Health Insurance Waiver Form

Health Insurance Waiver Form Template for Indonesia

Create a bespoke document in minutes, or upload and review your own.

4.6 / 5

4.8 / 5

Let's create your Health Insurance Waiver Form

1. Select your governing law and document type:

2. Enter your key requirements:

3. Create your document to edit, review or download

Get your first 2 documents free

Your data doesn't train Genie's AI

You keep IP ownership of your information

Key Requirements PROMPT example:

"I need a Health Insurance Waiver Form in both English and Bahasa Indonesia for our tech company's foreign employees who already have international health coverage, to be implemented from January 2025."

Document background

The Health Insurance Waiver Form serves as a crucial legal document in Indonesia's healthcare system, where health insurance coverage is generally mandatory under the national health insurance program (JKN). This document is utilized when an individual, under specific circumstances, chooses to opt out of health insurance coverage, whether it's the national BPJS Kesehatan program or an employer-sponsored plan. The form is designed to protect all parties involved by clearly documenting the individual's informed decision, understanding of risks, and acknowledgment of financial responsibilities. It includes essential information such as personal details, reason for waiver, alternative coverage details (if any), and period of waiver. The document must comply with Indonesian healthcare regulations, particularly the SJSN Law and BPJS Law, while providing clear documentation of the decision-making process and associated risks.

Suggested Sections

1. Personal Information: Individual's full details including name, NIK (National ID number), date of birth, address, and contact information

2. Declaration of Understanding: Clear statements that the individual understands the nature and consequences of waiving health insurance coverage, including potential financial risks

3. Reason for Waiver: Explanation of why the individual is choosing to waive health insurance coverage

4. Alternative Coverage: Details of any alternative health insurance coverage the individual maintains

5. Period of Waiver: Specification of the time period for which this waiver is valid

6. Legal Responsibility: Statement accepting full financial and legal responsibility for medical expenses during the waiver period

7. Acknowledgment and Signature: Final declarations and space for dated signatures of the individual and witness

Optional Sections

1. Employer Information: Required when the waiver is being submitted in an employment context, including employer details and relevant policies

2. Emergency Contact Information: Optional section for providing emergency contact details during the period of waived coverage

3. Reinstatement Process: Information about how and when the individual can reinstate their health insurance coverage, included when applicable to the specific situation

4. Translation Declaration: Required when the form is provided in multiple languages, certifying that translations are accurate

Suggested Schedules

1. Schedule A - Risk Acknowledgment Checklist: Detailed checklist of specific risks and consequences the individual acknowledges when waiving coverage

2. Schedule B - Alternative Insurance Verification: Documentation of alternative insurance coverage, if applicable, including policy details and coverage periods

3. Appendix 1 - Rights and Responsibilities: Detailed explanation of the individual's rights and responsibilities while uninsured

4. Appendix 2 - Healthcare Resources: List of available healthcare resources and facilities for uninsured individuals

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

Education

Manufacturing

Technology

Retail

Professional Services

Construction

Hospitality

Transportation

Relevant Teams

Human Resources

Legal

Compliance

Administration

Operations

Risk Management

Employee Relations

Payroll

Benefits Administration

Relevant Roles

Human Resources Manager

Benefits Coordinator

Compliance Officer

Legal Counsel

HR Administrator

Employee Relations Manager

Payroll Manager

Risk Manager

Operations Manager

Administrative Assistant

Personnel Director

Benefits Specialist

Find the exact document you need

Personal Accident Claim Form

An Indonesian-compliant Personal Accident Claim Form for filing insurance claims related to personal accidents, adhering to OJK regulations.

tiktok���˰�

How a Sales & Marketing Lead uses tiktok���˰� to reduce contract drafting time by 95%

Let's create your Health Insurance Waiver Form

Authors

Alex Denne

Find the exact document you need

Personal Accident Claim Form

Professional Indemnity Proposal Form

Medical Insurance Claim Form

Insurance Claim Form

Health Insurance Waiver

Insurance Waiver

Accident Claim Form

Medical Claim Form

Insurance Reimbursement Form

Motor Claim Form

Insurance Verification Form

Car Insurance Form

Travel Insurance Form

Expired Medicare Card Renewal Form

Waiver Of Subrogation General Liability

General Liability Form

Insurance Certificate Of Liability

Workers Comp Exemption Certificate

Health Waiver Form

Workers Compensation Waiver

Waiver Of Subrogation Form

Health Insurance Waiver Form

Group Insurance Form

Insurance Proposal Form

Insurance Declaration Form

Insurance Affidavit

Download our whitepaper on the future of AI in Legal

�ұ�Ծ���’s Security Promise

Your documents are private:

Your documents are protected:

Organizational security

Innovation in privacy:

Want to know more?

Use Cases

tiktok��˰�

How a Sales & Marketing Lead uses tiktok��˰� to reduce contract drafting time by 95%

�ұ�Ծ��’s Security Promise