Regulation Of The Minister Of Health Number 2833/menkes/per/x/2011 2011

Original Language Title: Peraturan Menteri Kesehatan Nomor 2052/MENKES/PER/X/2011 Tahun 2011

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Read the untranslated law here: http://peraturan.go.id/inc/view/11e44c50c8b973709721313233303537.html

Microsoft Word-bn671-2011 REPUBLIC of INDONESIA No. 671, 2011 MINISTRY OF HEALTH. Permission. Implementation. The Practice Of Medicine. REGULATION of the MINISTER of HEALTH of the REPUBLIC of INDONESIA NUMBER 2833/MENKES/PER/X/2011 ABOUT PERMISSION PRACTICES and IMPLEMENTATION of the PRACTICE of MEDICINE by the GRACE of GOD ALMIGHTY the MINISTER of HEALTH of the REPUBLIC of INDONESIA, Considering: a. that as implementation of Article 38 paragraph (3) and article 43 of the Act Number 29 of 2004 concerning the practice of medicine, has been assigned the regulation of the Minister of health the number 512/Menkes/Per/IV/2007 on Permit the practice and implementation of medical practice; b. that to meet the development and needs of the law, the need for revision of the regulation of the Minister of health the number 512/Menkes/Per/IV/2007; c. that based on considerations as referred to in letter a and letter b, need to establish the regulation of the Minister of health about Permission practices and implementation of the practice of Medicine; Remember: 1. Act No. 29 of 2004 concerning the practice of Medicine (State Gazette of the Republic of Indonesia Number 116 of 2004, an additional Sheet of the Republic of Indonesia Number 4431); www.djpp.kemenkumham.go.id 2011, no. 671 2 2. Law Number 32 of 2004 concerning Regional Government (State Gazette of the Republic of Indonesia Number 125 of 2004, an additional Sheet of the Republic of Indonesia Number 4437) as last amended by law No. 12 of 2008 (State Gazette of the Republic of Indonesia Number 59 in 2008, an additional Sheet of the Republic of Indonesia Number 4844); 3. Act No. 36 of 2009 about health (State Gazette of the Republic of Indonesia Number 144 in 2009, an additional Sheet of the Republic of Indonesia Number 5063); 4. Legislation – Act 44 of 2009 Number of hospitals (State Gazette of the Republic of Indonesia Number 153 in 2009, an additional Sheet of the Republic of Indonesia Number 5072); 5. Government Regulation Number 32 in 1996 about the health workforce (Gazette of the Republic of Indonesia Number 49 in 1996, an additional Sheet of the Republic of Indonesia Number 3637); 6. Government Regulation Number 38 in 2007 about Government Affairs Divisions between the Government, local governance And local governance Provincial district/city (State Gazette of the Republic of Indonesia Number 82 in 2007, an additional Sheet of the Republic of Indonesia Number 4737); 7. Regulation of the Minister of health Number 1231/Menkes/Per/XI/2007 on special assignment Health Human resources; 8. Regulation of the Minister of health the number 299/Menkes/Per/II/2010 about organizing the Program Placement And Post-graduate Physicians Internsip Internsip; 9. Regulation of the Minister of health the number 317/Menkes/Per/III/2010 about utilization of health workforce foreign citizens In Indonesia; 10. Regulation of the Minister of health the number 1144/Menkes/Per/VIII/2010 about the Organization and the work of the Ministry of health (news of the Republic of Indonesia year 2010 Number 585); Decide: www.djpp.kemenkumham.go.id 2011, no. 6713 Set: REGULATION of the MINISTER of HEALTH ABOUT PERMISSION PRACTICES and IMPLEMENTATION of the PRACTICE of medicine. CHAPTER I GENERAL PROVISIONS article 1 In this ministerial regulation is: 1. The practice of medicine is a series of activities conducted by doctors and dentists are against the patient in exercising health efforts. 2. Physicians and Dentists is a graduate education in medicine or dentistry both inside and outside the country that is recognized by the Government of the Republic of Indonesia in accordance with laws-invitation. 3. additional authority is a doctor with doctors and dentists with additional clinical authority acquired through education and training recognized professional organizations to perform certain medical practice independently. 4. Permit the practice, further abbreviated SIP is written evidence given district/city health services to doctors and dentists who will run a medical practice after fulfilling the requirements. 5. Letter of Assignment is written evidence that was provided to the provincial health Office to the doctor or dentist in the framework of the implementation of the practice of medicine in a particular health care facility. 6. the Certificate of registration, hereinafter abbreviated to STR is written evidence given by Medical Council, Indonesia to doctors and dentists who have been registered. 7. health care Facilities is the venue for the efforts of the health services that can be used for the practice of medicine or dentistry. 