Expired Medicare Card Renewal Form

Expired Medicare Card Renewal Form Template for Indonesia

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Key Requirements PROMPT example:

"I need an Expired Medicare Card Renewal Form for Indonesia that includes coverage for myself and three family members, with our cards expiring in March 2025, and we require the premium subsidy application section due to changes in employment status."

Document background

The Expired Medicare Card Renewal Form is a crucial document within Indonesia's healthcare system, designed to maintain continuous healthcare coverage for residents under the National Health Insurance Program (JKN). This form becomes necessary when an existing Medicare/BPJS Healthcare card reaches its expiration date, requiring renewal to ensure uninterrupted access to healthcare services. The document complies with Indonesian healthcare regulations, particularly Law No. 40 of 2004 and BPJS Healthcare guidelines, collecting essential information about the cardholder, including personal details, membership category, and payment preferences. It serves as an official mechanism for updating records and maintaining active healthcare coverage status while ensuring compliance with current regulatory requirements.

Suggested Sections

1. Personal Information: Basic details including full name, place/date of birth, national ID number (NIK), and current address

2. Expired Card Details: Previous Medicare/BPJS card number, expiration date, and membership category

3. Family Members Information: Details of dependent family members covered under the same card (if applicable)

4. Contact Information: Current phone numbers, email address, and preferred method of communication

5. Employment Status: Current employment details affecting premium category and payment method

6. Payment Information: Preferred payment method and frequency for premium payments

7. Declaration: Applicant's declaration confirming the accuracy of provided information and acknowledgment of terms

8. Signature Section: Space for applicant's signature and date

Optional Sections

1. Change of Details: Section for updating any personal information that has changed since the previous card was issued

2. Additional Coverage Options: Section for selecting supplementary coverage options if available in the applicant's category

3. Proxy Authorization: To be included when the renewal is being submitted by an authorized representative

4. Special Circumstances: For declaring any special conditions or requirements affecting healthcare coverage

5. Premium Subsidy Application: For applicants seeking government premium assistance based on financial conditions

Suggested Schedules

1. Required Documents Checklist: List of supporting documents that must be submitted with the renewal form

2. Premium Payment Schedule: Table showing premium payment amounts and due dates based on membership category

3. Coverage Terms Summary: Brief overview of healthcare coverage terms and conditions

4. Office Locations Appendix: List of BPJS Healthcare offices where the form can be submitted in person

Authors

Alex Denne

Head of Growth (Open Source Law) @ tiktok��˰� | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

alex.den.21@genieai.co

Relevant legal definitions

Clauses

Relevant Industries

Healthcare

Insurance

Public Administration

Social Services

Government Services

Employment Benefits

Financial Services

Public Health

Relevant Teams

Human Resources

Benefits Administration

Healthcare Administration

Customer Service

Compliance

Data Processing

Public Relations

Operations

Member Services

Relevant Roles

Healthcare Administrator

BPJS Officer

Human Resources Manager

Benefits Coordinator

Healthcare Facility Manager

Social Security Administrator

Customer Service Representative

Compliance Officer

Insurance Coordinator

Administrative Assistant

Public Relations Officer

Data Entry Specialist

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