Proxy Authorization Form for Access and Copy of Medical Records
① Delegate	Name	Given name, Sur name	Tel.
	Social Security No. (Alien Registration No.)		Relationship to Patient
	Address
② Patient	Name	Given name, Sur name	Tel.
	Social Security No. (Alien Registration No.)
	Address
Please write your date of birth if you do not have a social security number or an alien registration number.
I agree to allow the delegate, named above, access to my medical information as stated in the “Proxy Authorization Form for Access and Copy of Medical Records” 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 ______________________