The Affidavit of Next of Kin for Medical Records is a crucial document in the Indonesian healthcare and legal system, designed to protect patient privacy while ensuring legitimate access to medical records by family members. This document becomes necessary when a patient is deceased or incapacitated and their medical records are required for various purposes such as insurance claims, ongoing medical treatment, or legal proceedings. The affidavit must comply with Indonesian healthcare privacy laws, including Law No. 29 of 2004 on Medical Practice and related regulations. It requires the declarant to provide detailed information about their relationship to the patient, supporting documentation, and specific reasons for requiring access to the medical records. The document must be properly notarized and often requires supporting documentation such as identification papers, death certificates (if applicable), and proof of relationship to the patient.
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1. Title and Introduction: Formal title of the affidavit and opening statement identifying it as a sworn statement
2. Declarant Information: Full legal name, address, and identification details of the person making the affidavit
3. Patient Information: Full details of the patient whose medical records are being requested, including their last known address and date of birth/death if applicable
4. Relationship Declaration: Clear statement of the relationship between the declarant and the patient, establishing next of kin status
5. Supporting Evidence: List of documents provided to prove relationship and next of kin status
6. Purpose Statement: Specific declaration of the purpose for requesting the medical records
7. Medical Records Details: Specific details of the medical records being requested, including date ranges and healthcare providers
8. Legal Authority: Statement citing legal authority under Indonesian law to access these records
9. Declaration of Truth: Formal statement affirming that all information provided is true and correct
10. Signature Block: Space for declarant's signature, date, and notary authentication
1. Urgency Statement: Include when there is a time-sensitive need for the medical records
2. Additional Authorized Parties: Include when other family members or legal representatives are also authorized to access the records
3. Previous Attempts Declaration: Include when there have been previous attempts to obtain the records through other means
4. Interpreter Certification: Include when the declarant requires an interpreter for the affidavit
5. Digital Records Request: Include when specifically requesting electronic format of medical records
1. Identity Documents: Copies of declarant's identification documents and proof of address
2. Relationship Evidence: Documents proving relationship to patient (birth certificates, marriage certificates, etc.)
3. Death Certificate: If applicable, copy of patient's death certificate
4. Power of Attorney: If applicable, any power of attorney documents
5. Previous Correspondence: If applicable, copies of previous correspondence with healthcare providers regarding records request
Relevant legal definitions
Affidavit
Declarant
Next of Kin
Medical Records
Healthcare Provider
Patient
Medical Information
Authorized Representative
Healthcare Facility
Confidential Information
Legal Representative
Personal Data
Medical Documentation
Electronic Health Records
Physical Health Records
Treatment History
Healthcare Institution
Protected Health Information
Notary Public
Supporting Documents
Family Member
Legal Authority
Deceased Person
Identity Documents
Proof of Relationship
Declarant
Next of Kin
Medical Records
Healthcare Provider
Patient
Medical Information
Authorized Representative
Healthcare Facility
Confidential Information
Legal Representative
Personal Data
Medical Documentation
Electronic Health Records
Physical Health Records
Treatment History
Healthcare Institution
Protected Health Information
Notary Public
Supporting Documents
Family Member
Legal Authority
Deceased Person
Identity Documents
Proof of Relationship
Clauses
Relevant Industries
Healthcare
Legal Services
Medical Administration
Hospital Management
Records Management
Public Health
Healthcare Compliance
Medical Insurance
Relevant Teams
Legal Affairs
Medical Records
Compliance
Patient Services
Risk Management
Documentation
Healthcare Administration
Privacy and Security
Relevant Roles
Medical Records Manager
Healthcare Administrator
Legal Compliance Officer
Hospital Administrator
Medical Documentation Specialist
Healthcare Privacy Officer
Legal Affairs Director
Patient Services Coordinator
Medical Records Clerk
Healthcare Risk Manager
Notary Public
Healthcare Legal Counsel
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