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Consent Letter For Medical Report

Consent Letter For Medical Report Template for Indonesia

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Key Requirements PROMPT example:

Consent Letter For Medical Report

"I need a Consent Letter for Medical Report in Indonesian and English for an insurance claim, allowing my insurance company to access my medical records from Jakarta General Hospital for the period January 2025 to March 2025, with specific provisions for electronic transmission of the records."

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Document background
The Consent Letter For Medical Report is a crucial document in Indonesian healthcare administration, required whenever medical information needs to be shared with third parties. This document is mandated by Indonesian healthcare regulations, particularly under Law No. 36 of 2009 on Health and related ministerial regulations. It serves as a legal safeguard ensuring patient privacy while facilitating necessary information sharing between healthcare providers and authorized recipients. The letter becomes necessary in various scenarios including insurance claims, employment requirements, legal proceedings, or transfer of medical care. It must be drafted in Bahasa Indonesia or accompanied by an official translation, and requires specific components to be legally valid under Indonesian jurisdiction.
Suggested Sections

1. Patient Information: Full legal name, date of birth, ID number (NIK), address, and contact details of the patient

2. Healthcare Provider Details: Name and address of the healthcare facility/provider, relevant registration numbers

3. Purpose of Consent: Clear statement of the purpose for which the medical report is being requested and will be used

4. Scope of Authorization: Specific details about what medical information is authorized for release, including time period covered

5. Recipient Information: Details of the person or organization to whom the medical report will be released

6. Duration of Validity: Specification of how long the consent remains valid

7. Declaration of Consent: Clear statement of consent with acknowledgment of understanding

8. Signature Block: Space for patient's signature, date, and witness signature if required

Optional Sections

1. Guardian Information: Required when the patient is a minor or legally incapacitated - includes guardian's details and legal authority

2. Specific Exclusions: Optional section to explicitly state any medical information that should NOT be included in the report

3. Translator Confirmation: Required when the patient's primary language is not Indonesian - confirms that contents have been explained in patient's preferred language

4. Revocation Rights: Optional but recommended section explaining how the patient can revoke the consent

5. Electronic Distribution Consent: Required if the medical report may be distributed electronically - specific consent for digital transmission

Suggested Schedules

1. List of Requested Medical Records: Detailed checklist of specific medical records being requested (e.g., consultation notes, test results, imaging reports)

2. Identity Verification Documents: Copies of identity documents used to verify the patient's identity

3. Authorization Form for Special Categories: Additional authorization forms for sensitive information like mental health, HIV status, or genetic information if applicable

Authors

Alex Denne

Head of Growth (Open Source Law) @ Genie AI | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

Linkedin in social icon imageX social icon image
alex.den.21@genieai.co
Relevant legal definitions
Medical Report
Medical Records
Healthcare Provider
Medical Information
Confidential Information
Authorized Recipient
Consent Period
Personal Data
Medical Facility
Treatment Information
Health Information
Protected Health Information
Electronic Health Records
Medical Documentation
Patient Identification
Legal Representative
Healthcare Services
Medical History
Diagnostic Information
Clinical Notes
Laboratory Results
Discharge Summary
Treatment Plan
Consultation Records
Valid Consent
Relevant Industries

Healthcare

Insurance

Legal Services

Human Resources

Education

Immigration

Corporate Health Management

Occupational Health and Safety

Medical Tourism

Clinical Research

Relevant Teams

Medical Records

Legal

Compliance

Human Resources

Patient Administration

Quality Assurance

Data Protection

Clinical Operations

Insurance Processing

International Patient Services

Relevant Roles

Medical Records Officer

Healthcare Administrator

Compliance Officer

Legal Counsel

Human Resources Manager

Insurance Claims Processor

Medical Secretary

Clinical Research Coordinator

Privacy Officer

Healthcare Facility Manager

Occupational Health Nurse

Immigration Medical Officer

Industries
Law No. 36 of 2009 on Health (UU Kesehatan): The primary health law in Indonesia that establishes fundamental rights of patients, including the right to privacy and confidentiality of medical information
Law No. 29 of 2004 on Medical Practice (UU Praktik Kedokteran): Regulates medical practice and establishes requirements for medical documentation, including consent requirements and medical record management
Minister of Health Regulation No. 269/MENKES/PER/III/2008: Specific regulation on medical records, including requirements for content, maintenance, and confidentiality of medical records
Law No. 11 of 2008 on Electronic Information and Transactions: Relevant for electronic medical records and digital consent forms, governing electronic documents and signatures
Minister of Health Regulation No. 36 of 2012: Regulates patient confidentiality and medical secrets, including the circumstances under which medical information can be disclosed
Indonesian Medical Ethics Code (KODEKI): Professional ethics guidelines that include provisions on patient confidentiality and proper handling of medical information
Teams

Employer, Employee, Start Date, Job Title, Department, Location, Probationary Period, Notice Period, Salary, Overtime, Vacation Pay, Statutory Holidays, Benefits, Bonus, Expenses, Working Hours, Rest Breaks,  Leaves of Absence, Confidentiality, Intellectual Property, Non-Solicitation, Non-Competition, Code of Conduct, Termination,  Severance Pay, Governing Law, Entire Agreemen

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