■ 의료법 시행규칙 [별지 제9호의3서식] <개정 2024.11.07>
Power of Attorney to Release Medical Information & Records
Authorized Recipient	Name	Date of Birth
	Contact Number (email)	Relationship with Delegating Person
	Address
Delegating Person (Patient)	Name	Date of Birth
	Contact Number (email)
	Address
I(Delegating Person) delegate all authority to Authorized Recipient about stated matter in 「Authorization to Release Medical Information & Records」paper forms, according to the third clause of Article 21 of Medical Service Act and the third clause of Article 13 of enforcement rule of the same law. _____/_____/_____(date/month/year) Delegating Person ________________ (signature)
210mm×297mm[백상지 80g/㎡(재활용품)