〔별지 제5호 서식〕

Consent for reading treatment report and issuing copies

진료기록 열람 및 사본발급 동의서

Patient

Name

Mobile

Alien ID No.

or Date of birth

Address

Delegatee

Name

Relation to the patient

Alien ID No.

or Date of birth

Mobile

Address

Scope of reading and issuing copies

Medical institution

Period of treat

Contents and reasons for reading and issuing copies

Attention

Any other person who forges patient’s signature to get his/her medical records shall be sentenced to less than 5- year imprisonment under Article 231 and 232 the Criminal Law for private document forgery .

※ Documents that show the relation to the patient, Copy of the patient's ID card

※ If a patient is below 14 , this should be written by a legal guardian.

I( or legal guardian ) hereby consent to the delegate (       ) reading my treatment report or issuing copies based on the medical law no. 21-3 and enforcement regulation no.13-3

day ____ month _____  yr _____

Patient ( or legal guardian )                           (signature)

Busan Adventist Hospital

〔별지 제5호의2서식〕

Authorization for reading treatment report and issuing copies

진료기록 열람 및 사본발급 위임장

Patient

Name

Mobile

Alien ID No.

or Date of Birth

Address

Delegatee

Name

Mobile

Alien ID No.

or Date of Birth

Relation to the patient

Address

Attention

Any other person who forges patient’s signature to get his/her medical records shall be sentenced to less than 5- year imprisonment under Article 231 and 232 the Criminal Law for private document forgery .

※ Required documents : Consent for reading treatment report and issuing copies

, Copy of the patient's ID card

I delegate authority to the acceptor for receiving the medical records mentioned on the「 Consent for reading treatment report and issuing copies 」

based  on the 「 medical law 」 no. 21-3 and enforcement regulations no. 13 -3

day  ____  month ____ yr _____

Patient ( or legal guardian )                       (Signature)

Busan Adventist Hospital