Surat Dokter Form PDF Details

In today’s world, navigating the intricacies of health insurance claims can be as daunting as dealing with the health issues themselves, particularly when it comes to specific ailments like cancer. The Surat Dokter form is a critical document in this complex process, designed exclusively for the Sequis Lady Protection Rider cancer claim. This comprehensive form demands detailed information to be filled out by the attending physician, covering a wide spectrum of details concerning the patient's condition. From basic personal information such as name, medical record number, age, gender, and address, to more specific medical data including the type and diagnosis of cancer, diagnosis date, stage, location, whether it has metastasized, and various other critical specifics like the presence of cervical intraepithelial neoplasia or tumors not yet classified as malignant. Furthermore, the form inquires about the history of the disease, any surgical or other therapeutic interventions taken, prognosis, and the referral source if any. This ensures a thorough review process, enabling the insurance provider to assess the claim with all requisite details. It mandates that aside from the verbal submission, medical reports, pathology results, laboratory tests, and any additional diagnostic information supporting the diagnosis be attached, underscoring the necessity of a meticulous documentation process tailored to streamline the claim's approval, all while maintaining the confidentiality of the patient’s sensitive health information.

QuestionAnswer
Form NameSurat Dokter Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namessurat sakit dokter, surat sakit dokter pdf, surat sakit online, surat dokter kosong pdf

Form Preview Example

SURAT KETERANGAN DOKTER

KHUSUS UNTUK KLAIM SEQUIS LADY PROTECTION RIDER

PENYAKIT KANKER

HARUS DIISI DENGAN LENGKAP OLEH DOKTER YANG MENGOBATI / MERAWAT SI SAKIT

Mohon dapat diberikan secara rinci hal-hal yang berhubungan dengan penyakit di atas pada pasien :

Nama

: _______________________________________________________ No. MR_______________________________

Umur

: _______________________________________________________________________________________________

Jenis Kelamin

:

 

Perempuan

 

Pekerjaan

: _______________________________________________________________________________________________

Alamat

: _______________________________________________________________________________________________

 

 

 

 

Diagnosa penyakit ini didasarkan atas hal-hal tersebut dibawah ini :

a.Jenis/diagnosa kanker yang diderita : _________________________________________________________________________________

Tanggal diagnosa : ____/____/_______ dd/mm/yyyy

Stadium : T ____ N ____ M ____

Lokasinya : __________________________________________________________________________________________________________

Bagaimana Klasifikasinya ? __________________________________________________________________________________________

Apakah telah meluas ke kelenjar getah bening dan telah terjadi anak sebar /metastase ? _______________________________

_______________________________________________________________________________________________________________________

b.Apakah penyakit yang diderita termasuk di bawah ini ?

Mohon berikan tanda centang ( ) pada pilihan berikut :

Stadium CIN (Cervical Intraepithelial Neoplasia)

Tumor yang belum dikategorikan ganas

Kanker yang belum menyebar (kanker in-situ)

Tumor ganas sebagai akibat terdapatnya Human Immunodeficiency Virus

Lain-lain ___________________________________________________________________________________

c.Hasil Patologi Anatomi (makroskopik dan mikroskopik)

d.Kapan pertama kali gejala penyakit tersebut dirasakan ?

e.Tindakan / pembedahan yang telah dilakukan dan kapan dilaksanakannnya ?

!"#$ % & !!' ! !()#$ % &* + $",-./0.12-3330.

f.Selain tindakan pembedahan, apakah diperlukan terapi lain ? Bila Ya, mohon disebutkan jenis terapi tersebut ?

g.Bagaimana prognosa dan harapan hidup dari pasien

Ya

Tidak

h.Apakah pasien merupakan rujukan dari dokter atau rumah sakit lain ?

Ya

Tidak

Jika Ya, nama dokter : ___________________________ rumah sakit ______________________________________

_______________________________________________________________________________________________

i.Hal lain yang masih dianggap perlu untuk dijelaskan

Untuk memperlancar proses klaim ini, mohon dokter dapat melampirkan laporan medis, hasil pemeriksaan patalogi anatomi, hasil laboratorium, pemeriksaan penunjang lainnya yang mendukung ditegakkannya diagnosis penyakit di atas.

Tempat & tanggal dibuat, _________________________

Dokter yang merawat,

(_________________________________________________)

nama jelas, tandatangan & cap stempel

Mohon surat keterangan ini tidak diberikan kepada pasien atau keluarganya, tetapi dikirim langsung kepada

PT AJ Sequis Life yang akan memperlakukan informasi ini dengan penuh kerahasiaan

!"#$ % & !!' ! !()#$ % &* + $",-./0.12-3330.

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surat dokter pdf completion process detailed (stage 1)

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surat dokter pdf completion process outlined (portion 2)

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surat dokter pdf writing process outlined (part 3)

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surat dokter pdf completion process described (stage 4)

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