8. Medical Service is the health services provided by doctors and dentists in accordance with its competence and which can be either promotif, preventive services, consultative, diagnostic, curative, or rehabilitative. 9. Service standard is a guideline that should be followed by a doctor or dentist in the practice of medicine. 10. Professional standard is the limitation of the ability (knowledge, skill and www.djpp.kemenkumham.go.id 2011, no. 671 4 professional attitude) at a minimum that must be mastered by a doctor or dentist to be able to perform his professional activities at the community independently created by professional organizations. 11. standard operating procedures is a set of instructions/steps to complete a standardized work process a certain routine that gives the correct and best step based on a consensus together to carry out the activities and functions of the service made by healthcare facilities based on standards of the profession. 12. The organization of the profession is Doctor Indonesia Ties to doctor and Dentist Union of Indonesia for the dentist. 13. Medical Council Indonesia, hereinafter abbreviated KKI is an autonomous body, independent, non structural, and are independent of the Medical Council and the Councils of dentistry. 14. The Tribunal of honor Medical Discipline Indonesia, further abbreviated as MKDKI is the authorized institution to determine whether or not there was an error committed doctors and dentists in the application of the disciplines of medicine and dentistry, and set of sanctions. 15. the Minister is the Minister who organized a Government Affairs in the field of health. CHAPTER II General PRACTISE is considered Part of article 2 (1) each of the doctors and dentists who run a medical practice required to have SIP. (2) the SIP as intended in paragraph (1) is issued by the head of Department of health district/city. (3) the head of Department of health district/municipality in providing SIP should consider the balance between the number of doctors and dentists with health care needs. Article 3 (1) SIP for doctors and dentists can be a SIP of doctors, dentists, SIP by SIP, and SIP a specialist dentist specialist. (2) the SIP for doctor internsip program participants be SIP Internsip with authority similar to that of a doctor. (3) the SIP for participants Education Program Specialist (PPDS) or www.djpp.kemenkumham.go.id 2011, no. 6715 Dentist Education Program Specialist (PPDGS) in the form of a SIP or SIP doctor dentist with appropriate authority of competence established by the Chairman of the study Program (KPS). (4) the SIP program for participants with additional authority to acquire special assignment in certain health care facilities in the form of a SIP of doctors with authority as stated in the certificate of competency issued by the College. Article 4 (1) SIP doctors and dentists are given at most for three (3) place of practice, both at the Government-owned health care facilities, private, or individual practice. SIP (2) three (3) places of practice as referred to in paragraph (1) may be in the district/city of the same or different in the same province or provinces. Article 5 (1) SIP for doctors and dentists as a staff educator who practise medicine or dentistry practice in teaching hospital, applies also to the education of medicine and dentistry in other teaching hospital and the hospital or other health care facilities that serve as a networking degree. (2) a hospital or other healthcare facility as educational networks as referred to in paragraph (1) established through the cooperation of the Dean of the Faculty of medicine/Dean of the Faculty of dentistry with a teaching hospital based on the standards of the hospital as a place of education. (3) cooperation as referred to in paragraph (3) mandatory reported Dean Faculty of medicine/Dean of the Faculty of dentistry to the head of Department of health district/city. Article 6 (1) in order to implement equitable health service: a. SIP for doctors and dentists who practise medicine at a Government healthcare facilities are valid also for Government healthcare facilities in his region that doesn't have a doctor/dentist. b. the SIP for doctors and dentists who practise a particular specialty of medicine at a health care facility is valid also for Government healthcare facilities in another area www.djpp.kemenkumham.go.id


