The Hospital Authorization Form is a critical legal document required by Indonesian healthcare facilities before providing medical treatment or services to patients. This document, mandated by Indonesian healthcare regulations including Law No. 36 of 2009 on Health, serves multiple essential purposes: it documents informed consent for medical procedures, establishes financial responsibility, authorizes information sharing, and acknowledges patient rights and responsibilities. The form is particularly important in both routine and emergency medical situations, protecting both the healthcare provider's and patient's interests while ensuring compliance with Indonesian medical practice regulations. It must be available in Indonesian language (Bahasa Indonesia) and may be accompanied by translations for international patients, though the Indonesian version remains legally binding.
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1. Patient Information: Complete details of the patient including full name, ID number (KTP/passport), date of birth, address, and contact information
2. Legal Representative Information: Details of the person authorized to give consent if the patient is unable to do so (for minors, unconscious patients, or mentally incapacitated patients)
3. Medical Procedure Authorization: Clear description of the medical procedures, treatments, or care being authorized, including general hospital care and specific procedures if known
4. Financial Responsibility: Declaration of financial responsibility and agreement to pay for medical services, including insurance information
5. Consent for Information Sharing: Authorization for the hospital to share medical information with specified healthcare providers, insurance companies, and family members
6. Rights and Responsibilities: Statement of patient rights and responsibilities as per Indonesian healthcare laws
7. Declaration and Signatures: Formal declaration of understanding and agreement, with spaces for signatures of patient/legal representative, witness, and healthcare provider
1. Emergency Care Authorization: Additional authorization for emergency procedures when immediate action is required - used only in forms for emergency department or high-risk procedures
2. Religious/Cultural Preferences: Section for specifying any religious or cultural preferences that may affect treatment decisions - included when hospital serves diverse populations
3. Interpreter Confirmation: Section confirming use of interpreter services and their details - included when patient requires language assistance
4. Research Participation: Optional authorization for use of medical information in research studies - included in teaching hospitals or research institutions
5. Photography/Recording Consent: Permission for medical photography or recording - included for procedures that may require documentation for medical or educational purposes
1. Schedule A - List of Authorized Procedures: Detailed list of specific medical procedures being authorized, with associated risks and benefits
2. Schedule B - Financial Terms: Detailed breakdown of expected costs, payment terms, and insurance coverage details
3. Schedule C - Authorized Representatives: List of persons authorized to receive medical information or make decisions on patient's behalf
4. Appendix 1 - Patient Rights Document: Complete list of patient rights and responsibilities as per Indonesian law
5. Appendix 2 - Hospital Policy Summary: Summary of relevant hospital policies affecting patient care and treatment
Relevant legal definitions
Clauses
Relevant Industries
Healthcare
Medical Services
Hospital Administration
Insurance
Legal Services
Healthcare Technology
Medical Records Management
Patient Care Services
Emergency Medical Services
Relevant Teams
Legal
Compliance
Patient Services
Admissions
Medical Records
Risk Management
Quality Assurance
Emergency Services
Clinical Operations
Administrative Services
Patient Relations
Insurance Coordination
Relevant Roles
Hospital Administrator
Medical Director
Legal Counsel
Compliance Officer
Risk Manager
Patient Services Manager
Admissions Coordinator
Emergency Department Director
Chief Medical Officer
Healthcare Facility Manager
Medical Records Manager
Patient Rights Advocate
Insurance Coordinator
Quality Assurance Manager
Clinical Operations Manager
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