F010R02-0200

INSURANCE CLAIM FORM

INFORMATION ON DEATH
(To be filled out by Attending Physician)
B FORMULIR ISIAN KLAIM ASURANSI KETERANGAN KEMATIAN ( Diisi oleh Dokter yang merawat )
IMPORTANT [ PENTING ]
Complete this form clearly and carefully Check each appropriate box
[ Lengkapi formulir ini dengan jelas ] [ Beri tanda D pada kotak yang anda pilih ]
Patient's name Sex Male Female
[ Nama pasien ] [ Jenis kelamin ] [ Laki-laki ] [ Wanita ]

Place of birth Date of birth Date Month Year

[ Tempat lahir ] [ Tgl. lahir ] [ Tgl. ] [ Bulan ] [Tahun]

ANAMNESIS [ ANAMNESA ]
Most recent medical history :
[ Riwayat penyakit sekarang ]

Previous medical history :

[ Riwayat penyakit dahulu ]

Habits / family history / occupation influencing cause of death :

[ Kebiasaan/sejarah keluarga / pekerjaan yang mempengaruhi sebab kematian ]

EXAMINATION [ PEMERIKSAAN ]
Physical examination : Supporting examinations :
[ Pemeriksaan fisik ] [ Pemeriksaan penunjang ]

DIAGNOSIS [ DIAGNOSA ]
Diagnosis :
[ Diagnosa ]

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F010R02-0200

CAUSE / UNDERLYING DISEASE [ CAUSE / UNDERLYING DISEASE ]

Cause / underlying disease in current illness : Since when the patient has experienced cause / underlying disease :
[ Causa / underlying disease dari sakit / kelainan tsb ] [ Causa / underlying disease diderita sejak ]

TREATMENT AND THERAPY [ TINDAKAN DAN TERAPI ]

Treatment and therapy :
[ Tindakan dan terapi ]

DATA ON DEATH [ DATA KEMATIAN ]

Suspected cause of death : Place of treatment :
[ Dugaan sebab kematian ] [ Tempat perawatan ]

Date of treatment : Date Month Year

[ Tanggal perawatan ] [ Tgl .] [ Bulan ] [ Tahun ]

Place of death :
[ Tempat meninggal dunia ]

Date of death : Date Month Year

[ Tanggal meninggal dunia ] [ Tgl .] [ Bulan] [ Tahun ]

DATA ON DOCTORS / HOSPITALS [ DATA DOKTER / RUMAH SAKIT ]

Names & addresses of doctors / hospitals previously visited / consulted : Names & addresses of referral doctors :
[ Nama & alamat dokter / RS yang pernah dikunjungi sebelumnya ] [ Nama & alamat dokter yang pernah dirujuk ]

OTHER INFORMATION [ KETERANGAN LAIN-LAIN ]

Other information :
[ Keterangan lain-lain ]

STATEMENT OF ATTENDING PHYSICIAN [ PERNYATAAN DOKTER ]

As the Doctor handling the care of the above-mentioned Patient, I hereby state that I have read and
answered the questions in this form clearly and completely Signed by : Date :
[ Saya sebagai Dokter yang merawat / menangani Pasien tersebut di atas menyatakan telah membaca dan menjawab [ Ditandatangani di ] [ Tanggal ]
pertanyaan-pertanyaan tersebut di atas dengan lengkap dan benar } .
Name of Doctor/Hospital :
[ Nama Dokter / RS ]
Specialization :
[ Spesialisasi ]
Address :
[ Alamat ] Signature of doctor and seal of hospital doctor's
Tanda Tangan dan stempel Dokter / RS
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