Consent Form for Proxy Access to and Copy of Medical Records
Patient	Name	Given name, Sur name	Tel.
	Social Security No. (Alien Registration No.)
	Address
Delegate	Name	Given name, Sur name	Relationship to patient
	Social Security No. (Alien Registration No.)		Tel.
	Address
Scope of Access	Reason for requesting access
	Reason for requesting a copy
Please write your date of birth if you do not have a social security number or an alien registration number
I (or the Legally Authorized Representative) agree to allow the delegate, named ( ), access to my medical information or a copy of my medical record in accordance with Article 21, Clause 2 of the Korea Medical Service Act and Article 13-2 of the Enforcement Decree of the Medical Service Act. Date: Month Date, Year Signature of Patient or LAR _
Note: If the patient is under age 15, then the Legally Authorized Representative shall fill in this document.