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1. Religious or Cultural Preferences: Section specifying any religious or cultural considerations that should be taken into account during treatment, particularly relevant for Indonesia's diverse religious population

2. Specific Treatment Exclusions: Section listing any specific treatments or procedures that the patient does not consent to, used when patient has specific religious, personal, or medical reasons for refusing certain treatments

3. Insurance Information: Details of health insurance coverage and policy numbers, included when patient has insurance coverage

4. Power of Attorney Designation: Section designating a specific individual to make medical decisions if the patient becomes incapacitated, used when patient wants to specify decision-making authority

5. Language Preference: Specification of preferred language for communication, particularly relevant in areas with diverse linguistic populations

1. Appendix A - List of Authorized Procedures: Detailed list of specific medical procedures and interventions that are pre-authorized

2. Appendix B - Medical History Form: Detailed medical history form for optional completion to provide more comprehensive health information

3. Appendix C - Hospital Network List: List of affiliated hospitals and medical facilities where the permission form is automatically accepted

4. Appendix D - Insurance Information Details: Detailed insurance information and coverage specifics if applicable