The Permission Letter for Medical Treatment is a crucial document in Indonesian healthcare settings, required under Law No. 36 of 2009 on Health and Minister of Health Regulation No. 290/MENKES/PER/III/2008. This document is essential whenever a patient requires medical treatment or procedures that need explicit consent, serving as both a legal protection for healthcare providers and a formal record of patient authorization. It becomes particularly important in situations involving major medical procedures, treatment of minors or incapacitated individuals, or when specific cultural or religious considerations need to be documented. The letter must comply with Indonesian medical practice regulations and typically includes comprehensive patient information, specific treatment details, healthcare provider information, and formal declarations. It may also incorporate provisions for emergency situations and include relevant medical documentation as supporting evidence.
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1. Patient Information: Full legal name, date of birth, ID number (KTP/passport), and contact details of the patient
2. Legal Representative Information: If applicable, details of parent/guardian/authorized representative giving consent, including their relationship to the patient
3. Healthcare Provider Information: Name and address of the hospital/medical facility and attending physician(s)
4. Treatment Authorization: Clear statement of consent for the specified medical treatment or procedure
5. Scope of Authorization: Specific details of the medical procedures being authorized, including any reasonable variations that might become necessary
6. Duration of Authorization: Time period for which the authorization is valid
7. Declaration and Signature: Formal declaration of understanding and signatures of all relevant parties with dates
1. Emergency Contact Information: Additional contact persons in case of emergency - included when patient requests
2. Religious/Cultural Preferences: Any specific religious or cultural considerations that may affect treatment - included when relevant to the patient's care
3. Insurance Information: Details of health insurance coverage - included when treatment is being covered by insurance
4. Interpreter Confirmation: Details of interpreter if used for non-Indonesian speaking patients - included when language assistance is required
5. Specific Risk Acknowledgment: Detailed acknowledgment of specific risks for high-risk procedures - included for complex medical procedures
1. Medical Procedure Description: Detailed description of the proposed medical treatment or procedure
2. Cost Estimate: Estimated costs of the treatment and payment terms if applicable
3. Supporting Medical Documentation: Copies of relevant medical reports, test results, or diagnoses
4. Witness Statement: If required, signed statements from witnesses confirming the consent process
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Medical Secretary
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