REQUEST FOR DISCLOSURE OR REPRODUCTION OF MEDICAL RECORDS
Patient	Name	Contact Information
	Foreign Registration Number
	Address
Records are to Be Released to :	Name	Relationship to the Patient
	Foreign Registration Number	Contact Information
	Address
Scope of the Records Requested & Grounds for the Request	in the Case of Disclosure (for Reading Only)
	in the Case of Reproduction (for Photocopying)
I, as the Patient(or a legal representative of the Patient), hereby request that any and all of my medical records and related information pertaining to my care and treatment should be released to ( MENTIONED ABOVE ) in such manner as stated above, in accordance with Clause 2 of Article 21 of Medical Service Act and Article 13-2 of ENFORCEMENT RULES of the same Act. Date Patient Signature
Note: If the Patient is under age 14, his or her legal representative shall sign this form.