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Dokumen ini menyediakan contoh format surat permohonan, termasuk identitas pemohon dan data sarana, serta ketentuan lampiran yang harus disertakan. Turut disajikan daftar kelengkapan administrasi permohonan izin atau surat terdaftar, meliputi berkas legalitas, status bangunan, perizinan terkait, dokumen tenaga kesehatan, rekomendasi dinas kesehatan, tarif, serta jenis pelayanan dan keterangan jam operasional.",{"@graph":51,"@context":98},[52,68,89],{"@type":53,"itemListElement":54},"BreadcrumbList",[55,59,62,65],{"item":56,"name":57,"@type":58,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":60,"name":10,"@type":58,"position":61},"https://docshare.wps.com/id/template/",2,{"item":63,"name":15,"@type":58,"position":64},"https://docshare.wps.com/id/template/formulir/",3,{"item":66,"name":47,"@type":58,"position":67},"https://docshare.wps.com/id/template/health-service-facility-permit-application-document-format-pasuruan-mayor-regulation-annex-iii-no-122017/204472/",4,{"url":66,"name":47,"@type":69,"image":70,"author":75,"headline":47,"publisher":78,"fileFormat":81,"inLanguage":45,"description":49,"dateModified":82,"datePublished":83,"encodingFormat":81,"isAccessibleForFree":84,"interactionStatistic":85},"DigitalDocument",{"url":71,"@type":72,"width":73,"height":74},"https://docshare.wps.com/thumbnails/health-service-facility-permit-application-document-format-pasuruan-mayor-regulation-annex-iii-no-122017/204472.png","ImageObject",442,249,{"name":76,"@type":77},"นรินทร์","Person",{"url":56,"name":79,"@type":80},"DocShare","Organization","application/pdf","2026-09-18","2026-09-05",true,{"@type":86,"interactionType":87,"userInteractionCount":61},"InteractionCounter",{"@type":88},"ViewAction",{"@type":90,"mainEntity":91},"FAQPage",[92],{"name":93,"@type":94,"acceptedAnswer":95},"Dokumen apa yang disertakan terkait tenaga medis dan tenaga kefarmasian dalam persyaratan?","Question",{"text":96,"@type":97},"Persyaratan mencakup fotokopi SIP/SIK yang masih berlaku untuk dokter penanggung jawab, SIPA untuk apoteker penanggung jawab, SIP untuk tenaga medis, dokumen ijazah/SIP/SIK tenaga keperawatan, serta dokumen terkait asisten apoteker dan tenaga non medis.","Answer","https://schema.org",{"og:url":66,"og:type":100,"og:title":47,"og:site_name":79,"og:description":49},"article",{"robots":102,"canonical":66},"index,follow",{"doc_id":104,"site_id":44},204472,1788573769,{"code":4,"msg":5,"data":107},{"doc_id":104,"user_id":108,"nickname":76,"user_avatar":109,"doc_module":9,"category_id":14,"category_name":15,"doc_title":47,"doc_description":49,"doc_content":110,"file_id":111,"file_url":112,"file_type":113,"file_size":114,"view_count":4,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":115,"language":116,"language_code":45,"site_id":44,"html_lang":45,"table_of_contents":117,"faqs":118,"seo_title":119,"seo_description":49,"update_tm":105,"read_time":120},2336475104957,"https://ap-avatar.wpscdn.com/avatar/22000c4c6bd8a5076e1?x-image-process=image/resize,m_fixed,w_180,h_180&k=1787554080175789136","-30-  \nLAMPIRAN III  \nPERATURAN WALIKOTA PASURUANNOMOR 12 TAHUN 2017  \nTENTANG  \nPETUNJUK PELAKSANAAN PERATURAN DAERAH KOTA PASURUAN NOMOR 09 TAHUN 2013 TENTANG PERIZINAN  \nBIDANG KESEHATAN  \nFORMAT DOKUMEN PERMOHONAN IZIN/SERTIFIKAT  \nA. FORMAT DOKUMEN PERMOHONAN IZIN FASILITAS PELAYANAN KESEHATAN  \n1. FORMAT SURAT PERMOHONAN  \nPasuruan, ...................... 20…….  \nKepada  \nNomor : Yth. Walikota Pasuruan  \nLampiran : cq. Kepala Dinas Penanaman  \nPerihal : Permohonan Izin ...... / Modal dan PTSP Kota Pasuruan  \nSurat Terdaftar ........... di  \nPASURUAN  \nYang bertanda tangan di bawah ini:  \nNama : ............................................ ..............................................  \nAlamat Rumah : .................................... ...................................................   