Get Surat Cacat Dari Dokter

Filling out the Surat Cacat Dari Dokter online is an important process for individuals seeking to document their medical conditions for claims. This comprehensive guide provides step-by-step instructions to help you navigate the form with ease.

Follow the steps to complete your form accurately.

1. Click ‘Get Form’ button to obtain the form and open it in the online editor.
2. Enter the patient's name in the first field labeled 'Nama pasien/Name of the patient'.
3. In the next section, fill in the 'No Rekam Medik/Medical Record No'. Provide the medical record number of the patient.
4. Ensure to input the patient's age in the 'Usia/Age' section.
5. Select the patient's sex from the options given in the 'Jenis Kelamin/Sex' section: Laki-laki/Male or Perempuan/Female.
6. Record the 'Tanggal perawatan/Date of treatment', specifying the exact date of the patient's treatment.
7. Indicate the 'Tanggal gejala atau keluhan pertamakali diketahui pasien' for the date symptoms were first observed.
8. Fill in the 'Tanggal pertamakali konsultasi untuk sakit tersebut' with the date of the first consultation regarding the illness.
9. Provide the name and address of the referring doctor in the section labeled 'Nama dan alamat dokter yang merujuk'.
10. Document the 'Jenis dan hasil pemeriksaan' including details of physical examination results, lab results, and any imaging tests in the appropriate section.
11. Enter the final diagnosis in the 'Diagnosa atau dugaan diagnose' field.
12. Specify the 'Tanggal pertamakali diagnosa ditegakkan', providing the date when the diagnosis was first established.
13. In the 'Diagnosa diatas berhubungan dengan' section, check the appropriate boxes to indicate how the diagnosis is related.
14. Complete the section regarding causative factors that may have contributed to the diagnosis.
15. If applicable, answer whether the patient has previously consulted or been hospitalized, and provide details if they answered yes.
16. Provide information about any underlying diseases related to the illness in the specified fields.
17. Add any further information that may assist in the claims process as instructed.
18. Finally, ensure that the form is duly signed by the attending doctor, with the hospital stamp, in the designated fields.
19. After completing all sections, make sure to save your changes, and then download, print, or share the form as needed.

Take action now and complete your document online.