A Medical Authorization Letter is essential in situations where an individual needs to delegate medical decision-making authority to another person in Indonesia. This document becomes crucial in emergencies, during planned medical procedures, or when a patient may be temporarily or permanently unable to make their own medical decisions. The letter, governed by Indonesian healthcare regulations including Law No. 36 of 2009 on Health and Minister of Health Regulation No. 4 of 2018, must clearly specify the scope of authority granted, identify all parties involved, and include proper witnessing and verification. The document is widely used in healthcare facilities across Indonesia and serves as a legal protection for both the grantor and the authorized representative while ensuring healthcare providers can act with confidence when accepting instructions from the authorized person.
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1. Date and Location: Current date and place where the authorization letter is being executed
2. Grantor Details: Full name, ID number (KTP), date of birth, and contact information of the person giving medical authorization
3. Authorized Person Details: Full name, ID number (KTP), date of birth, and contact information of the person being authorized to make medical decisions
4. Relationship Declaration: Statement of the relationship between the grantor and authorized person
5. Scope of Authorization: Specific medical decisions and actions the authorized person can make, including any limitations
6. Duration of Authority: Time period for which the authorization is valid
7. Medical Information Access: Specific authorization for accessing medical records and receiving medical information
8. Declaration of Sound Mind: Statement that the grantor is of sound mind and giving authorization voluntarily
9. Signature Block: Space for signatures of grantor, authorized person, and witnesses
1. Emergency Contact Information: Additional emergency contacts beyond the authorized person, used when multiple layers of contact are needed
2. Specific Treatment Preferences: Detailed preferences for specific medical treatments or procedures, included when the grantor has particular wishes
3. Religious or Cultural Considerations: Special instructions regarding religious or cultural preferences in medical treatment, included when relevant to the grantor's beliefs
4. Revocation Clause: Specific terms for how the authorization can be revoked, included when the grantor wants to specify these conditions
5. Language Declaration: Statement about translation if the letter is bilingual, included when multiple languages are used
1. Witness Details Form: Form containing complete details and signatures of witnesses
2. Healthcare Provider List: List of specific healthcare providers or facilities where the authorization is to be used
3. Identity Documents: Copies of KTP or other identification documents of all parties
4. Medical History Summary: Brief summary of relevant medical history, if applicable to the scope of authorization
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