■ 의료법 시행규칙 [별지 제9호의2서식] <개정 2018. 9. 27.>
Consent to Release of Health Information
Patient	Name	Phone No.
	Date of Birth (Alien Registration No.)
	Address
Legal Represen-tative	Name	Relationship
	Date of Birth (Alien Registration No.)	Phone No.
	Address
Type of Medical Record & Scope of the Records Requested	Name of medical institution
	Point-of-care period
	Reason for Issuance
	Range of Issuance (The patient should fill out the form in person)
I (Legal Representative) authorize to release my health information including copies of my medical record to the following person or entity , according to the third clause of Article 21 of Korean Medical Law, and the third clause of Article 13 of Regulation of the same law. / / (Day/Month/Year) (signature)
In case of the patient under the age of 14, it would be completed by a legal representative.
210mm×297mm[백상지 80g/㎡(재활용품)]