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Copy of the latest medical record power of attorney template
Copy the medical record authorization template 1

_ _ _ _ _ _ Hospital:

I am _ _ _ _ _ _ _ (ID number _ _ _ _ _ _ _ _), and I was hospitalized in your hospital on _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _.

Patient's signature: (handprint) _ _ _ _ _ _ _

Signature of the trustee (handprint) _ _ _ _ _ _ _

Date: _ _ _ _ _ _

Copy Medical Record Authorization Template 2

Principal: _ _ _ _ _ _ _

ID number: _ _ _ _ _ _

Authorized person: _ _ _ _ _ _

ID number: _ _ _ _ _ _

Entrusting authority: copy the medical records hospitalized in _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _.

Photocopying purposes: _ _ _ _ _ _1,disability appraisal 2, medical insurance reimbursement 3, follow-up visit 4, judicial use 5, others: _ _ _ _ _ _ _

The term of this authorization is: from the date of signing to _ _ _ _ _ _ _ _ _ _ _.

The power of attorney signed by the client is true and valid. If it is untrue, I will bear all legal responsibilities.

Signature of the client: (signature handprint) _ _ _ _ _ _ _ _

Signature of the client: (signature handprint) _ _ _ _ _ _ _ _

Date: _ _ _ _ _ _

Copy Medical Record Authorization Template 3

Customer name: _ _ _ _ _ _ _

ID number: _ _ _ _ _ _

Name of trustee: _ _ _ _ _ _ _

ID number: _ _ _ _ _ _

Entrusting reasons and matters: I am too busy to go to _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _. Used for: disability appraisal, medical insurance reimbursement, medical treatment, judicial use, others: _ _ _ _ _ _.

I acknowledge all relevant documents signed by the trustee within the scope of authorization and voluntarily assume all legal responsibilities.

Term of entrustment: from the date of signing to the date of completion of the above matters.

Signature of person in charge: _ _ _ _ _ _ _

Signature of the trustee: _ _ _ _ _ _ _ _

Date: _ _ _ _ _ _

Copy Medical Record Authorization Template 4

Client (patient himself): _ _ _ _ _ _

Trustee: _ _ _ _ _ _

I was hospitalized on _ _ _ _ _ _ _ _. I solemnly entrust _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ company.

After the client signs the consent form, the consequences will be borne by the patient himself.

Patient's signature: _ _ _ _ _ _ (handprint)

Signature of the trustee: _ _ _ _ _ _ (handprint)

Date: _ _ _ _ _ _