The Patient Declaration Form is a standardized document required by Indonesian healthcare regulations for use in hospitals, clinics, and other medical facilities across Indonesia. This form must be completed before any non-emergency medical treatment can begin, serving as a comprehensive record of patient information and consent. It includes sections for personal details, medical history, treatment consent, and acknowledgment of rights and responsibilities, all in compliance with Indonesian healthcare laws and regulations, particularly Law No. 36 of 2009 on Health and Minister of Health Regulation No. 290/MENKES/PER/III/2008 on informed consent. The form should be available in both Indonesian and English languages, though the Indonesian version holds legal precedence. It's designed to protect both healthcare providers and patients by ensuring clear communication and documented understanding of all aspects of medical care and associated responsibilities.
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1. Patient Information: Essential personal details including full name, ID number (NIK), date of birth, address, and emergency contact information
2. Medical Insurance Details: Information about the patient's insurance coverage, including BPJS or private insurance details
3. General Health Declaration: Patient's declaration about their current health status, existing conditions, and medication history
4. Consent for Treatment: General consent for medical examination and treatment, acknowledging that specific procedures may require additional consent
5. Financial Responsibility: Declaration of understanding and acceptance of financial obligations for medical services
6. Patient Rights Acknowledgment: Confirmation that the patient has been informed of and understands their rights under Indonesian law
7. Data Privacy Consent: Authorization for collection, use, and sharing of personal health information in accordance with Indonesian data protection laws
8. Truth Declaration: Patient's confirmation that all provided information is true and accurate
9. Signature Block: Space for patient/guardian signature, date, and witness signature if required
1. Guardian Authorization: Required when the patient is a minor or unable to provide consent, including guardian's details and relationship to patient
2. Interpreter Confirmation: Required when the patient needs language interpretation services, including interpreter details and confirmation of accurate translation
3. Religious/Cultural Preferences: Optional section for declaring specific religious or cultural requirements that may affect treatment
4. Research Participation Consent: Optional authorization for use of medical data in research, required only in teaching hospitals or research institutions
5. Photography Consent: Optional consent for medical photography or recording, typically needed for certain procedures or teaching purposes
1. Patient Rights and Responsibilities: Detailed list of patient rights and responsibilities as per Indonesian healthcare regulations
2. Hospital Policy Summary: Summary of key hospital policies and procedures that patients need to be aware of
3. Financial Terms and Conditions: Detailed explanation of billing procedures, payment terms, and insurance claiming process
4. Privacy Policy: Detailed explanation of how patient data is collected, used, stored, and protected
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Compliance
Patient Administration
Medical Records
Quality Assurance
Risk Management
Patient Services
Clinical Operations
Registration
Administration
Relevant Roles
Hospital Administrator
Medical Director
Compliance Officer
Legal Counsel
Admissions Manager
Patient Services Coordinator
Medical Records Manager
Quality Assurance Manager
Risk Management Officer
Healthcare Facility Manager
Nurse Manager
Patient Relations Officer
Medical Secretary
Registration Staff
Clinical Operations Manager
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