MOU LABORATORIUM LABORATORIUM PERJANJIAN KERJASAMA ANTARA LABORATORIUM KLINIK ………………………. DENGAN RS…………………………………………….. TENTANG PELAYANAN PELAYANAN LABORAT LA BORATORIUM ORIUM KLINIK No. ……. / MoU/ I / 2011 Pada hari ii!…………………. Ta"""a# ……………………………. B$#a…………………….. %ah$ d$a ri&$ '(&(#a'! ) …*…*2011 + di B(,a'i! -ara -iha, a" &(r%ada %a"a di&aah ii Naa
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Da#a ha# ii &(r%ida, $%$, da a%a' aa La&ora%ori$ K#ii, Ido(d '(#a$%a di'(&$% Piha, P(r%aa Naa
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Da#a ha# ii &(r%ida, $%$, da a%a' aa RS ……………………………… S(#a$%a di'(&$% Pihak Kedua K(d$a &(#ah -iha, %(r#(&ih dah$#$ ((ra",a
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Baha Piha, P(r%aa ada#ah '$a%$ -(r$'ahaa a" (#a,$,a ,("ia%a $'aha da#a &ida" a'a -(#aaa La&ora%ori$ ,#ii,. Baha Piha, K(d$a 3ada#ah '$a%$ -(r$'ahaa a" &(r"(ra, di&ida" -(#aaa ,('(ha%a. Baha ,(d$a &(#ah -iha, '(-a,a% $$%, ("ada,a ,(ra'aa da#a ha# r$$,a -((ri,'aa #a&ora%ori$ K#ii, di La&ora%ori$ K#ii, ………………….
B(rda'ar,a ha# 4 ha# %(r'(&$% dia%a'! a,a ,(d$a &(#ah -iha, '(-a,a% $%$, (#a,'aa,a -(raia ,(ra'aa d("a ,(%(%$a*,(%(%$a '(&a"ai &(ri,$% Pasal 1 Maksud dan Tujuan
Piha, K(d$a a,a (r$$, &aha -((ri,'aa #a&ora%ori$ ,(-ada Piha, P(r%aa! diaa Piha, P(r%aa a,a ((ria a,'$d %(r'(&$% d("a (#a,'aa,a -((ri,'aa #a&ora%ori$ '('$ai d("a -(ri%aa Piha, K(d$a da &(rda'ar,a ,(%(%$a -((ri,'aa a" %(#ah di'(-a,a%i o#(h ,(d$a &(#ah -iha,. Pasal 2 Tata Cara Pelaksanaan
1. Baha -((ri,'aa a" dir$$, o#(h Piha, K(d$a ,(-ada -iha, -(r%aa &(r$-a &aha a" 'ia- di-(ri,'a ) 'a-(# + da a%a$ &aha a" &(#$ 'ia- di-(ri,'a ) '-(5i( +. 2. Baha -((ri,'aa a" dir$$, o#(h Piha, K(d$a ,(-ada Piha, P(r%aa har$' (($hi -(r'ara%a -("iria '-(5i(/'a-(# a" %(#ah di%(%a-,a! ai%$ '('$ai d("a Da6%ar P((ri,'aa R$$,a a" di&$a% o#(h Piha, P(r%aa. 7. Baha -((ri,'aa a" di,iri o#(h Piha, K(d$a ,(-ada Piha, P(r%aa har$' di#(",a-i d("a da%a a" #(",a-! a%ara #ai o
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Ta""a# da a -("a&i#a &aha -((ri,'aa
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Kodi'i -a'i( 'aa% &aha -((ri,'aa dia&i# )i'a#8 -$a'a! '(da" (a#ai %h(ra-/-("o&a%a %(r%(%$! d'## + Kodi'i &aha ) i'a# 9o#$(! ara! &a$! 9i'5o'i%a'! a",a a,%$ -(i-aa! '$h$ -(i-aa! d## +
:. A-a&i#a &aha da a%a$ id(%i%a' -((ri,'aa a" di%(ria o#(h Piha, P(r%aa dari Piha, K(d$a %ida, (($hi -(r'ara%a a%a$ %ida, #(",a-! a,a Piha, P(r%aa &(rha, (#a,$,a ha# 4 ha# '(&a"ai &(ri,$% o
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M(#a,$,a ,o6ira'i! a-a&i#a da%a &(r$-a id(%i%a' da a%a$ i6ora'i %(%a" &aha -((ri,'aa %ida, #(",a-! %(rhada- ,(adaa ii. Piha, K(d$a a, a (#(",a-i da%a a" di&$%$h,a o#(h Piha, P(r%aa '(5ara %(r%$#i'. M(o#a, &aha -((ri,'aa a-a&i#a ,odi'i &aha -((ri,'aa %ida, '('$ai d("a -(r'ara%a a" di%(%a-,a '(&a"aiaa dia%$r da#a Da6%ar P((ri,'aa R$$,a! -(o#a,a a%a' &aha -((ri,'aa har$' di#a,$,a '(5ara %(r%$#i' d("a ((#a',a '(&a& a%a$ a#a'a -(o#a,a %(r'(&$%.
