[Attachment No. 3 of 9 format] [별지 제9호의3서식]
Authorization for Disclosure and Copy of Medical Records (진료기록 열람 및 사본발급 위임장)
① Trustee (수임인)	Name (성명)		Contact No. (전화번호)
	Social Security Number (주민등록번호) (Alien Card Number) (외국인등록번호)	Please write you date of birth if you do not have a social security number or ARC number	Relationship to Patient (위임인과의 관계)
	Address (주소)
② Patient (위임인)	Name (성명)		Contact No. (전화번호)
	Social Security Number (주민등록번호) (Alien Card Number) (외국인등록번호)
	Address (주소)
I, the patient give power of attorney to the Trustee as written in the 「Authorization for Disclosure and Copy of Medical Records」 to disclose and copy the patient’s medical records according to the 「Medical Law」 Article 21 clause 2 of the Korea Medical Service Act and Article 13-2 of the Enforcement Decree of the Medical Services Act. (위임인은 「의료법」제21조제2항 및 같은 법 시행규칙 제13조의2에 따라 「진료기록 등 열람 및 사본발급 동의서」에 기재된 사항에 대하여 일체 권한을 상기 수임인에게 위임합니다.) Year Month Day (년) (월) (일) Patient (or Patient’s Legal Guardian) (Signature) (위임인) (자필서명)
210㎜×297㎜[Plain Paper 60g/㎡(For Recycling)] (210㎜×297㎜[일반용지 60g/㎡(재활용품)])