The Consent Letter For Medical Report is a crucial document in Indonesian healthcare administration, required whenever medical information needs to be shared with third parties. This document is mandated by Indonesian healthcare regulations, particularly under Law No. 36 of 2009 on Health and related ministerial regulations. It serves as a legal safeguard ensuring patient privacy while facilitating necessary information sharing between healthcare providers and authorized recipients. The letter becomes necessary in various scenarios including insurance claims, employment requirements, legal proceedings, or transfer of medical care. It must be drafted in Bahasa Indonesia or accompanied by an official translation, and requires specific components to be legally valid under Indonesian jurisdiction.
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1. Patient Information: Full legal name, date of birth, ID number (NIK), address, and contact details of the patient
2. Healthcare Provider Details: Name and address of the healthcare facility/provider, relevant registration numbers
3. Purpose of Consent: Clear statement of the purpose for which the medical report is being requested and will be used
4. Scope of Authorization: Specific details about what medical information is authorized for release, including time period covered
5. Recipient Information: Details of the person or organization to whom the medical report will be released
6. Duration of Validity: Specification of how long the consent remains valid
7. Declaration of Consent: Clear statement of consent with acknowledgment of understanding
8. Signature Block: Space for patient's signature, date, and witness signature if required
1. Guardian Information: Required when the patient is a minor or legally incapacitated - includes guardian's details and legal authority
2. Specific Exclusions: Optional section to explicitly state any medical information that should NOT be included in the report
3. Translator Confirmation: Required when the patient's primary language is not Indonesian - confirms that contents have been explained in patient's preferred language
4. Revocation Rights: Optional but recommended section explaining how the patient can revoke the consent
5. Electronic Distribution Consent: Required if the medical report may be distributed electronically - specific consent for digital transmission
1. List of Requested Medical Records: Detailed checklist of specific medical records being requested (e.g., consultation notes, test results, imaging reports)
2. Identity Verification Documents: Copies of identity documents used to verify the patient's identity
3. Authorization Form for Special Categories: Additional authorization forms for sensitive information like mental health, HIV status, or genetic information if applicable
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Medical Records
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Human Resources
Patient Administration
Quality Assurance
Data Protection
Clinical Operations
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International Patient Services
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Medical Records Officer
Healthcare Administrator
Compliance Officer
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Insurance Claims Processor
Medical Secretary
Clinical Research Coordinator
Privacy Officer
Healthcare Facility Manager
Occupational Health Nurse
Immigration Medical Officer
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