;. Baha -((ri,'aa a" dir$$, o#(h Piha, K(d$a ,(-ada Piha, P(r%aa a,a dia&i# o#(h Piha, P(r%aa ,( #o,a'i La& RS …………………………. <. =a,%$ -((riaa &aha -((ri,'aa o#(h Piha, P(r%aa ada#ah '(&a"ai &(ri,$% >ari S(i '.d Sa&%$ 8 -$,$# 0?.70 '.d 20.70 =IB>ari Mi""$ / #i&$r P$,$#
[email protected] '.d 1.00 =IB ?. K(d$a &(#ah -iha, ai& (#a,'aa,a / (a%$hi ,(%(%$a da#a -(raia ii d("a -($h %a""$" aa& da ,(%(%$a #aia a" &(r#a,$ '(&a"ai '%adar -(#aaa La&ora%ori$ a%a$-$ '%adar -ro'(d$r a" &(r#a,$. Pasal Kerahasian Medis
K(d$a &(#ah -iha, '(#aa -(#a,'aa -(raia ii a$-$ '(%(#ah '(#a'aia -(raia ii! ai& '(a%ia'a (a"a ,(raha'iaa da%a/id(%i%a' -a'i( da ha'i# -((ri,'aa '(&a"aiaa ,(%(%$a -(r$da" 4$da"a a" ("a%$r ("(ai ,(raha'ia (di'. Pasal ! Penan""un" #a$a% dan Ala&at K'res('ndensi
1. P(a""$" aa& haria Piha, P(r%aa ada#ah Naa
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Maa"(r O-(ra'ioa# Kor('-od('i
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2. P(a""$" aa& haria a" di%(%a-,a o#(h Piha, K(d$a ada#ah Naa
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Kor('-od('i
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7. S$ra% ($ra% '(h$&$"a d("a -(#a,'aa -(raia ii di%$$,a ,(-ada -(a""$" aa& haria da dia""a- %(#ah di%(ria i,a di'(r%ai d("a %ada -((riaaa. Pasal ) La('ran *asil Pe&eriksaan
1. Piha, P(r%aa a,a ((r&i%,a ha'i# -((ri,'aa da#a &(%$, a%a$ %a-i#a da 6ora% '('$ai d("a 6ora% &a,$ a" %(#ah di%(%$,a Piha, P(r%aa. 2. >a'i# -((ri,'aa a,a di'(rah,a ,(-ada Piha, K(d$a d("a 5ara di,iri o#(h Piha, P(r%aa ,(-ada Piha, K(d$a '(#a&a%*#a&a%a 7 ) %i"a + hari '(%(#ah -(#a,'aaa -((ri,'aa a%a$ '('$ai ada#. Pasal + Pen"ulan"an Pe&eriksanan
1. A-a&i#a ($r$% Piha, K(d$a %(rda-a% ha'i# -((ri,'aa a" (ra"$,a '(hi""a di-(r#$,a -((ri,'aa $#a"! a,a Piha, P(r%aa &(r'(dia $%$, (#a,$,a -((ri,'aa $#a"! d("a ,(%(%$a •
>a'i# -((ri,'aa %ida, '('$ai d("a -ro"o'a do,%(r -((ri,'a a%a$ %(rda-a% a#a'a 4 a#a'a #ai a" da-a% di-(r%a""$"aa&,a '(5ara (di'.
