0pt'>
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<td height=20 class=xl638298 style='height:15.0pt'></td>
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<td class=xl638298></td>
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<td class=xl638298></td>
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<td class=xl638298></td>
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<td class=xl638298></td>
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</tr>
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<tr height=21 style='height:15.75pt'>
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<td colspan=5 height=21 class=xl688298 width=588 style='height:15.75pt;
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width:440pt'>Yang bertanda tangan di bawah ini :</td>
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</tr>
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<tr height=21 style='height:15.75pt'>
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<td colspan=2 height=21 class=xl658298 style='height:15.75pt'>Nama </td>
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<td class=xl648298>:</td>
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<td colspan=2 class=xl658298><?php echo $nama_keluarga; ?></td>
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</tr>
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<tr height=21 style='height:15.75pt'>
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<td colspan=2 height=21 class=xl658298 style='height:15.75pt'>Alamat (Sesuai KTP)</td>
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<td class=xl648298>:</td>
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<td colspan=2 class=xl658298><?php echo $alamat_keluarga; ?></td>
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</tr>
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<tr height=21 style='height:15.75pt'>
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<td colspan=2 height=21 class=xl658298 style='height:15.75pt'>Umur</td>
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<td class=xl648298>:</td>
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<td colspan=2 class=xl658298><?php echo $umur_keluarga; ?> Th</td>
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</tr>
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<tr height=21 style='height:15.75pt'>
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<td colspan=2 height=21 class=xl658298 style='height:15.75pt'>Pekerjaan</td>
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<td class=xl648298>:</td>
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<td colspan=2 class=xl658298><?php echo $pekerjaan_keluarga; ?></td>
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</tr>
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<tr height=21 style='height:15.75pt'>
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<td colspan=2 height=21 class=xl658298 style='height:15.75pt'>No Telp / HP</td>
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<td class=xl648298>:</td>
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<td colspan=2 class=xl658298><?php echo $notelp_keluarga; ?></td>
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</tr>
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<tr height=40 style='mso-height-source:userset;height:30.0pt'>
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<td colspan=5 height=40 class=xl688298 width=588 style='height:30.0pt;
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width:440pt'>Dengan ini menyatakan :</td>
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</tr>
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<tr height=21 style='height:15.75pt'>
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<td colspan=2 height=21 class=xl658298 style='height:15.75pt'>Nama Pasien</td>
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<td class=xl648298>:</td>
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<td colspan=2 class=xl658298><?php echo $nama_ybs; ?></td>
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</tr>
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<tr height=21 style='height:15.75pt'>
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<td colspan=2 height=21 class=xl658298 style='height:15.75pt'>Alamat </td>
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<td class=xl648298>:</td>
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<td colspan=2 class=xl658298><?php echo $alamat_ybs; ?></td>
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</tr>
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<tr height=21 style='height:15.75pt'>
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<td colspan=2 height=21 class=xl658298 style='height:15.75pt'>No. RM / No. Billing</td>
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<td class=xl648298>:</td>
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<td colspan=2 class=xl658298><?php echo $nomr.' / '.$nobilling; ?></td>
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</tr>
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<tr height=21 style='height:15.75pt'>
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<td colspan=2 height=21 class=xl658298 style='height:15.75pt'>Tgl MRS / Tgl KRS</td>
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<td class=xl648298>:</td>
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<td colspan=2 class=xl658298><?php echo $tanggal_mrs; ?></td>
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</tr>
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<tr height=21 style='height:15.75pt'>
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<td colspan=2 height=21 class=xl658298 style='height:15.75pt'>Tempat Layanan</td>
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<td class=xl648298>:</td>
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<td colspan=2 class=xl658298><?php echo $ruang; ?></td>
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</tr>
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<tr height=21 style='height:15.75pt'>
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<td colspan=5 height=21 class=xl688298 width=588 style='height:15.75pt;
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width:440pt'>Adalah benar masih mempunyai tanggungan biaya sejumlah Rp. <?php echo $total.' <br>( '.$dengan_huruf.' )'; ?></td>
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</tr>
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<tr height=21 style='height:15.75pt'>
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<td height=21 class=xl648298 colspan=5 style='height:15.75pt'>Adapun tanggungan tersebut akan kami selesaikan dalam waktu <?php echo $jumlah_hari; ?> hari.</td>
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</tr>
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<?php if($keterangan != '') {?>
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<tr height=21 style='height:15.75pt'>
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<td height=21 class=xl648298 colspan=5 style='height:15.75pt'><?php echo $keterangan; ?> </td>
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</tr>
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<?php } ?>
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<tr height=21 style='height:15.75pt'>
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<td height=21 class=xl648298 colspan=5 style='height:15.75pt'>Demikian pernyataan ini dibuat untuk dipergunakan sebagaimana mestinya.</td>
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</tr>
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<tr height=21 style='height:15.75pt'>
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<td height=21 class=xl648298 style='height:15.75pt'></td>
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<td class=xl648298></td>
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<td class=xl648298></td>
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<td class=xl648298></td>
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<td class=xl648298></td>
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</tr>
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<tr height=21 style='height:15.75pt'>
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<td height=21 class=xl648298 style='height:15.75pt'></td>
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<td class=xl648298></td>
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<td class=xl648298></td>
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<td class=xl648298></td>
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<td class=xl648298></td>