Pekerjaan : ....................................... ...................................................  \nAtas nama Perorangan/Badan:  \nNama : ............................................ ..............................................  \nAlamat : .......................................... ................................................  \nBersama ini mengajukan permohonan untuk mendapatkan Izin ........../Surat Terdaftar .......... dengan data, sebagai berikut:  \nNama Sarana : .................................... ...................................................   Alamat : ......................................... .................................................  \nKecamatan : ...................................... ................................................... .  \nKota : Pasuruan  \nDengan Pemilik (khusus Rumah Sakit)/Penanggung Jawab:  \nNama : .......................................... ..............................................  \nAlamat Rumah : .................................. ...................................................   Pekerjaan : ..................................... ...................................................  \nNomor SIP/SIK : ................................. ................................................... ....  \nSebagai bahan pertimbangan kami lampirkan:  \n1    \n2    \n3. dst. (sesuai persyaratan)  \nDemikian permohonan ini dibuat dengan harapan untuk dapat disetujui.  \nPemohon,  \nMaterai Rp6.000,00  \n-31-  \n2. FORMAT DAFTAR KELENGKAPAN ADMINISTRASI  \nDAFTAR KELENGKAPAN ADMINISTRASI  \nPERMOHONAN IZIN ........../SURAT TERDAFTAR ……….  \nNama Sarana : ..................................... ........................................  \nAlamat : .......................................... ...................................  \nKelurahan : ....................................... ......................................  \nKecamatan : ....................................... ......................................  \nKota : Pasuruan  \nNama Pemohon : .................................... .........................................  \nAlamat : .......................................... ...................................  \nTelepon : .............………………………………….…………………..  \nNama Penanggung Jawab: .............……………………………………………………... Alamat :   .............    \nTelepon : ......................................... ....................................  \nTanggal diterima : ................................ .............................................  \n\n| NO. | JENIS BERKAS | KETERANGAN |\n| --- | --- | --- |\n| 1. | Permohonan Kepada Walikota melalui Kepala Dinas Penanaman Modal dan PTSP bermaterai Rp6.000,00\u003Cbr>Nomor ………………………….…………………Tanggal ……………………… | Ada/Tidak |\n| 2. | Fotokopi Akte Pendirian\u003Cbr>a. Nama   Nomor ..………………..………...............…. Tanggal …...……….....…… Nama Notaris   di  \u003Cbr>b. KTP\u003Cbr>Nomor ......................................... ................................................... .. Tanggal ...................................... berlaku s.d. .................................. | Ada/Tidak |\n| 3. | Fotokopi Izin Gangguan/HO\u003Cbr>Nama   Nomor   Tanggal …………………………………………..………………................... .... | Ada/Tidak |\n|","cbCaigH682lplte2","https://ap.wps.com/l/cbCaigH682lplte2","pdf",217996,22,"Indonesian","# Format Surat Permohonan\n## Identitas pemohon dan data sarana\n# Format Daftar Kelengkapan Administrasi\n## Daftar berkas persyaratan permohonan","[{\"question\":\"Dokumen apa yang disertakan terkait tenaga medis dan tenaga kefarmasian dalam persyaratan?\",\"answer\":\"Persyaratan mencakup fotokopi SIP/SIK yang masih berlaku untuk dokter penanggung jawab, SIPA untuk apoteker penanggung jawab, SIP untuk tenaga medis, dokumen ijazah/SIP/SIK tenaga keperawatan, serta dokumen terkait asisten apoteker dan tenaga non medis.\"}]","Format Dokumen Permohonan Izin Fasilitas Pelayanan Kesehatan - Lampiran III Perwal Pasuruan Nomor 12 Tahun 2017 | PDF",8]