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I%(r-r(%a'i ha'i# -((ri,'aa a" dia""a- (ra"$,a %(r'(&$% di'a-ai,a '(5ara %(r%$#i' dari do,%(r -("iri. P("$#a"a -((ri,'aa d("a ("$a,a &aha -((ri,'a a" '$dah ada! a%a$ &aha -((ri,'aa &ar$ di%(%$,a &(rda'ar,a '%a&i#i%a' &aha -((ri,'aa %(r'(&$%. Da#a ha# har$' di#a,$,a -((ri,'aa $#a" d("a &aha -((ri,'aa &ar$! a,a ,odi'i -a'i( har$' 'aa d("a ,odi'i -ada 'aa% &aha -((ri,'aa '(&(#$a dia&i#. Pasal , Tari- Pe&eriksaan
1. Tari6 -((ri,'aa #a&ora%ori$ a" di&(r#a,$,a da#a -(raia ii 'aa d("a %ari6 a" '(da" di&(r#a,$,a '(5ara $$ o#(h Piha, P(r%aa di #a&ora%ori$ ,#ii,a. 2. Da#a ha# Piha, P(r%aa a,a (#a,$,a -(r$&aha %ari6 -((ri,'aa! a,a Piha, P(r%aa a,a (&$a% '$ra% -(&(ri%ah$a ,(-ada Piha, K(d$a -a#i" #a&a% 70 )%i"a -$#$h+ hari '(&(#$ %ari6 &ar$ %(r'(&$% di&(r#a,$,a. 7. A-a&i#a Piha, K(d$a %ida, ((%$$i -(r$&aha %ari6 -((ri,'aa )'(&a"aiaa di a%$r da#a -a'a# aa% 2 -a'a# ii+ da a%ara ,(d$a &(#ah -iha, %ida, %(r5a-ai ,('(-a,a%a ("(ai ha# ii! a,a -(raia ii (adi -$%$' da &(ra,hir d("a '(diria. P($%$'a -(raia ,(ra'aa ha# ii %ida, '(r%a (r%a ("ha-$' '("a#a ,(ai&a a" &(#$ %(r'(#('ai,a. Pasal P't'n"an Tari- Pe&eriksaan
Piha, P(r%aa a,a (&(ri,a -o%o"a %ari6 -((ri,'aa '(&('ar …… )……. -(r'(+ ,(-ada Piha, K(d$a $%$, '(%ia- -((ri,a'aa a" di r$$, o#(h Piha, K(d$a ,(-ada Piha, P(r%aa.
Pasal / Tata Cara Pe&%a0aran
1. Piha, K(d$a a,a (&aar '(%(#ah '($a -((ri,'aa %(r'(&$% '(#('ai da ha'i# '$dah di%(ria o#(h Piha, ,(d$a.
2. >ar"a a" di,(a,a &(rda'ar,a $#ah da (i' -((ri,'aa #a&ora%ori$ a" %(#ah dir$$, o#(h Piha, K(d$a.
Pasal 1 #an"ka aktu Perjanjian
1. P(raiia ,(ra'aa ii &(r#a,$ a",a a,%$ 2 )d$a+ %ah$! %(rhi%$" '(a, di%ada %a"aia '$ra% -(raia ii da a,a &(ra,hir %a""a# …….. J$i 2017 2. A-a&i#a -ara -iha, i"i ("a,hiri -(raia ,(ra'aa ii a,a -ara -iha, &(r,(ai&a $%$, (&(ri%ah$,a 'a%$ d("a a" #aia -a#i" #a&a% 2 )d$a+ &$a# '(&(#$ &(ra,hira a'a -(raia ii. 7. B(ra,hira a'a &(r#a,$ -(raia &(,(ra'aa ii %ida, '(r%a(r%a ("ha-$',a ,(ai&a a'i" 4 a'i" -iha, %(rhada- -iha, #aia a" &(#$ %(ra#i'a'i,a.
Pasal 11 3'r4e Majeure
1. K(d$a &(#ah -iiha, '(-a,a% a-a&i#a dida#a (#a,$,a -((ri,'aa! '(-(r%i %(r'(&$% -ada -a'a# 1 ) dia%a' +! Piha, P(r%aa ("a#ai ,(%(r#a&a%a a" di'(&a&,a o#(h ,(adaa 6or5( (a$r(! a,a Piha, P(r%aa har$' (&(ri%ah$,a '(5ara %(r%$#i' ("(ai ,(adaa %(r'(&$% ,(-ada Piha, K(d$a '(#a&a% 4 #a&a%a 2 C 2: a '(%(#ah %(radia 6or5( a($r( %(r'(&$%. 2. K(adaa 6or5( a($r( '(-(r%i %(r'(&$% -ada aa% 1 ) 'a%$ + dia%a' %(ra'$, %(%a-i %ida, %(r&a%a' -ada ha# 4 ha# '(&a"ai &(ri,$% -(-(ra"a! h$r$*hara! $$, ra'a a''a! -(ro&a,a! ,ri'i a'ioa#! ,(&a,ara! 'a&o%a'(! (-id(i5! &(5aa a#a '(-(r%i &air! "(-a &$i. 7. A-a&i#a %(radi ,(adaa 6or5( a($r( '(-(r%i dia%a'! '(hi""a %ida, ($",i,a Piha, P(r%aa da Piha, K(d$a (#a$%,a -(raia ,(ra'aa ii! a,a ,(d$a &(#ah -iha, '(-a,a% $%$, ((#('ai,a '("a#a '('$a%$a '(5ara $'aarah.