2011, no. 671 6 which does not yet have the same specialization services. (2) health care Facilities as referred to in paragraph (1) letter a include health care facilities belonging to the TNI/POLRI, health centers, and health/treatment Hall Hall belonging to the Government. (3) health care Facilities as referred to in paragraph (1) letter b include the Government-owned hospitals are public who cooperate in the form of a sister hospital. (4) the giving of medical services as referred to in paragraph (1) letter a and letter b must be notified to the head of the Department of health of the Kabupaten/Kota. Article 7 (1) doctors and dentists that have had a SIP of medical services or providing consulting expertise in terms of: a. required by a health care facility within the framework of the fulfillment of the medical service that is special, which is not continuous or not scheduled; b. in order to perform an act of social/humanitarian; c. in order to State duties; d. in order to do the handling of disaster or other emergency aid; e. in order to provide medical services to aid the family, neighbors, friends, home visits and services help communities could not afford the incidental nature; don't need a SIP at the venue. (2) the granting of medical services as referred to in paragraph (1) letter a, letter b, letter c and d must be notified to the head of the Department of health of the Kabupaten/Kota. (3) the notice referred to in subsection (2) may be made by the institution of the organizers. The second part of the requirements and procedures of article 8 (1) to obtain a SIP, doctors and dentists must apply to the head of the health service district/city where medical practice implemented by attaching: a. photocopying STR published and original legalized by KKI; www.djpp.kemenkumham.go.id 2011, no. 6717 b. affidavit having a practice, or a certificate from a health care facility as a place of practice; c. letter of approval from a direct supervisor for doctors and dentists who work at agencies/government health care facilities or in establishments/other health care facilities are full time; d. letters of recommendation from professional organizations, according to the place of practice; and e. pas 4x6 size color photos as many as three (3) sheets and 3x4 as much as two (2) pieces. (2) the filing of a petition in the SIP as intended in paragraph (1) should expressly demand SIP for first practice, second or third. (3) Sample application letter as referred to in paragraph (1) are listed in the attached form I. Article 9 (1) doctors and dentists who have meet the requirements referred to in article 8 paragraph (1) was given a SIP for 1 (one) place of practice. (2) examples of the format SIP doctors and dentists as referred to in paragraph (1) are listed in the form II attached. Article 10 (1) the head of Department of health district/city direct/auto provides SIP to doctors and dentists that have had STR stationed in healthcare facilities belonging to the local Government upon the petition in question meets the requirements with a fixed gain of SIP. (2) the SIP to a place referred to in subsection (1) is calculated as 1 (one) place of practice. Article 11 the petition gained SIP Internsip filed Doctor Program to health services Head Internsip district/city where the practice of medicine by attaching: a. photocopying STR for authority internsip published and original legalized by KKI or receipt of management STR of KKI; b. certificate of Doctor Internsip Indonesia Committee; c. letters of recommendation from professional organizations, according to the place of practice; and d. pas 4x6 size color photos as many as three (3) sheets and 3x4 as much as two (2) pieces. www.djpp.kemenkumham.go.id 2011, no. 671 8 article 12 (1) the application for obtaining the SIP to the doctor or dentist who becomes a participant Education Program Specialist (PPDS) or Dentist Education Program Specialist (PPDGS), submitted by the Dean of the Faculty of medicine/Dean of the Faculty of dentistry collectively to the head of Department of health district/city where the Hospital where specialists are education, keeping to meet the requirements in obtaining the SIP. (2) the Application referred to in subsection (1) accompanied by a list of networks of hospitals and healthcare facilities are used. (3) a physician or dentist as referred to in paragraph (1) provided the doctor or SIP SIP dentists with the appropriate authority of competence established by the Chairman of the study Program (KPS) to run a medical practice. (4) the SIP as intended in paragraph (3) applies in the facilities place education program implemented and the entire health care facility who became the hospital's education and networking facilities designated health services. (5) for the doctor or the dentist Education Program Specialist (PPDS) or Dentist Education Program Specialist (PPDGS) who got a special assignment in a particular health care facility by the Minister, to the concerned are automatically given appropriate authority with SIP competencies by head of Department Health Kabupaten/Kota. The third part of the Validity of article 13 (1) SIP SIP of doctors, dentists, specialists, and SIP SIP dentist specialist referred to in article 3 paragraph (1) is valid for 5 (five) years. (2) the SIP Internsip as stipulated in article 3 paragraph (2) is valid for 1 (one) year. (3) a physician or SIP SIP dentists as stipulated in article 3 paragraph (3) applies as long as education Program Specialist (PPDS) or Specialist Dentist Education Program (PPDGS) and ever after 5 (five) years and can be extended with the same procedures. (4) additional authority doctor with SIP as stipulated in article 3 paragraph (4) is valid