■ ENFORCEMENT RULE OF THE MEDICAL LAW ACT [Form No. 9-2 of the attached document] <RE 20.JUN.2025>
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	01. Reading [ ] / 02. Issuance of copies [ ] / 03. Transfer/send to other medical institutions [ ] (Please “√” the item you agree to)
	Name of Medical Institution	Name of the medical institution that will receive the information (In case of transmission/submission of medical records)
	Treatment Period
	Reason for issuance
	Type of Medical Record (Please write it down)
	Ex) Copies of medical records, prescription, surgical records, inspection contents and findings, nursing record, premature birth records, diagnosis, death certificate or autopsy report, CD copy of images (X-ray/CT/MRI), etc.
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
210mm×297mm[백상지 80g/㎡(재활용품)]