■ 의료법 시행규칙 [별지 제9호의2서식] <개정 2024.11.07>
Authorization to Release Medical Information & Records
Patient	Name	Date of Birth
	Contact Number (email)
	Address
Applicant	Name	Relationship with Patient
	Contact Number (email)	Date of Birth
	Address
Scope of Disclosure & Copies	Name of Medical Institution
	Period of Treatment
	Type of Medical Record and Reason for issuance
I, as the patient(or Legal Representative) undersigned, authorize Daewoo General Hospital to release records and copies of my health information including all protected health report related my treatment. So I consent the above applicant ( ) can read or receive all about my medical record and copies in accordance with the third clause of Article 21 of the Medical Service Act and the third clause of Article 13 of enforcement rule in the same law. _____/_____/_____(date/month/year) Patient (or Legal Representative) ______________________ (signature)
※ Remark: If the patient is under full 14 years of age, the legal representative need to fill out this authorization.
210mm×297mm[백상지 80g/㎡(재활용품)