for 5 (five) years. www.djpp.kemenkumham.go.id 2011, no. 6719 articles 14 (1) the applicable SIP along STR is still valid and still practices in accordance with the place listed in the SIP, and can be extended for eligible. (2) the extension of the SIP as intended in paragraph (1) must be submitted to the head of Department of health district/city selambat the latest three (3) months before the expiration of the SIP ends. (3) in case STR expires, SIP can be extended if the application for an extension of the STR has been processed which is evidenced by a receipt issued by the Organization's management profession with a validity period of not longer than 6 (six) months. The fourth part of the task Letter Article 15 (1) for the purposes of fulfilling the needs of the medical service, the head of the provincial health Office on behalf of the Minister may provide a letter of Assignment to a specialist doctor or dentist specific specialists who already have a SIP to work in health care facilities or hospitals without requiring specific SIP at the venue, a request by the head of the health service district/city. (2) a letter of Assignment referred to in subsection (1) may only be granted in areas where there is no specialist to provide specialist medical services. (3) the letter of Assignment referred to in subsection (1) apply for a period of 1 (one) year. (4) an extension letter of Assignment referred to in subsection (3) may be made along the approval of the head of the local Provincial Health Office on behalf of the Minister. (5) the head of Department of health district/city in filing a request letter of Assignment of a specialist doctor or dentist a particular specialist referred to in subsection (1) must consider the balance between the needs of the Ministry with the capabilities of a specialist doctor or a specialist dentist. (6) a balance between the needs of the Ministry with the capabilities of a specialist doctor or a specialist dentist should be considered by the head of the district/city health service referred to in subsection (5) on the basis of an agreement between the head of the health service district/municipality, related professional organizations, and www.djpp.kemenkumham.go.id


2011, no. 671 of 10 Association of local perumahsakitan. (7) Letter format Example Tasks as listed in the attached Form III. The fifth part of the discontinuation of the practice of article 16 (1) doctors and dentists who will stop the activities of medical practice or the practice of dentistry in a place, compulsory informing the head of the Health Office of Kabupaten/Kota. (2) the notice referred to in subsection (1) do the refund in writing with SIP. (3) the head of a district/city health service referred to in subsection (1), must restore the original legalized photocopy STR by KKI belongs to the doctors and dentists as soon as the SIP is returned. (4) in case of photocopying the original legalized by STR KKI as referred to in paragraph (3) is missing, the head of the district/city health Office should make a statement about the loss of STR to request a photocopy of the original to the legalization of KKI STR. The sixth doctor and Dentist foreign nationals article 17 (1) doctors and dentists foreign citizens can be given SIP all meet the requirements referred to in article 8 paragraph (1). (2) in addition to requirements as referred to in paragraph (1), doctor and Dentist foreign nationals also must: a. have been performed evaluations and have a work permit and a residence permit in accordance with the regulations; and b. has the ability to speak in Indonesia as evidenced by proof of graduation from the Indonesian Language Center of Indonesian Language. Article 18 (1) doctors and dentists foreign citizens can only work at the request of certain health care facilities within the scope of: a. training in order giver over science and technology; and www.djpp.kemenkumham.go.id 2011, no. 67111 b. givers Ministry. (2) doctors and dentists barred foreign citizens practise independently. (3) the prohibition referred to in paragraph (1) excluded for granting relief on a disaster upon the permission of the authorities. Article 19 (1) the criteria and requirements of physicians and dentists foreign citizens, health care facility requirements the user doctors dentist and foreign nationals, and the procedures for application for utilization of physician and dentist foreign citizens carried out in accordance with the provisions of the legislation. (2) certification, Licensing, and Registration for doctors and dentists foreign citizens carried out in accordance with the provisions of the legislation. CHAPTER III ORGANIZATION of the PRACTICE of article 20 (1) doctors and dentists who have had a SIP is authorized to organize medical practices, which include, among others: a. interviewed patients; b. check the physical and mental patients; c. determine the supporting examination; d. enforce the diagnosis; e. determine the management and treatment of patients; f. action