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The Patient Consent Form For Case Report is a crucial document required in Indonesian healthcare settings whenever medical professionals wish to publish or present interesting or educational patient cases in medical literature, conferences, or academic forums. This document is essential for compliance with Indonesian healthcare regulations, particularly Law No. 29 of 2004 on Medical Practice and related privacy laws. It serves as a formal agreement between the healthcare provider and the patient, documenting informed consent for sharing medical information while protecting patient privacy. The form should be used when a healthcare provider identifies a case with educational or scientific value that warrants sharing with the broader medical community. It typically includes detailed information about the case's intended use, privacy protection measures, and the scope of patient consent, while ensuring compliance with both local and international medical publishing standards.

1. Header and Title: Hospital/institution letterhead, document title, and form identification number

2. Parties: Identification of the healthcare provider/institution and the patient (including full name, medical record number, date of birth, and contact information)

3. Background: Brief explanation of why the case report is being written and its importance to medical knowledge

4. Definitions: Clear definitions of technical terms used in the document

5. Case Report Details: Description of what aspects of the patient's case will be included in the report

6. Data Usage and Publication: Explanation of how the patient's medical information will be used and where it may be published

7. Patient Rights: Clear statement of patient's rights including right to withdraw consent

8. Confidentiality Measures: Description of how patient privacy will be protected

9. Declaration of Consent: Formal consent statement and signature blocks for all parties