Medical Release Physician's Statement Form - Indonesia

Medical Release Physician's Statement Form for Indonesia

Medical Release Physician's Statement Form Template for Indonesia

A standardized medical documentation form used in Indonesia that enables physicians to officially document and communicate a patient's medical condition, diagnosis, and related professional opinions. The document complies with Indonesian healthcare regulations, particularly Law No. 29 of 2004 on Medical Practice and relevant Ministry of Health regulations. It serves as an official medical statement that can be used for various purposes including insurance claims, employment requirements, legal proceedings, or other situations requiring verified medical information. The form includes provisions for patient privacy protection and information release authorization in accordance with Indonesian medical practice standards.

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What is a Medical Release Physician's Statement Form?

The Medical Release Physician's Statement Form is a crucial document in Indonesian healthcare documentation and information sharing. It is primarily used when formal medical verification or information sharing is required, such as for insurance claims, employment purposes, legal proceedings, or other official matters requiring authenticated medical information. The form must comply with Indonesian regulations, particularly Law No. 29 of 2004 on Medical Practice and Ministry of Health regulations regarding medical records and informed consent. It contains detailed medical findings, professional opinions, and specific authorization for information release, while maintaining patient confidentiality and professional standards. This document serves as a bridge between healthcare providers and various stakeholders who require official medical information, while protecting patient privacy and ensuring proper information handling.

What sections should be included in a Medical Release Physician's Statement Form?

1. Patient Information: Essential identifying details including full name, date of birth, gender, ID number, and contact information

2. Physician Information: Treating physician's details including name, medical license number, hospital/clinic affiliation

3. Medical Examination Details: Date, time, and location of examination or treatment

4. Medical Findings: Current medical condition, diagnosis, and relevant clinical findings

5. Professional Opinion: Physician's professional assessment and recommendations

6. Information Release Authorization: Specific details about what medical information is authorized for release and to whom

7. Certification: Physician's declaration of truth and accuracy of the statement

8. Signatures: Designated spaces for physician's signature, date, and official stamp

What sections are optional to include in a Medical Release Physician's Statement Form?

1. Treatment History: Previous relevant medical treatments and procedures, included when historical context is necessary

2. Medication List: Current medications and treatments, included when relevant to the purpose of the statement

3. Fitness Declaration: Statement about patient's fitness for specific activities, included when required for work, insurance, or legal purposes

4. Follow-up Requirements: Recommended follow-up care or restrictions, included when ongoing care is necessary

5. Third Party Authorization: Additional authorization section when information needs to be released to multiple parties

6. Translator Certification: Required when the form needs to be translated for non-Indonesian speaking patients

What schedules should be included in a Medical Release Physician's Statement Form?

1. Medical Test Results: Relevant laboratory results, imaging reports, or other diagnostic test findings

2. Treatment Records: Detailed records of treatments provided, if relevant to the statement

3. Specialist Reports: Additional medical opinions or specialist consultations

4. Patient Medical History Form: Comprehensive medical history provided by the patient

5. Consent Forms: Copies of relevant patient consent forms for information release

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What is a Medical Release Physician's Statement Form?

What sections should be included in a Medical Release Physician's Statement Form?

What sections are optional to include in a Medical Release Physician's Statement Form?

What schedules should be included in a Medical Release Physician's Statement Form?

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