of medicine or dentistry; g. write prescription drugs and health equipment; h. publish a description of a physician or dentist; i. Save and give the medicine in the number and type of which in accordance with the standard; and j. preparing and submitting the drug to patients, those who practice in remote areas where there is no pharmacy. (2) the scope and level of authority of the Organization of medical practice referred to in subsection (1) for each doctor or dentist in accordance with a certificate of competence, and/or the certificate of competence of Chairman or Chairman of the College Courses on behalf of the Chairman of the College's educational Program for Physicians www.djpp.kemenkumham.go.id 2011, no. 671 12 specialists (PPDS) or Dentist Education Program specialists (PPDGS). Article 21 (1) medical practice was carried out on the basis of an agreement based on a relationship of trust between doctors and dentists with patients in health maintenance, disease prevention, health promotion, treatment of disease and restore health. (2) an agreement referred to in subsection (1) is the maximal efforts devoted to the medical profession to do doctors and dentists in healing and restoration of the health of the patient in accordance with standard service, professional standard, standard operating procedures and medical needs of the patient. (3) maximum Effort as referred to in paragraph (2) in accordance with the circumstances and local conditions. Section 22 (1) a physician or dentist in performing medical practice must comply with authority and competence. (2) in order to provide help on the State of emergency in order to rescue lives, doctor or dentist may perform acts of medicine or dentistry outside clinical authority in accordance with medical needs. (3) the exercise of the powers referred to in subsection (1) and paragraph (2) shall be conducted in accordance with the standards of the profession. Article 23 (1) the physician or dentist may give pelimpahan an act medicine or dentistry to nurses, midwives or certain other health care personnel in carrying out actions in writing to the medical or dentistry. (2) action of medicine or dentistry as referred to in paragraph (1) can only be made in circumstances where there are needs for services that exceed the availability of doctors or dentists in the service facilities. (3) Pelimpahan the action referred to in subsection (1) done with the terms: a. assigned actions included in the abilities and skills that had been owned by the recipient of the pelimpahan; www.djpp.kemenkumham.go.id 2011, no. 67113 b. implementation of assigned actions still under the supervision of the giver of the pelimpahan; c. giver pelimpahan remains responsible for the actions assigned throughout the implementation of the action in accordance with the given pelimpahan; d. actions assigned does not include clinical decision as the basis for the implementation of the action; and e. action not assigned continuously. Article 24 (1) doctors and dentists who work in hospitals and healthcare facilities educational jejaringnya, in carrying out the task of supervision can provide education/implementation/supervision to participants or dentistry medical education to do the service of the medicine to the patient. (2) the execution of the services of medicine to patients by medical education participants or dentistry as referred to in subsection (1) is carried out under the supervision and responsibility of the supervisor. Article 25 (1) leadership of the mandatory healthcare facilities create a list of doctors and dentists who practise medicine at health care facilities are concerned. (2) a list of doctors and dentists as referred to in subsection (1) includes doctors and dentists who have SIP on healthcare facilities are concerned. (3) a compulsory health care facilities Leadership put a list of doctors and dentists as referred to in paragraph (2) at a place which is easily seen. Article 26 (1) doctors and dentists who have had a SIP and hosted individual compulsory practice putting up signage medical practice. (2) the nameplate as referred to in paragraph (1) shall contain the name of the doctor or the dentist, the number of STR, and SIP numbers. (3) in case your doctor or dentist as referred to in paragraph (2) was unable to carry out the practice may appoint a substitute doctor or dentist. (4) a physician or dentist's replacement as referred to in paragraph (3) should a doctor or dentist who has the equivalent of SIP and not have to SIP at the venue. www.djpp.kemenkumham.go.id 2011, no. 671 2 (5) in certain circumstances for the purposes of fulfilling the needs of the Ministry, the doctor or dentist who has a SIP can replace a specialist doctor or specialist dentist, with the replacement of divulging to the patient. Article 27 (1) the physician or dentist who was unable to carry out a practice or has appointed a doctor or a dentist's replacement as stipulated in article 26 paragraph (3) is required to make a notification. (2) the