PERSYARATAN REKOMENDASI SURAT IZIN PRAKTIK (SIP)

KETERANGAN
NO URAIAN JUMLAH
Ada Tdk Ada
1 Permohonan Rekomendasi SIP 3 Lbr
2 Surat Pernyataan Etika 3 Lbr
3 Surat Pernyataan Tempat Praktik 3 Lbr
4 Pas Photo 3x4 3 Lbr
5 Foto Copy KTP 3 Lbr
6 Foto Copy KTA IDI Medan & KTA IDI Pusat bagi yang sudah ada 3 Lbr
7 Foto Copy Ijazah Dokter Umum / Ijazah Dokter Spesialis 3 Lbr
8 Foto Copy STR & STR Legalisir Asli 3 Lbr
Surat Persetujuan dari Atasan Langsung bagi Dokter yang
9 Bekerja pada Instansi / Fasilitas Pelayanan Kesehatan 1 Lbr
Pemerintah Diluar Jam Dinas / Jam Kerja (Khusus PNS)
10 Surat Keterangan dari Perhimpunan (Dokter Umum / Spesialis) 3 Lbr
11 Surat Keterangan dari Tempat Praktik/Instansi (RS / Klinik) 3 Lbr
Biaya Administrasi Rekomendasi Dokter Umum Rp 50.000/Rekomendasi
Biaya Administrasi Rekomendasi Dokter Spesialis Rp 100.000/Rekomendasi

Adapun rekomendasi SIP yang akan dibuat rekomendasi yang ke I

Nama Sarana Pelayanan Kesehatan : .............................................................................................................................

Rt/Rw : .............................................................................................................................
Kelurahan : .............................................................................................................................
Kecamatan : .............................................................................................................................
Kabupaten/ Kotamadya : .............................................................................................................................

Adapun rekomendasi SIP yang akan dibuat rekomendasi yang ke II

Nama Sarana Pelayanan Kesehatan : .............................................................................................................................

Alamat : .............................................................................................................................
Rt/Rw : .............................................................................................................................
Kelurahan : .............................................................................................................................
Kecamatan : .............................................................................................................................
Kabupaten/ Kotamadya : .............................................................................................................................

Adapun rekomendasi SIP yang akan dibuat rekomendasi yang ke III

Nama Sarana Pelayanan Kesehatan : .............................................................................................................................

Alamat : .............................................................................................................................
Rt/Rw : .............................................................................................................................
Kelurahan : .............................................................................................................................
Kecamatan : .............................................................................................................................
Kabupaten/ Kotamadya : .............................................................................................................................

Admin

………………………………

NB : Lengkapi persyaratan sesuai tempat yang akan di buat.

Perihal : Permohonan Rekomendasi Izin Praktek Form - I
Tenaga Medis Dokter Umum / Dokter Spesialis *
Kepada Yth
Ketua IDI Cabang Medan
Di Medan

Salam Sejawat,
Yang bertanda tangan di bawah ini, saya :
Nama : ..................................................................................................................................................
Tempat / Tanggal Lahir : ..................................................................................................................................................
Jenis Kelamin : ..................................................................................................................................................
NPA : ..................................................................................................................................................
No. STR : ..................................................................................................................................................
Tempat Bekerja/Instansi : ..................................................................................................................................................
Alamat Rumah : ..................................................................................................................................................
RT / RW : ..................................................................................................................................................
Kelurahan : ..................................................................................................................................................
Kecamatan : ..................................................................................................................................................
Kabupaten / Kotamadya : ..................................................................................................................................................
Dokter : Umum / Spesialis *
 Status Dokter Umum
Lulusan FK/Tahun Lulus :.......................................................................................................................... / ...............
 Status Dokter Spesialis
Spesialis :.................................................................................................................................................
Lulusan FK/Tahun Lulus :.......................................................................................................................... / ...............
Anggota IDI Cabang : ..................................................................................................................................................
Telp/HP : ..................................................................................................................................................

Dengan ini mengajukan permohonan rekomendasi izin praktik dokter umum / spesialis * dengan alamat sebagai berikut:
1. Nama Sarana Pelayanan Kesehatan :
Alamat : ..................................................................................................................................................
RT / RW : ………… / …………
Telp : ..................................................................................................................................................
Kelurahan : ..................................................................................................................................................
Kecamatan : ..................................................................................................................................................
Kabupaten / Kotamadya : ..................................................................................................................................................

2. Nama Sarana Pelayanan Kesehatan :

Alamat : ..................................................................................................................................................
RT / RW : ………… / …………
Telp : ..................................................................................................................................................
Kelurahan : ..................................................................................................................................................
Kecamatan : ..................................................................................................................................................
Kabupaten / Kotamadya : ..................................................................................................................................................

3. Nama Sarana Pelayanan Kesehatan :

Alamat : ..................................................................................................................................................
RT / RW : ………… / …………
Telp : ..................................................................................................................................................
Kelurahan : ..................................................................................................................................................
Kecamatan : ..................................................................................................................................................
Kabupaten / Kotamadya : ..................................................................................................................................................

Demikian permohonan ini saya buat dengan sebenarnya, sungguh-sungguh dan penuh rasa tanggung jawab. Besar harapan saya
bila permohonan ini dapat dikabulkan.