Pasal 12 Pe&indahtan"anan Perjanjian
1. S(#aa -(#a,'aaa -(#a,'aaa -(raia ii &(r#a"'$"! ,(d$a &(#ah -iha, di#ara" $%$, (idah%a"ai &ai, '(&a"ia a%a$ '(#$r$h i'i da ,odi'i -(raia ii ,(-ada Piha, K(%i"a a%a$ -iha, #aia. 2. K(%(%$a -ada aa% )1+ -a'a# ii %ida, &(r#a,$ a-a&i#a %(radi ,(adaa di #$ar ,(,$a'aa da ,(a-$a Piha, P(r%aa $%$, ("(da#i,a a%a$ ("a%a'ia )'(&a"aiaa di a,'$d da#a -a'a# ; aa% )7+! da d("a '(ii Piha, K(d$a %(r'(&$% ,( La&ora%ori$ K#ii, r(,aa Piha, P(r%aa.
Pasal 1 Pen0elesaian Perselisihan
1. Ji,a %(radi -(r'(#i'iha '(&a"ai a,i&a% dari -(#a,'aaa -(raia ii! a,a ,(d$a &(#ah -iha, '(-a,a% $$%, ((#('ai,a -(ra#aha %(r'(&$% '(5ara $'aarah "$a (5a-ai $6a,a%. 2. A-a&i#a d("a $'aarah %ida, %(r5a-ai ,a%a $6a,a% a,a ,(d$a &(#ah -iha, '(-a,a% $%$, ((#('ai,a -(ra'a#aha P("adi#a N("(ri B(,a'i.
Pasal 1! Pe&utus 5 Pe&%atalan Perjanjian
1. P(raia ii (adi &a%a# d(i h$,$ a%a$ da-a% di -$%$',a '(%ia- 'aa% '(&(#$ a,%$a! d("a %(r#(&ih dah$#$ (a-ai,a '$ra% -(&(ri%ah$a / -(ri"a%a! a-a&i#a %(radi ha# 4 ha# '(-(r%i &(ri,$% ii 1. Da#a ha# -ara -iha, %ida, da-a% (($hi ,(ai&aa da a%a$ (#a,$,a -(#a""ara %(rhada- ,(%(%$a 4 ,(%(%$a da#a -(raia ii. 2. Da#a ha# %(radia 6or5( a($r( '(&a"aiaa dia,'$d da#a -a'a# 11.
7. Para -iha, &(rha, ("a,hiri -(raia ii '(&(#$ a,%$a a-a&i#a di da#a -(#a,'aaa -(raia 'a#ah 'a%$ a%a$ ,(d$a &(#ah -iha, %ida, a-$ (($hi ,(%(%$a a" %(#ah di a%$r dida#a -(raia ii a%a$ ada 'aa% -ro'(' -(&$a%a a%a$ '(#aa ii -(raia ii &(r#a"'$" (&(ri,a ,(%(ra"a -a#'$ a%a$ di-a#'$,a. >a# ii di#a,$,a '(5ara %(r%$#i' o#(h a'i" 4 a'i" -iha, 70 )%i"a -$#$h+ hari '(&(#$ -(raia ii dia%a,a dia,hiri. 1. S(h$&$"a d("a &a%a# / a%a$ -$%$'a -(raia ii '(&a"aiaa dia,'$d aa% )1+ -a'a# ii! ,(d$a &(#ah -iha, '(-a,a% $%$, ("('a-i",a &(r#a,$a ,(%(%$a -a'a# 12<< da 12 Ki%a& $da" 4 $da" >$,$ P(rda%a a" ("a%$r %(%a" &a%a#a -(raia.
Pasal 1) Lain 6 lain
S(#aa &(r#a"'$"a ,(ra'aa ii! ha# 4 ha# a" $",i %i&$# '(h$&$"a -(#a,'aaa -(raia da &(#$ dia%$r da#a S$ra% P(raia K(ra'aa ii a,a di '(#('ai,a da di a%$r a%'a da'ar -(r'(%$$a &(r'aa da#a '(&$ah add(d$ a" (r$-a,a &a"ia a" ("i,a% '(r%a %ida, %(r-i'ah,a dari -(raia ii.
Pasal 1+ Penutu(
1. S$ra% -(raia ii di &$a% ra",a- 2 )d$a+ di%ada%a"ai di a%a' a%(rai a" 5$,$da (-$ai ,(,$a%a h$,$ a" 'aa ,$a%a! a'i" 4 a'i" $%$, Piha, P(r%aa da Piha, K(d$a '(r%a da-a% di -(r&aa, '('$ai ,(&$%$ha 2. S$ra% P(raia K(ra'aa ii di &$a% da di%ada%a"ai di B(,a'i -ada %a""a# %(r'(&$% di a%a'.
PI>AK PERTAMA La&ora%ori$ K#ii, ……
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PI>AK KEDUA RS……………………………..
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