notice referred to in subsection (1) must be affixed or placed on a place that is easily visible. Article 28 (1) of the social work by doctors and dentists who have SIP which was done in the same district/city can be implemented by notifying the Chief of health services district/city. (2) social work by doctors and dentists who have SIP which was done in a different district/city was carried out with the permission of the head of Department of health district/city and involve local doctors and dentists. (3) social work by doctors and dentists foreign nationals must be carried out in cooperation and is under the responsibility of the doctors and dentists who have STR and SIP in Indonesia with equal competence, and obtain permission from the head of the Health Office of Kabupaten/Kota. CHAPTER IV RECORD KEEPING and the REPORTING of article 29 (1) the head of Department of health district/city obligatory registration of all SIP doctors and dentists who have been rendered. (2) the records referred to in subsection (1) is submitted at regular intervals of at least three (3) months to the head of the Agency for the development and empowerment of human resources for Health Ministry of health, KKI, and copy to the head of the provincial health Office and local professional organizations. (3) the head of the Provincial Health Office is obligated to perform the recording of all the mail task medical specialists and dentists who have particular specialist grant. (4) the records referred to in subsection (3) is submitted at regular intervals of at least three (3) months to the Secretary General of the Ministry of health. www.djpp.kemenkumham.go.id


2011, no. 67115 chapter V the CONSTRUCTION and SUPERVISION of article 30 (1) the Minister, KKI, local governments, and professional organizations doing construction and supervision of the implementation of the regulation of the Minister in accordance with the functions, duties, and powers of each. (2) the construction and the supervision referred to in subsection (1) is directed on Equalization and improved quality services provided by doctors and dentists. Article 31 (1) in the framework of coaching and supervision, head of Department of health district/city can take action against violation of the administrative regulations of the Minister. (2) administrative Sanctions referred to in paragraph (1) may include an oral warning, written up to revocation of the SIP. (3) the head of Department of health district/municipality in providing administrative sanctions referred to in paragraph (2) in advance can hear consideration organization of the profession. Article 32 heads of district/city health Office can revoke the SIP doctors and dentists in terms of: a. on the basis of the recommendation of the MKDKI; b. STR doctors and dentists revoked by KKI; c. place the practices not in accordance with SIPnya; and/or d. repealed rekomendasinya by professional organizations through the hearing conducted specifically for it. Article 33 (1) Repeal the SIP committed head of Department of health district/city mandatory presented to doctors and dentists are concerned within a period of at least 14 (fourteen) days counted from the date of the decision. (2) in the event of a decision as referred to in article 32 of the letters c and d are not accepted, which concerned may file an objection to the head of the Provincial Health Office to be forwarded to the Minister within 14 (fourteen) days after the decision is received. (3) at least 14 (fourteen) days after receiving the letter of objection referred to in subsection (2), the Minister in the case of medical discipline violations, forward it to MKDKI. www.djpp.kemenkumham.go.id 2011, no. 671 16 Article 34 head of Department of health district/city report any repeal SIP doctors and dentists to the head of the Agency for the development and empowerment of human resources for Health Ministry of health, head of the Health Department and head of KKI provinces, as well as tembusannya was delivered to local organizations. CHAPTER VI TRANSITIONAL PROVISIONS Article 35 at the time of this Ministerial Regulation entered into force, the Education Specialist Program participants (PPDS) or Dentist Education Program Specialist (PPDGS), which obtained a special assignment in certain health care facilities, otherwise has had a SIP based on ministerial regulation. CHAPTER VII PROVISIONS COVER Article 36 at the time of this Ministerial Regulation entered into force, the regulation of the Minister of health the number 512/Menkes/Per/IV/2007 on Permit practices and implementation of the practice of medicine, revoked and declared inapplicable. Article 37 of this Ministerial Regulation comes into force on the date of promulgation. In order to make everyone aware of it, ordered the enactment of this Ministerial Regulation with its placement in the news of the Republic of Indonesia. Established in Jakarta on October 6, 2011 MINISTER of HEALTH of the REPUBLIC of INDONESIA, ENDANG RAHAYU SEDYANINGSIH Enacted