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</tr>
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<tr height=21 style='height:15.75pt'>
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<td height=21 class=xl648298 style='height:15.75pt'></td>
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<td class=xl648298></td>
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<td class=xl648298></td>
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<td class=xl648298></td>
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<td class=xl648298></td>
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</tr>
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<tr height=21 style='height:15.75pt'>
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<td height=21 class=xl648298 style='height:15.75pt'>Mengetahui,</td>
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<td class=xl648298></td>
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<td class=xl648298></td>
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<td class=xl648298></td>
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<td class=xl648298>Malang, Tgl, <?php echo $tanggal_akad; ?></td>
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</tr>
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<tr height=21 style='height:15.75pt'>
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<td height=21 class=xl648298 style='height:15.75pt'>Petugas Loket</td>
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<td class=xl648298></td>
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<td class=xl648298></td>
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<td class=xl648298></td>
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<td class=xl648298>Yang membuat pernyataan</td>
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</tr>
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<tr height=21 style='height:15.75pt'>
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<td height=21 class=xl648298 style='height:15.75pt'></td>
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<td class=xl648298></td>
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<td class=xl648298></td>
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<td class=xl648298></td>
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<td class=xl648298></td>
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</tr>
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<tr height=21 style='height:15.75pt'>
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<td height=21 class=xl648298 style='height:15.75pt'></td>
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<td class=xl648298></td>
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<td class=xl648298></td>
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<td class=xl648298></td>
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<td class=xl648298></td>
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</tr>
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<tr height=21 style='height:15.75pt'>
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<td height=21 class=xl648298 style='height:15.75pt'></td>
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<td class=xl648298></td>
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<td class=xl648298></td>
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<td class=xl648298></td>
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<td class=xl648298></td>
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</tr>
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<tr height=21 style='height:15.75pt'>
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<td height=21 class=xl648298 style='height:15.75pt'></td>
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<td class=xl648298></td>
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<td class=xl648298></td>
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<td class=xl648298></td>
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<td class=xl648298></td>
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</tr>
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<tr height=21 style='height:15.75pt'>
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<td height=21 class=xl648298 style='height:15.75pt'>( <?php echo $_SESSION['NAMA_PEGAWAI']; ?> )</td>
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<td class=xl648298></td>
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<td class=xl648298></td>
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<td class=xl648298></td>
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<td class=xl648298>( <?php echo $nama_keluarga; ?> )</td>
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</tr>
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<tr height=21 style='height:15.75pt'>
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<td height=21 class=xl648298 style='height:15.75pt'></td>
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<td class=xl648298></td>
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<td class=xl648298></td>
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<td class=xl648298></td>
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<td class=xl648298></td>
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</tr>
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<tr height=21 style='height:15.75pt'>
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<td height=21 class=xl648298 style='height:15.75pt'></td>
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<td class=xl648298></td>
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<td class=xl648298></td>
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<td class=xl648298></td>
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<td class=xl648298></td>
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</tr>
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<tr height=21 style='height:15.75pt'>
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<td height=21 class=xl648298 style='height:15.75pt'>Keterangan :</td>
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<td class=xl648298></td>
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<td class=xl648298></td>
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<td class=xl648298></td>
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<td class=xl648298></td>
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</tr>
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<tr height=21 style='height:15.75pt'>
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<td height=21 class=xl648298 style='height:15.75pt'>Lembar 1</td>
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<td colspan=4 class=xl668298>: Bagian Tagihan - Sub. Bag. Penerimaan & Pendapatan</td>
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</tr>
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<tr height=21 style='height:15.75pt'>
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<td height=21 class=xl648298 style='height:15.75pt'>Lembar 2</td>
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<td colspan=4 class=xl668298>: Pasien / Penangung Jawab Pasien</td>
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</tr>
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<tr height=21 style='height:15.75pt'>
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<td height=21 class=xl648298 style='height:15.75pt'>Lembar 3</td>
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<td colspan=4 class=xl668298>: Tempat Layanan</td>
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</tr>
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<![if supportMisalignedColumns]>
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<tr height=0 style='display:none'>
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<td width=123 style='width:92pt'></td>
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<td width=75 style='width:56pt'></td>
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<td width=16 style='width:12pt'></td>
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<td width=179 style='width:134pt'></td>
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<td width=195 style='width:146pt'></td>
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</tr>
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<![endif]>
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</table>
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</div>
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</body>
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</html>
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