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Welcome,
to the Pertamedika IHC MCU Reservation Application
 
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Cek Hasil MCU
Reservation Terms & Initial Disclaimer

Welcome to the Medical Check-Up Reservation Application

Reservation Terms:

  • Before the examination, you will be asked to fill out three types of forms:

    1. Registration Form
    2. File Upload
    3. Anamnesis Form

  • Please prepare a photo/scan of your KTP or Letter of Guarantee/Introduction. Contact the medical department to obtain a letter of guarantee/introduction.

  • Enter your mobile phone number (WhatsApp) to receive notifications.

  • Enter the form completely using accurate information.

  • All data entered through this application will be kept confidential by the hospital (in accordance with general consent).

Disclaimer:

  • Your personal data will be protected in accordance with applicable security standards, including the use of encryption technology and access restrictions.

  • We ensure that only authorized parties can access your data, and all access activities will be logged for audit purposes.

  • Your data will not be shared with other parties without your consent, unless required by law.

General Consent for Health Examination and Personal Data Processing

I. CONSENT FOR MEDICAL EXAMINATION
1. I acknowledge that I will undergo a medical examination and authorize doctors and other health professionals to perform diagnostic procedures as deemed necessary in their professional judgment.
2. These diagnostic and medical procedures may include examination of sensitive areas (breasts, genitals), electrocardiograms, X-rays, lab tests, IV insertion, vaccination, NGT insertion, urinary catheter placement, oxygen therapy, suctioning, enemas/glycerin suppositories, CTG (for in-labor patients), etc., as well as drug administration (oral/injection/rectal/vaginal).
3. I understand that the practice of medicine and surgery is not an exact science and acknowledge that no guarantees have been made to me regarding the results of any procedures or examinations performed.
4. I understand and acknowledge that:
a. I have the right to ask questions regarding the procedures being carried out (including the identity of each person performing them) at any time;
b. I have the right to consent to or refuse any procedure.
II. PATIENTS PERSONAL BELONGINGS
1. I understand that the hospital is not responsible for the loss of any of my personal belongings. I am personally responsible for valuables I own, including money, jewelry, checkbooks, mobile phones, credit cards, and other items. If needed, I may deposit my belongings with the hospital for safekeeping.
2. I also understand that I must notify or hand over to the hospital any dentures, glasses, contact lenses, prosthetics, or other items that need to be secured.
III. CONSENT TO RELEASE MEDICAL INFORMATION
1. I understand that my personal information, including diagnosis, lab results, and diagnostic test results, will be used for medical care and that the hospital/clinic guarantees its confidentiality.
2. I authorize the hospital to provide information regarding my diagnosis, services received, and treatment for the purpose of insurance/health benefit/company/government claim processing.
3. Based on Law No. 17 of 2023 on Health and Ministry of Health Regulation No. 24 of 2022 on Medical Records, I allow the company-designated management to access my medical record documents from the health examination conducted by: (can select more than one)
3.
- Employing Company:
- Cost-Guaranteeing Company:
4. I trust the company-designated management mentioned in point 3 to maintain the confidentiality of my medical examination results, which are of a highly private nature, and not to discuss them in writing without prior written consent from company leadership.
5. Should there be a written request from my employer in the future, I permit the release of my current medical examination information to that company.
6. I authorize the hospital to provide information about my diagnosis, services, and treatment to my family members, specifically to:
Name Family Relationship Phone Number
1.
2.
3.
IV. RIGHTS AND RESPONSIBILITIES, AND RULES FOR PATIENTS AND COMPANIONS
1. I have the right to be involved in decisions regarding my illness, medical care, and treatment plans.
2. I have received information regarding Patient Rights and Responsibilities through leaflets and banners provided by hospital staff.
3. I understand that I am not allowed to document (take photos or record, etc.) any healthcare service process in any form without the hospitals permission. If I need medical information about the patient, I will use my right to ask the attending doctor.
V. COST INFORMATION
1. I understand the information regarding treatment or procedure costs as explained by hospital staff and am willing to pay the full cost of care.
2. I understand there may be interim bills and I will proactively ask about such interim charges.
3. The Hospital / Clinic will never ask Patients or Patient Families to transfer any amount of money for medical procedures via telephone.
4. The Hospital / Clinic does not process REIMBURSEMENT claims for patients covered under BPJS Kesehatan or Pertamina Retirees.
5. I understand that for treatments, medical procedures, or diagnostic examinations with individual costs exceeding:
This will be carried out only after I agree to the treatment/medical procedure/diagnostic examination.
VI. CONSENT FOR PERSONAL DATA PROCESSING
1. I declare that I have read and understood that my personal data will be processed for the following purposes:
- To provide medical services to me.
- To fulfill applicable legal obligations.
- To support research (with anonymized data where applicable).
- To manage administrative processes such as insurance claims and health reporting.
2. I declare that I have read and understood that my personal data may include:
- Identity Data: name, date of birth, identity number.
- Medical Data: diagnosis, lab results, other examination results, and medical summaries.
- Contact Data: address, phone number, email.
3. I have the right to:
- Access, update, or delete my personal data.
- Withdraw this consent at any time by contacting the hospital.
VII. DECLARATION AND SIGNATURE
I hereby declare that:
• I have read and understood the contents of this general consent.
• I give my consent for the medical examination and personal data processing as described above.
• I sign this form fully aware and without any coercion from any party.