The Medical Authorization Form For Adults is essential in Indonesian healthcare settings where an individual needs to delegate medical decision-making authority to a trusted representative. This document becomes particularly important in situations where adults may become temporarily or permanently incapacitated and unable to make their own medical decisions. Under Indonesian law, specifically Law No. 36 of 2009 on Health and related regulations, healthcare providers must obtain informed consent before providing treatment. This authorization form provides a legal mechanism for that consent to be given by a designated agent, ensuring continuous access to necessary medical care while protecting the rights and preferences of the principal. The form includes comprehensive details about the scope of authority, privacy permissions, and specific medical preferences, all structured to comply with Indonesian legal requirements and healthcare regulations.
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1. Principal Information: Details of the person granting authorization (the principal), including full legal name, ID number (KTP), date of birth, and contact information
2. Agent Information: Details of the person(s) being authorized to make medical decisions (the agent), including full legal name, ID number (KTP), relationship to principal, and contact information
3. Authority Granted: Specific powers granted to the agent regarding medical decisions, including authority to consent to or refuse treatment, access medical records, and make end-of-life decisions
4. Duration of Authority: Specification of when the authorization becomes effective and when it terminates, including any triggering events
5. Privacy Authorization: Authorization for release of medical information to the agent in compliance with Indonesian privacy laws
6. Revocation Rights: Statement of the principal's right to revoke the authorization and the procedure for doing so
7. Signatures and Witnessing: Execution requirements including signatures of principal, agent(s), and witnesses, with date and place of signing
1. Alternate Agents: Designation of backup agents if the primary agent is unavailable or unable to serve
2. Specific Medical Conditions: Special instructions regarding specific known medical conditions or treatments
3. Religious or Cultural Preferences: Specific instructions regarding religious or cultural considerations in medical treatment
4. Organ Donation: Specific instructions regarding organ donation preferences
5. Geographic Limitations: Any geographical restrictions or considerations for the use of the authorization
1. Schedule A - Specific Medical Procedures: Detailed list of specific medical procedures that are explicitly authorized or prohibited
2. Schedule B - Healthcare Facilities: List of preferred or authorized healthcare facilities where the authorization is intended to be used
3. Appendix 1 - Witness Attestation Form: Standard form for witness attestation including witness details and declarations
4. Appendix 2 - Agent Acceptance Form: Form for designated agents to formally accept their appointment and responsibilities
Relevant legal definitions
Principal
Agent
Alternate Agent
Healthcare Provider
Medical Facility
Medical Treatment
Medical Procedure
Emergency Care
Incapacity
Healthcare Decision
Medical Records
Personal Data
Informed Consent
Life-Sustaining Treatment
Palliative Care
Revocation
Effective Date
Termination Date
Witness
Medical Authorization
Healthcare Facility
Sensitive Personal Information
Emergency Contact
Treatment Plan
Medical Privacy
Legal Representative
Mental Capacity
Healthcare Services
Medical Information
Attending Physician
Agent
Alternate Agent
Healthcare Provider
Medical Facility
Medical Treatment
Medical Procedure
Emergency Care
Incapacity
Healthcare Decision
Medical Records
Personal Data
Informed Consent
Life-Sustaining Treatment
Palliative Care
Revocation
Effective Date
Termination Date
Witness
Medical Authorization
Healthcare Facility
Sensitive Personal Information
Emergency Contact
Treatment Plan
Medical Privacy
Legal Representative
Mental Capacity
Healthcare Services
Medical Information
Attending Physician
Clauses
Authority Grant
Powers of Agent
Medical Privacy
Consent to Treatment
Data Protection
Duration and Effectiveness
Revocation Rights
Emergency Powers
Agent Obligations
Healthcare Provider Rights
Liability and Indemnification
Succession of Agents
Geographic Scope
Witness Requirements
Medical Records Access
Religious and Cultural Preferences
Organ Donation
End-of-Life Decisions
Communication Protocol
Dispute Resolution
Powers of Agent
Medical Privacy
Consent to Treatment
Data Protection
Duration and Effectiveness
Revocation Rights
Emergency Powers
Agent Obligations
Healthcare Provider Rights
Liability and Indemnification
Succession of Agents
Geographic Scope
Witness Requirements
Medical Records Access
Religious and Cultural Preferences
Organ Donation
End-of-Life Decisions
Communication Protocol
Dispute Resolution
Relevant Industries
Healthcare
Insurance
Emergency Services
Elder Care
Legal Services
Social Services
Medical Tourism
Healthcare Administration
Relevant Teams
Legal
Compliance
Patient Relations
Medical Records
Emergency Services
Risk Management
Admissions
Social Services
Insurance
Healthcare Administration
Relevant Roles
Hospital Administrator
Medical Director
Legal Counsel
Healthcare Compliance Officer
Patient Relations Manager
Medical Records Manager
Emergency Department Director
Risk Management Officer
Healthcare Facility Manager
Admissions Coordinator
Social Services Coordinator
Insurance Claims Manager
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