A Medical Affidavit serves as a crucial document in Indonesia's healthcare and legal systems, providing a formal mechanism for medical professionals to make sworn statements about patient conditions, treatments, or professional medical opinions. This document type is commonly required in various situations including legal proceedings, insurance claims, disability applications, or when formal documentation of medical conditions is needed. The affidavit must comply with Indonesian legal requirements, particularly those outlined in Law No. 29 of 2004 on Medical Practice and related healthcare regulations. It requires proper notarization and typically includes detailed medical information, professional opinions, and supporting documentation. The Medical Affidavit's primary purpose is to provide verified, professional medical testimony that can be used as evidence or official documentation in formal proceedings.
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1. Declaration Header: States document type as Medical Affidavit and jurisdiction (Indonesia)
2. Declarant Information: Full name, professional qualifications, medical license number, and current practice details of the medical professional making the declaration
3. Patient Information: Complete identification details of the patient including full name, date of birth, and medical record number
4. Purpose of Affidavit: Clear statement of why the affidavit is being prepared and its intended use
5. Medical Facts: Detailed account of relevant medical information, diagnoses, treatments, and observations
6. Professional Opinion: Medical professional's expert opinion based on examination, treatment, and/or review of medical records
7. Basis of Knowledge: Statement explaining how the declarant has direct knowledge of the medical facts presented
8. Declaration of Truth: Formal statement affirming that all information provided is true and accurate to the best of declarant's knowledge
9. Execution: Date, location, signature of declarant, and notary information
1. Treatment History: Detailed chronological account of treatments provided - include when affidavit concerns ongoing or complex medical cases
2. Prognosis: Professional opinion about expected outcomes - include when future medical implications are relevant
3. Third Party Observations: Information from other medical professionals or witnesses - include when multiple healthcare providers were involved
4. Capacity Assessment: Evaluation of patient's mental capacity - include when relevant to patient's decision-making ability
5. Insurance Information: Details of relevant insurance coverage - include when affidavit is for insurance purposes
6. Disability Assessment: Evaluation of functional limitations - include when affidavit relates to disability claims
7. Cost of Care: Details of medical expenses - include when affidavit is for financial or legal proceedings
1. Medical Records: Copies of relevant medical records, test results, and clinical notes
2. Diagnostic Reports: Copies of laboratory results, imaging reports, or other diagnostic test results
3. Photographic Evidence: Relevant medical photographs or imaging results (if applicable)
4. Professional Credentials: Copies of medical license, certifications, and qualifications of the declarant
5. Treatment Plans: Detailed treatment protocols or rehabilitation plans if relevant
6. Medical Bills: Itemized medical expenses and billing records if relevant to the purpose of the affidavit
7. Supporting Declarations: Additional statements from other healthcare providers or relevant parties
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Healthcare Compliance Officer
Notary Public
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Medical Director
Clinical Department Head
Risk Management Officer
Quality Assurance Manager
Patient Care Coordinator
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