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Intake Form

Intake Form Template for Indonesia

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Key Requirements PROMPT example:

Intake Form

"I need an Intake Form for my Jakarta-based medical clinic that collects comprehensive patient information including medical history and insurance details, while ensuring compliance with Indonesian healthcare regulations and data protection laws."

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Document background
The Intake Form serves as a crucial initial point of contact between service providers and clients/patients in Indonesia, designed to collect necessary personal information while ensuring compliance with Indonesian data protection regulations. This document type is essential for organizations that need to gather comprehensive information about their clients or patients at the first interaction. The Intake Form must comply with Law No. 27 of 2022 on Personal Data Protection and includes sections for personal details, contact information, consent declarations, and service-specific information. It's particularly valuable for healthcare providers, educational institutions, financial services, and professional service firms operating in Indonesia, where proper documentation and data protection compliance are mandatory.
Suggested Sections

1. Personal Information: Basic identification details including full name, ID number (KTP), date of birth, and gender

2. Contact Information: Complete contact details including address, phone numbers, email, and preferred contact method

3. Data Protection Notice: Mandatory notice explaining how personal data will be collected, used, and protected in compliance with Indonesian PDP Law

4. Consent Declaration: Explicit consent section for data collection and processing, with clear opt-in mechanisms

5. Emergency Contact Details: Information for emergency contacts including name, relationship, and contact numbers

6. Basic Medical Information: Essential health information including allergies, chronic conditions, and current medications

7. Declaration of Truth: Statement confirming all provided information is true and accurate

Optional Sections

1. Insurance Information: Details of health insurance or other relevant insurance policies - include when form is for medical or financial services

2. Employment Details: Work-related information - include when form is for professional services or employment-related purposes

3. Financial Information: Banking and financial details - include when form is for financial services or payment processing

4. Special Needs Section: Information about any special requirements or accommodations - include when providing services to persons with disabilities or special needs

5. Guardian Information: Details of legal guardian - include when the form is for minors or persons under guardianship

Suggested Schedules

1. Required Documents Checklist: List of supporting documents that need to be submitted with the intake form

2. Privacy Policy: Detailed privacy policy document explaining data handling practices

3. Terms and Conditions: General terms and conditions applicable to the service or relationship

4. Consent Forms: Additional specific consent forms for particular services or data processing activities

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 Industries

Healthcare

Financial Services

Education

Legal Services

Social Services

Professional Services

Insurance

Real Estate

Banking

Human Resources

Medical Services

Hospitality

Relevant Teams

Administration

Client Services

Compliance

Data Protection

Front Office

Patient Services

Enrollment

Customer Relations

Legal

Registration

Human Resources

Relevant Roles

Administrative Officer

Intake Coordinator

Client Relations Manager

Compliance Officer

Data Protection Officer

Healthcare Administrator

Patient Services Coordinator

Enrollment Officer

Customer Service Manager

Legal Compliance Manager

Front Desk Supervisor

Registration Specialist

Human Resources Manager

Industries
Law No. 27 of 2022 on Personal Data Protection (PDP Law): Indonesia's comprehensive data protection law that regulates the collection, processing, and storage of personal data. This is crucial for intake forms as they typically collect personal information.
Law No. 11 of 2008 on Electronic Information and Transactions (EIT Law): Governs electronic transactions and recognizes electronic documents as legal evidence. This is relevant if the intake form is in electronic format.
Law No. 8 of 1999 on Consumer Protection: If the intake form is used for commercial purposes, this law ensures fair treatment of consumers and transparency in data collection.
Indonesian Civil Code (Kitab Undang-Undang Hukum Perdata): Provides the basic framework for contracts and legal documents in Indonesia, including requirements for valid documentation.
Government Regulation No. 71 of 2019 on Electronic Systems and Transactions: Provides detailed requirements for electronic system operations and electronic document handling.
Minister of Communication and Informatics Regulation No. 20 of 2016: Specific regulations on personal data protection in electronic systems, including requirements for consent and data handling.
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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