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						inner join petugas on surat_pernyataan_pasien_umum.nip=petugas.nip
						inner join kelurahan on pasien.kd_kel=kelurahan.kd_kel
						inner join kecamatan on pasien.kd_kec=kecamatan.kd_kec
						inner join kabupaten on pasien.kd_kab=kabupaten.kd_kab
						inner join propinsi on pasien.kd_prop=propinsi.kd_prop]]>
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				<text><![CDATA[SEBAGAI PASIEN UMUM]]></text>
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				<text><![CDATA[Yang bertanda tangan di bawah ini :]]></text>
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				<text><![CDATA[Penanggung Jawab Pasien]]></text>
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				<text><![CDATA[No. RM]]></text>
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				<text><![CDATA[Dengan ini atas permintaan sendiri, meminta dilayani sebagai ...............................................]]></text>
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				<text><![CDATA[dan]]></text>
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				<text><![CDATA[sanggup membayar biaya perawatan dan pengobatan sebagai pasien UMUM dan tidak akan menggunakan]]></text>
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				<text><![CDATA[BPJS / KIS Asuransi Lainnya sampai batas waktu perawatan selesai serta tidak akan melakukan klaim]]></text>
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				<text><![CDATA[terhadap biaya perawatan dan pengobatan yang dikeluarkan untuk pasien :]]></text>
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