Authorization For Release of Health Information
Patient	Name	Phone No.
	Date of Birth ( Alien Registration No.)
	Address
Legal Representative	Name	Relationship
	Date of Birth ( Alien Registration No.)	Phone No.
	Address
Range of medical records released and copied	Name of Medical Institution
	Date(s) of treatment
	Reason for Issuance
	Type fo Medical Record (written by patient)
	Ex) Copy of medical records, prescription, operation records, examination and testing results, imaging (CD included), ursing records, copy of medical certificate, death certificate, etc.
I (or Legal Representative) authorize the release of my medical information including copies of my medical record to the above mentioned entity ( ) in accordance to article 21 clause 2 and article 13 clause 3 of the medical law. (year)/ (month)/ (date) Patient(or Legal Representative) (signature)