[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-id-113":3,"doc-seo-204469-113":41,"doc-detail-204469-id":110},{"code":4,"msg":5,"data":6},0,"success",[7,13,17,21,25,29,33,37],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":4,"slug":12},178,1,"Template","Faktur","faktur",{"id":14,"doc_module":9,"doc_module_name":10,"category_name":15,"show_sort_weight":4,"slug":16},192,"Formulir","formulir-192",{"id":18,"doc_module":9,"doc_module_name":10,"category_name":19,"show_sort_weight":4,"slug":20},180,"Media Sosial","media-sosial",{"id":22,"doc_module":9,"doc_module_name":10,"category_name":23,"show_sort_weight":4,"slug":24},179,"Poster","poster",{"id":26,"doc_module":9,"doc_module_name":10,"category_name":27,"show_sort_weight":4,"slug":28},176,"Presentasi","presentasi",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":4,"slug":32},177,"Resume","resume",{"id":34,"doc_module":9,"doc_module_name":10,"category_name":35,"show_sort_weight":4,"slug":36},182,"Surat","surat-a95d00d3aaf04f3b854ecf140f00d385",{"id":38,"doc_module":9,"doc_module_name":10,"category_name":39,"show_sort_weight":4,"slug":40},183,"Umum","umum-07d1ff437201438088836b2b1ed3c90f",{"code":4,"msg":42,"data":43},"ok",{"site_id":44,"language":45,"slug":46,"title":47,"keywords":48,"description":49,"schema_data":50,"social_meta":103,"head_meta":105,"extra_data":107,"updated_unix":109},113,"id","attending-physicians-statement-for-health-insurance-claim-individual","Surat Keterangan Dokter Klaim Kesehatan - Individu","","Formulir Surat Keterangan Dokter untuk keperluan klaim kesehatan individu berisi identitas pasien (nama, jenis kelamin, tanggal lahir/usia) serta informasi polis/policy number. Dokumen memuat riwayat penyakit dahulu dan riwayat penyakit sekarang beserta tanggal diagnosa awal, termasuk data perawatan dan jumlah hari perawatan. Bagian diagnosa dan prosedur tindakan mencantumkan keterangan ICD 10/ICD 9/CPT4, diikuti saran pengobatan serta pilihan diagnosa berhubungan (mis. komplikasi kehamilan, kecelakaan, HIV/AIDS, kelainan bawaan). Selain itu tersedia riwayat konsultasi/perawatan sebelumnya dan deklarasi dokter dengan tanda tangan, stempel rumah sakit, serta nomor formulir CLM. IND.02.2023.",{"@graph":51,"@context":102},[52,68,89],{"@type":53,"itemListElement":54},"BreadcrumbList",[55,59,62,65],{"item":56,"name":57,"@type":58,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":60,"name":10,"@type":58,"position":61},"https://docshare.wps.com/id/template/",2,{"item":63,"name":35,"@type":58,"position":64},"https://docshare.wps.com/id/template/surat/",3,{"item":66,"name":47,"@type":58,"position":67},"https://docshare.wps.com/id/template/attending-physicians-statement-for-health-insurance-claim-individual/204469/",4,{"url":66,"name":47,"@type":69,"image":70,"author":75,"headline":47,"publisher":78,"fileFormat":81,"inLanguage":45,"description":49,"dateModified":82,"datePublished":83,"encodingFormat":81,"isAccessibleForFree":84,"interactionStatistic":85},"DigitalDocument",{"url":71,"@type":72,"width":73,"height":74},"https://docshare.wps.com/thumbnails/attending-physicians-statement-for-health-insurance-claim-individual/204469.png","ImageObject",442,249,{"name":76,"@type":77},"วิน","Person",{"url":56,"name":79,"@type":80},"DocShare","Organization","application/pdf","2026-09-13","2026-09-05",true,{"@type":86,"interactionType":87,"userInteractionCount":61},"InteractionCounter",{"@type":88},"ViewAction",{"@type":90,"mainEntity":91},"FAQPage",[92,98],{"name":93,"@type":94,"acceptedAnswer":95},"Data