CLMPACC-07 SURAT KETERANGAN DOKTER / ATTENDING PHYSICIAN S STATEMENT KLAIM RAWAT JALAN - RAWAT INAP / OUTPATIENT - INPATIENT CLAIM B Laki-laki Nama pasien Wanita Male Patient s name Tanggal lahir / usia / Date of birth / age tanggal dd tahun bulan mm Female years Nomor rekam medis Medical report number Tanggal perawatan / jumlah hari perawatan Date of hospitalization / lengths of hospitalization s. d. to hari days Riwayat penyakit dahulu Previous medical history Recent medical history Diagnosa atau dugaan diagnosa Diagnose or pre diagnose Diagnosa di atas berhubungan dengan Kecelakaan Accident Obat terlarang Drug abuse HIV AIDS The diagnose relates to Ya Yes Tidak No Jenis serta hasil pemeriksaan fisik lab rontgen USG CT scan Patologi Anatomi dll Physical exam result lab X ray USG CT scan Pathology Anatomy etc Terapi atau tindakan Therapy or treatment Penyebab / penyakit yang mendasari Cause / underlying disease The date of the caused / underlying diseases occured Nama dan alamat Dokte....
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How to fill out the ID CLMPACC-07 online
The ID CLMPACC-07 form, also known as the attending physician's statement for outpatient and inpatient claims, is a vital document for healthcare providers and patients alike. This guide offers a clear, step-by-step process to assist you in accurately completing the form online.
Follow the steps to complete the ID CLMPACC-07 form online.
- Click the ‘Get Form’ button to access the form and open it in your preferred online editor.
- Enter the patient's name in the designated field under 'Nama pasien (Patient’s name)'.
- Fill in the patient's date of birth and age by selecting the appropriate day, month, and year in the 'Tanggal lahir / usia' section.
- Provide the medical record number in the corresponding field labeled 'Nomor rekam medis (Medical report number)'.
- Record the date of hospitalization and the total number of days of hospitalization under 'Tanggal perawatan / jumlah hari perawatan'. You will need to enter the start and end dates.
- Complete the medical history sections by describing the patient's previous medical history ('Riwayat penyakit dahulu') and recent medical history ('Riwayat penyakit sekarang').
- Indicate the diagnosis or pre-diagnosis in the field provided under 'Diagnosa, atau dugaan diagnosa'.
- Select the appropriate options relating to the diagnosis, such as 'Kecelakaan', 'Obat terlarang', and 'HIV', marking 'Ya' (Yes) or 'Tidak' (No) as applicable.
- Detail any physical examination results or tests carried out in 'Jenis serta hasil pemeriksaan'. Include information about lab tests, imaging, and other relevant assessments.
- Outline the therapy or treatment administered in the 'Terapi atau tindakan' section.
- State the underlying cause or disease in 'Penyebab / penyakit yang mendasari', including the date this condition first occurred.
- Fill in the name and address of the referral doctor in the relevant fields.
- Answer the question regarding previous consultations or hospitalizations by providing dates, diagnoses, and the names of doctors and hospitals where applicable.
- As the attending doctor, confirm the accuracy of the responses by signing the form, including filling in your name, hospital details, and the date. Ensure the hospital stamp is also included.
- After completing the form, save your changes, then download, print, or share the completed document as necessary.
Start filling out your ID CLMPACC-07 form online today to ensure accurate claims processing.
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