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Medical Disclosure Form

Medical Disclosure Form Template for Indonesia

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Key Requirements PROMPT example:

Medical Disclosure Form

"I need a Medical Disclosure Form for our new private hospital in Jakarta, specifically for surgical procedures, that includes both Indonesian and English translations and has extra sections for international patients who may need interpreter services."

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Document background
The Medical Disclosure Form is a crucial document required in Indonesian healthcare settings before conducting medical procedures or treatments. This form, mandated by Indonesian healthcare regulations including Law No. 36 of 2009 on Health and related ministerial regulations, serves as an official record of informed consent between healthcare providers and patients. It must be completed prior to any non-emergency medical procedure and contains detailed information about the proposed treatment, associated risks, benefits, and alternatives. The document protects both healthcare providers and patients by ensuring transparent communication and documented consent, while meeting all legal requirements for medical practice in Indonesia. It's particularly important in cases involving complex procedures, surgical interventions, or treatments with significant risks.
Suggested Sections

1. Patient Information: Complete identification details of the patient including name, date of birth, ID number, contact information, and medical record number

2. Healthcare Provider Information: Details of the healthcare facility and treating medical professional(s)

3. Medical Condition: Description of the current medical condition or diagnosis requiring treatment

4. Proposed Medical Procedure/Treatment: Detailed explanation of the recommended medical procedure or treatment

5. Risks and Benefits: Comprehensive explanation of potential risks, complications, and expected benefits of the procedure

6. Alternative Treatments: Description of alternative treatment options and their respective risks and benefits

7. Acknowledgment of Information: Patient's confirmation that they have received and understood all information provided

8. Consent Declaration: Formal statement of consent or refusal for the proposed treatment

9. Signature Section: Spaces for signatures of patient/guardian, physician, and witnesses with date and time

Optional Sections

1. Guardian/Representative Information: Required when the patient is a minor, mentally incapacitated, or otherwise unable to provide consent directly

2. Interpreter Declaration: Required when an interpreter is used to explain the content to non-Indonesian speaking patients

3. Emergency Consent Waiver: Used in emergency situations where immediate treatment is necessary and regular consent cannot be obtained

4. Religious/Cultural Considerations: Special section for documenting any religious or cultural factors affecting treatment decisions

5. Photography/Recording Consent: Optional section for consent to photograph or record the procedure for medical documentation or educational purposes

6. Clinical Trial Information: Required when the treatment is part of a clinical trial or research study

Suggested Schedules

1. Procedure Details: Detailed technical description of the medical procedure including diagrams or illustrations

2. Risk Statistics: Statistical data regarding success rates, complication rates, and risk factors

3. Post-Procedure Care Instructions: Detailed instructions for post-procedure care and recovery

4. Cost Disclosure: Breakdown of expected costs and financial responsibilities

5. Patient Rights Summary: Summary of patient rights under Indonesian law

6. Emergency Contact Form: Form for listing emergency contacts and their contact information

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 Procedure
Healthcare Provider
Medical Practitioner
Informed Consent
Patient
Legal Guardian
Medical Facility
Treatment Plan
Medical Records
Emergency Treatment
Competent Authority
Attending Physician
Witness
Material Risk
Alternative Treatment
Confidential Information
Medical Emergency
Capacity to Consent
Healthcare Services
Professional Medical Opinion
Side Effects
Complications
Pre-existing Condition
Standard of Care
Medical Team
Clinical Trial
Experimental Treatment
Medical Device
Surgical Intervention
Post-procedure Care
Recovery Period
Follow-up Care
Discharge Instructions
Medical Assessment
Diagnostic Procedure
Clauses
Patient Identification
Medical Provider Information
Procedure Description
Risk Disclosure
Consent Declaration
Confidentiality
Patient Rights
Emergency Provisions
Data Protection
Documentation Requirements
Treatment Alternatives
Financial Disclosure
Withdrawal of Consent
Liability
Information Access
Religious/Cultural Considerations
Language Declaration
Witness Requirements
Capacity Declaration
Medical Records
Photography and Recording
Teaching and Research
Post-Procedure Care
Contact Information
Governing Law
Relevant Industries

Healthcare

Medical Services

Hospitals

Clinical Practices

Medical Research

Pharmaceutical

Healthcare Education

Medical Tourism

Alternative Medicine

Emergency Medical Services

Relevant Teams

Legal Compliance

Medical Records

Patient Relations

Risk Management

Quality Assurance

Clinical Operations

Administrative Support

Patient Safety

Medical Affairs

Healthcare Operations

Relevant Roles

Medical Director

Chief Medical Officer

Hospital Administrator

Clinical Director

Legal Compliance Officer

Risk Management Officer

Medical Records Manager

Patient Relations Manager

Healthcare Facility Manager

Quality Assurance Manager

Medical Practitioner

Nurse Manager

Administrative Coordinator

Patient Safety Officer

Medical Legal Advisor

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 information and informed consent for medical procedures
Law No. 29 of 2004 on Medical Practice (UU Praktik Kedokteran): Regulates medical practice and establishes requirements for medical documentation, informed consent, and professional standards for healthcare providers
Minister of Health Regulation No. 269/MENKES/PER/III/2008: Specific regulation on medical records management, including requirements for documentation and patient information disclosure
Law No. 11 of 2008 on Electronic Information and Transactions: Governs the handling of electronic data, including electronic medical records and digital consent forms
Minister of Health Regulation No. 290/MENKES/PER/III/2008: Specific regulation on informed consent in medical procedures, detailing requirements for valid consent
Law No. 44 of 2009 on Hospitals: Establishes standards for hospital operations including patient rights and medical information management
Minister of Health Regulation No. 4 of 2018 on Hospital Obligations and Patient Responsibilities: Details specific obligations of healthcare facilities regarding patient information and consent procedures
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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