apa yang dibutuhkan untuk bagian riwayat penyakit dahulu dan riwayat penyakit sekarang?","Question",{"text":96,"@type":97},"Formulir meminta informasi diagnosa sebelumnya dan diagnosa saat ini, termasuk sejak kapan pertama kali pasien terdiagnosa dengan tanggal (dd, mm, yy).","Answer",{"name":99,"@type":94,"acceptedAnswer":100},"Apa saja elemen yang harus dilengkapi oleh dokter di bagian akhir formulir?",{"text":101,"@type":97},"Dokter menyatakan telah membaca dan menjawab pertanyaan dengan lengkap dan benar, lalu mengisi nama dokter, nama rumah sakit, alamat rumah sakit, tempat dan tanggal, serta menandatangani dan membubuhkan stempel rumah sakit, termasuk format tanggal yang diminta serta kode CLM. IND.02.2023.","https://schema.org",{"og:url":66,"og:type":104,"og:title":47,"og:site_name":79,"og:description":49},"article",{"robots":106,"canonical":66},"index,follow",{"doc_id":108,"site_id":44},204469,1788573745,{"code":4,"msg":5,"data":111},{"doc_id":108,"user_id":112,"nickname":76,"user_avatar":113,"doc_module":9,"category_id":34,"category_name":35,"doc_title":47,"doc_description":49,"doc_content":114,"file_id":115,"file_url":116,"file_type":117,"file_size":118,"view_count":61,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":119,"language_code":45,"site_id":44,"html_lang":45,"table_of_contents":120,"faqs":121,"seo_title":122,"seo_description":49,"update_tm":109,"read_time":4},2336475104736,"https://ap-avatar.wpscdn.com/avatar/22000c4c5e0e5b17e70?x-image-process=image/resize,m_fixed,w_180,h_180&k=1786591360781797222","No. Polis / Policy No:  \n\n|  |  |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n\nDiisi pasien / filled by patient.  \nSURAT KETERANGAN DOKTER / ATTENDING PHISICIAN’S STATEMENT  \n\n| Nama pasien\u003Cbr>(Patient’s name)\u003Cbr>Tanggal lahir / usia\u003Cbr>(Date ofbirth / age) | \u003Cbr>/  /\u003Cbr>\u003Cbr>\u003Cbr>Laki-laki (Male)\u003Cbr>\u003Cbr>Wanita (Female)\u003Cbr>tahun (years) |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- |\n|  | tanggal (dd) bulan (mm) tahun (yy) |  |  |  |  |  |  |\n| Nomor rekam medis\u003Cbr>(Medical record number) |  |  |  |  |  |  |  |\n| Tanggal perawatan & jumlah hari perawatan\u003Cbr>(Date of hospitalization & lengths of hospitalization) |  /  /  t.).  /  /  =  tanggal (dd) bulan (mm) tahun (yy) tanggal (dd) bulan (mm) tahun (yy) |  |  |  |  |  | tahun\u003Cbr>(years) |\n| Riwayat penyakit dahulu\u003Cbr>(Previous Diagnose)\u003Cbr>Sejak kapan pertama kali pasien terdiagnosa (On which date the patient first diagnosed) |  /  / \u003Cbr>tanggal (dd) bulan (mm) tahun (yy) |  |  |  |  |  |  |\n| Riwayat penyakit sekarang\u003Cbr>(Current Diagnose)\u003Cbr>Sejak kapan pertama kali pasien terdiagnosa (On which date the patient first diagnosed) |  /  / \u003Cbr>tanggal (dd) bulan (mm) tahun (yy) |  |  |  |  |  |  |\n| Diagnosa\u003Cbr>(Diagnose)\u003Cbr>Prosedur tindakan\u003Cbr>(Treatment procedure) | ICD 10:\u003Cbr>ICD 9/CPT4: |  |  |  |  |  |  |\n| Saran pengobatan\u003Cbr>(Recommended treatment) |  |  |  |  |  |  |  |\n| Diagnosa berhubungan dengan (Recommended treatment) | | Komplikasi Kehamilan (Pregnancy Complication) Komplikasi Kehamilan (Maternity complication) Kematian Janin (Death of Fetus)\u003Cbr>Kematian Kehamilan/Persalinan (Death of Maternal)\u003Cbr>Kecelakaan (Accident) | | Kosmetik (Cosmetic)\u003Cbr>Psikis/Psikosomatis (Psikis/Psychosomatic) Percobaan bunuh diri (Suicide)\u003Cbr>Kesuburan (Fertilitas)\u003Cbr>HIV/AIDS | | Gigi (Dental)\u003Cbr>Kelainan Bawaan (Congenital) Penyalahgunaan obat/alkohol (Drug Abuse)\u003Cbr>Penyakit menular seksual (Sexual transmitted disease) Lainnya, sebutkan...(Other Disease)\u003Cbr>|  |\n| Apakah pasien pernah konsultasi / dirawat sebelumnya?(Has the patient ever been consulted / hospitalized before?)\u003Cbr>Tanggal (Date)\u003Cbr>Diagnosa (Diagnose)\u003Cbr>Nama Dokter (Doctor’s name)\u003Cbr>Nama Rumah Sakit (Hospital’s name) |  /  / \u003Cbr>tanggal (dd) bulan (mm) tahun (yy) |  |  |  |  |  |  |\n\nSaya, sebagai Dokter yang menangani pasien tersebut di atas menyatakan telah membaca dan menjawab pertanyaan-pertanyaan tersebut di atas dengan lengkap dan benar.  \n(As the Doctor handling the care of above-mentioned patient, I hereby state that I have read and answered the questions in this form clearly and completely).  \nNama Dokter (Doctor’s name)  \nNama Rumah Sakit (Hospital’s name)  \nAlamat Rumah Sakit (Hospital’s address)  \nTempat dan tanggal (Place and date)  \n:  \n:  \n:  \n:  \n /  /   \ntanggal (dd) bulan (mm) tahun (yy)  \nTandatangan dan nama Dokter Stempel Rumah Sakit  \nCLM. IND.02.2023","cbCaisZ6k0BOSHaq","https://ap.wps.com/l/cbCaisZ6k0BOSHaq","pdf",51997,"Indonesian","# Surat Keterangan Dokter (Attending Physician’s Statement)\n## Identitas Polis dan Pasien\n## Riwayat Penyakit dan Perawatan\n## Diagnosa, Prosedur, dan Saran Pengobatan\n## Riwayat Konsultasi/Perawatan Sebelumnya\n## Pernyataan Dokter dan Tanda Tangan","[{\"question\":\"Data apa yang dibutuhkan untuk bagian riwayat penyakit dahulu dan riwayat penyakit sekarang?\",\"answer\":\"Formulir meminta informasi diagnosa sebelumnya dan diagnosa saat ini, termasuk sejak kapan pertama kali pasien terdiagnosa dengan tanggal (dd, mm, yy).\"},{\"question\":\"Apa saja elemen yang harus dilengkapi oleh dokter di bagian akhir formulir?\",\"answer\":\"Dokter menyatakan telah membaca dan menjawab pertanyaan dengan lengkap dan benar, lalu mengisi nama dokter, nama rumah sakit, alamat rumah sakit, tempat dan tanggal, serta menandatangani dan membubuhkan stempel rumah sakit, termasuk format tanggal yang diminta serta kode CLM. IND.02.2023.\"}]","Surat Keterangan Dokter Klaim Kesehatan - Individu | PDF"]