Medan, .............................................................
Hormat saya,

..........................................................................
* Coret yang tidak perlu NPA.IDI :
 MAJELIS KEHORMATAN ETIK KEDOKTERAN
(MKEK) IDI CABANG MEDAN
KETERANGAN KELAIKAN ETIKA
No: …………./Komtap Etika/……….…./…….……

Setelah memperhatikan daftar isian rekomendasi sejawat dan pernyataan diri yang bersangkutan, Majelis Kehormatan
Etik Kedokteran (MKEK) IDI Cabang Medan berkesimpulan bahwa Teman Sejawat :

Nama : .......................................................................................................................
Tempat/Tanggal Lahir : .......................................................................................................................
NPA IDI : .......................................................................................................................
No. Register IDI Cab Medan : .......................................................................................................................
No. STR : .......................................................................................................................
No. Telp/HP : .......................................................................................................................
Alamat Praktek : .......................................................................................................................
.......................................................................................................................

Pada saat ini secara etis sejawat tersebut laik untuk menjalankan praktik sebagai dokter.

Demikian keterangan kelaikan ini kami buat secermat mungkin dan akan ditinjau ulang bila diperlukan. Keterangan
ini berlaku sampai tanggal .................................................................................................................................................

Medan, …………………………………
Pengurus MKEK IDI Cabang Medan

( ..…………………………………………… )
NPA. IDI:
 SURAT PERNYATAAN Form A
(Non PNS)

Saya yang bertanda tangan dibawah ini :

Nama : ....................................................................................................................
Tempat /Tgl. Lahir : ....................................................................................................................
NPA.IDI : ....................................................................................................................

No. Register IDI Cab.Medan : ....................................................................................................................

No. STR : ....................................................................................................................
Alamat Rumah : ....................................................................................................................
....................................................................................................................
Telp / HP : ....................................................................................................................
Alumni Fakultas Kedokteran ( FK ) : ....................................................................................................................
No. Ijazah : ....................................................................................................................

Menyatakan dengan sebenarnya bahwa saya tidak melakukan Praktik Kedokteran lebih dari 3 (tiga) tempat
berdasarkan Undang-Undang Praktik No.29 Tahun 2004 dan PERMENKES No.2052/MENKES/PER/X/2011.
Adapun tempat praktik saya antara lain yaitu :
1. Nama Sarana Pelayanan Kesehatan : ....................................................................................................................
Alamat : ....................................................................................................................
2. Nama Sarana Pelayanan Kesehatan : ....................................................................................................................
Alamat : ....................................................................................................................
3. Nama Sarana Pelayanan Kesehatan : ....................................................................................................................
Alamat : ....................................................................................................................

Bila saya melanggar ketentuan tersebut di atas, saya besedia menanggung konsekuensi Hukum dikemudian hari.
Demikian surat pernyataan ini saya buat dengan sebenarnya.

Hormat Saya :

MATERAI

Rp. 6.000.-

…………………………………………
 SURAT PERNYATAAN Form B
(Bagi PNS)

Wajib diisi

Saya yang bertanda tangan dibawah ini :

Nama : ....................................................................................................................
Tempat / Tgl. Lahir : ....................................................................................................................
NPA.IDI : ....................................................................................................................
No. Register IDI Cab.Medan : ....................................................................................................................
No. STR : ....................................................................................................................
Alamat Rumah : ....................................................................................................................
....................................................................................................................

Telp / HP : ....................................................................................................................
Alumni Fakultas Kedokteran ( FK ) : ....................................................................................................................
No. Ijazah : ....................................................................................................................

Adalah benar bahwa saya bekerja sebagai Aparatur Sipil Negara (ASN) pada instansi :
.............................................................................................................................................................................................
dan telah mendapatkan izin dari atasan saya untuk bekerja pada instansi/fasilitas pelayanan kesehatan di luar Jam
Dinas/Jam Kerja (surat terlampir).

Adapun sarana Pelayanan Kesehatan tempat saya bertugas yaitu :

1. Nama Sarana Pelayanan Kesehatan : ..............................................................................................................

Alamat : ..............................................................................................................
Kelurahan : ..............................................................................................................
Kecamatan : ..............................................................................................................
Kabupaten/Kota : ..............................................................................................................

2. Nama Sarana Pelayanan Kesehatan : ..............................................................................................................

Alamat : ..............................................................................................................
Kelurahan : ..............................................................................................................
Kecamatan : ..............................................................................................................
Kabupaten/Kota : ..............................................................................................................

3. Nama Sarana Pelayanan Kesehatan : ..............................................................................................................

Alamat : ..............................................................................................................
Kelurahan : ..............................................................................................................
Kecamatan : ..............................................................................................................
Kabupaten/Kota : ..............................................................................................................

Menyatakan dengan sebenarnya bahwa saya tidak melakukan Praktik Kedokteran lebih dari 3 (tiga) tempat
berdasarkan Undang-Undang Praktik No.29 Tahun 2004 dan PERMENKES No.2052/MENKES/PER/X/2011.

Bila saya melanggar ketentuan tersebut di atas, saya besedia menanggung konsekuensi Hukum dikemudian hari.

Demikian surat pernyataan ini saya buat dengan sebenarnya.

Hormat Saya :

MATERAI

Rp. 6.000.-

………………………………………