Patient Release Form

Patient Release Form Template for Indonesia

A Patient Release Form is a critical legal and medical document used in Indonesian healthcare facilities to formally document a patient's discharge from medical care. The document complies with Indonesian healthcare regulations, particularly Minister of Health Regulation No. 4 of 2018 and Law No. 29 of 2004 on Medical Practice. It serves multiple purposes: documenting the patient's condition at discharge, providing post-discharge care instructions, confirming the patient's understanding of these instructions, and establishing a legal record of the discharge process. The form includes essential patient information, treatment summary, discharge instructions, and necessary signatures from all relevant parties, while ensuring compliance with Indonesian medical documentation requirements and patient rights regulations.

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What is a Patient Release Form?

The Patient Release Form serves as a crucial document in Indonesian healthcare settings, bridging medical care documentation and legal requirements. It is designed to comply with Indonesian healthcare regulations, particularly focusing on patient rights, medical documentation, and healthcare facility obligations. The document becomes necessary when a patient is being discharged from a healthcare facility, whether after routine treatment, emergency care, or extended hospitalization. It plays a vital role in risk management for healthcare facilities while ensuring proper documentation of patient care and discharge instructions. The form must adhere to strict documentation requirements under Indonesian law while remaining accessible and understandable to patients and their families.

What sections should be included in a Patient Release Form?

1. Patient Information: Complete identification details of the patient including full name, medical record number, date of birth, and ID number

2. Healthcare Facility Information: Name and address of the hospital/healthcare facility, department, and treating physician(s)

3. Admission and Treatment Summary: Brief summary of the reason for admission, treatment received, and current condition

4. Discharge Instructions: Detailed instructions for post-discharge care, medication schedules, and activity restrictions

5. Follow-up Care: Scheduled follow-up appointments, recommended consultations, and emergency contact information

6. Release Declaration: Formal statement confirming patient's voluntary discharge and understanding of instructions

7. Acknowledgment and Signatures: Signature sections for patient/guardian, attending physician, and witness with date and time

What sections are optional to include in a Patient Release Form?

1. Against Medical Advice Release: Additional declarations and warnings when patient chooses to leave against medical advice

2. Transfer Information: Details of transfer arrangements if patient is being transferred to another facility

3. Special Care Instructions: Additional detailed instructions for patients with complex medical conditions or special care needs

4. Insurance and Billing: Information regarding payment status and insurance claims if relevant to discharge

5. Guardian Authorization: Additional section when patient is a minor or unable to provide consent

6. Interpreter Declaration: For cases where an interpreter was used to explain the release form

What schedules should be included in a Patient Release Form?

1. Medication Schedule: Detailed list of prescribed medications, dosages, and administration schedules

2. Home Care Instructions: Detailed instructions for wound care, exercises, or other specific care requirements

3. Follow-up Appointment Schedule: Calendar of scheduled follow-up appointments and recommended check-ups

4. Equipment Instructions: Instructions for any medical equipment patient needs to use at home

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Alex Denne

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

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Title And Lien Release

An Indonesian law-governed document that releases security interests over property and confirms clear title transfer, subject to local property and security regulations.

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Download a Standard Patient Release Form

Review your own Patient Release Form

What is a Patient Release Form?

What sections should be included in a Patient Release Form?

What sections are optional to include in a Patient Release Form?

What schedules should be included in a Patient Release Form?

Authors

Alex Denne

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