in Jakarta on October 28, 2011 MINISTER of LAW and HUMAN RIGHTS Republic of INDONESIA, PATRIALIS AKBAR www.djpp.kemenkumham.go.id 2011, no. 67117 form I subject: application for Licence Practice (SIP) to the Designation, the head of the district/city health service ... ... ... ... ... ... .... Di ……………………………….. With respect, signed below, full name:......................................................................... Alamat : ......................................................................... Tempat, tanggal lahir : ......................................................................... Jenis kelamin : ......................................................................... Tahun Lulusan : ......................................................................... Nomor STR :...................................................................... Nomor rekomendasi OP :....................................................................... With this apply to obtain Licences (SIP) Practice for the practice to ... ... with an address on ... ... As this joint consideration of materials attached: a. photocopying STR published and original legalized by KKI; b. statement of practice or have a certificate from a health care facility as a place of practice; c. letters of recommendation from professional organizations, according to the place of practice; d. fitting color photos size 4 X 6 and as many as three (3) sheets and 3 x 4 as much as two (2) pieces; e. letter of approval from a direct supervisor for doctors and dentists who work at agencies/government health care facilities or in establishments/other health care facilities are full time. So over the attention of father/mother we say thank you. .....................,.................................... The applicant, ... ... ... ... ... ... ... ... ... .... www.djpp.kemenkumham.go.id 2011, no. 671 18 Form II LETTERHEAD district/city HEALTH OFFICE LICENCES (SIP) PRACTICE of DOCTORS/DENTISTS No......................................... Based on the regulation of the Minister of health Number 2833/Menkes/Per/X/2011 about Permission practices and implementation of the practice of medicine, signed below, head of Department of health district/city *).................................... give permission Practices on: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ (full name) Place/date of birth: ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... .... Alamat : ............................................................. The Address Of The Place Of Practice: ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Number STR:..................................... valid s/d .../.... Recommendation number OP: ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... .... To Practice as: dr/drg/drg/specialist dr. * Specialist) and clinical authority in accordance with the competencies **) Set on ... ... ... ... ... ... ... ... on ... ... ... ... ... ... ... .... Head Of Department Of Health District/City ... ... ... ... ... ... ... ... ... (………………………………….) Cc: 1. Minister of health 2. The Chairman of the Medical Council, Indonesia 3. The head of the Provincial Health Office 4. Professional organizations *) Streak. **) in accordance with a certificate of Competency by the College or Certificate of competence by the Chairman of the study Program. Pasfoto www.djpp.kemenkumham.go.id 2011, no. 67119 Form III PROVINCIAL HEALTH OFFICE LETTERHEAD a LETTER TASK SPECIALIST DOCTOR/DENTIST SPECIALIST No.......................................... Based on the regulation of the Minister of health Number 2833/Menkes/Per/X/2011 about Permission practices and implementation of the practice of medicine, signed below, the head of the Provincial Health Office ... ... ... ... ... ... ... ... ... ... ... ... give Assignments to: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ (full name) Place/date of birth: ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Alamat :......................................................... To Practice: dr/drg specialist specialist. *) address the place of Practice: ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Nomor STR : ......................................................... Nomor SIP Pertama :.......................................................... Nomor SIP Kedua :.......................................................... Nomor SIP Ketiga :.......................................................... Surat tugas ke :.......................................................... Letter assignments are valid up to date ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... .... Set on ... ... ... ... ... ... ... ... on ... ... ... ... ... ... .... a.n. Health Minister Provincial Health Office Head ... ... ... ... ... ... ... ... ... (………………………………….) Cc: 1. Minister of health 2. The Chairman Of The Medical Council, Indonesia. 3. Professional organizations; *) Mentioned her specialty, by the authority in accordance with clinical competencies Pasfoto www.djpp.kemenkumham.go.id