Hospital Authorization Form Template for Indonesia

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Key Requirements PROMPT example:

Hospital Authorization Form

"I need a Hospital Authorization Form in both English and Bahasa Indonesia for our new private hospital opening in Jakarta in March 2025, which will specialize in pediatric care and require specific sections for parental consent and guardian authorization."

Document background

The Hospital Authorization Form is a critical legal document required by Indonesian healthcare facilities before providing medical treatment or services to patients. This document, mandated by Indonesian healthcare regulations including Law No. 36 of 2009 on Health, serves multiple essential purposes: it documents informed consent for medical procedures, establishes financial responsibility, authorizes information sharing, and acknowledges patient rights and responsibilities. The form is particularly important in both routine and emergency medical situations, protecting both the healthcare provider's and patient's interests while ensuring compliance with Indonesian medical practice regulations. It must be available in Indonesian language (Bahasa Indonesia) and may be accompanied by translations for international patients, though the Indonesian version remains legally binding.

Suggested Sections

1. Patient Information: Complete details of the patient including full name, ID number (KTP/passport), date of birth, address, and contact information

2. Legal Representative Information: Details of the person authorized to give consent if the patient is unable to do so (for minors, unconscious patients, or mentally incapacitated patients)

3. Medical Procedure Authorization: Clear description of the medical procedures, treatments, or care being authorized, including general hospital care and specific procedures if known

4. Financial Responsibility: Declaration of financial responsibility and agreement to pay for medical services, including insurance information

5. Consent for Information Sharing: Authorization for the hospital to share medical information with specified healthcare providers, insurance companies, and family members

6. Rights and Responsibilities: Statement of patient rights and responsibilities as per Indonesian healthcare laws

7. Declaration and Signatures: Formal declaration of understanding and agreement, with spaces for signatures of patient/legal representative, witness, and healthcare provider

Optional Sections

1. Emergency Care Authorization: Additional authorization for emergency procedures when immediate action is required - used only in forms for emergency department or high-risk procedures

2. Religious/Cultural Preferences: Section for specifying any religious or cultural preferences that may affect treatment decisions - included when hospital serves diverse populations

3. Interpreter Confirmation: Section confirming use of interpreter services and their details - included when patient requires language assistance

4. Research Participation: Optional authorization for use of medical information in research studies - included in teaching hospitals or research institutions

5. Photography/Recording Consent: Permission for medical photography or recording - included for procedures that may require documentation for medical or educational purposes

Suggested Schedules

1. Schedule A - List of Authorized Procedures: Detailed list of specific medical procedures being authorized, with associated risks and benefits

2. Schedule B - Financial Terms: Detailed breakdown of expected costs, payment terms, and insurance coverage details

3. Schedule C - Authorized Representatives: List of persons authorized to receive medical information or make decisions on patient's behalf

4. Appendix 1 - Patient Rights Document: Complete list of patient rights and responsibilities as per Indonesian law

5. Appendix 2 - Hospital Policy Summary: Summary of relevant hospital policies affecting patient care and treatment

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

alex.den.21@genieai.co

Relevant legal definitions

Clauses

Relevant Industries

Healthcare

Medical Services

Hospital Administration

Insurance

Legal Services

Healthcare Technology

Medical Records Management

Patient Care Services

Emergency Medical Services

Relevant Teams

Legal

Compliance

Patient Services

Admissions

Medical Records

Risk Management

Quality Assurance

Emergency Services

Clinical Operations

Administrative Services

Patient Relations

Insurance Coordination

Relevant Roles

Hospital Administrator

Medical Director

Legal Counsel

Compliance Officer

Risk Manager

Patient Services Manager

Admissions Coordinator

Emergency Department Director

Chief Medical Officer

Healthcare Facility Manager

Medical Records Manager

Patient Rights Advocate

Insurance Coordinator

Quality Assurance Manager

Clinical Operations Manager

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