■ Enforcement Rules of Medical Service Act [Attachment No. 3 of Format 9] <Amended by Jun. 21, 2017> 의료법 시행규칙 [별지 제9호의3서식] <개정 2017. 6. 21>
Authorization for Disclosure and Copy of Medical Records 진료기록 열람 및 사본발급 위임장
Trustee (수임인)	Name (성명)	Contact No. (연락처)
	Date of Birth (Alien Card No.) (생년월일) (외국인등록번호)	Relationship to Patient (위임인과의 관계)
	Address (주소)
Patient (위임인)	Name (성명)	Contact No. (연락처)
	Date of Birth (Alien Card No.) (생년월일)(외국인등록번호)
	Address (주소)
I, the patient, give power of attorney to the Trustee for disclosure and copy of the patient's medical records as written in the 「 Consent Form for Disclosure and Copy of Medical Records 」 according to the 「Medical Law」, Article 21-3 of the Korea Medical Service Act and Article 13-3 of the Enforcement Rule of the Korea Medical Services Act. (위임인은 「의료법」제21조 제3항 및 같은 법 시행규칙 제13조의 3에 따라 「진료기록 등 열람 및 사본발급 동의서」에 기재된 사항에 대하여 일체 권한을 상기 수임인에게 위임합니다.) Year(년) Month(월) Day(일) Patient (Signature)
210mm×297mm[백상지 80g/㎡(재활용품)]