_ _ _ _ _ _ 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: _ _ _ _ _ _