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Medi Flower Copy of Medical Record Issue Policy

2017-08-03 15:00
<Protection of Privacy and Third Party Treatment Restriction>
All documents handled in the clinic contain extremely personal information of the patient. For this reason, We are under strict Medical and Privacy Law compliance guidelines that dictate how we handle and share patient’s medical information. If you are requesting release or transfer of protected health information to third parties, you need to follow the procedures outlined below.

<Instruction for the copy of Medical Record Issue and Required Documents>
1. Complete the entire section of the form with signature, relationship to patient, patient name, date of birth, date of signature and your name.
2. You may fax or email this information to 82-6925-6244 or at
3. There is a charge for production of medical records which is based on the size of the record.
Recipient's Relationship to the patient Required Documents
Patient herself Recipient’s ID
Patient’s Direct Relative
(e.g. Spouse, direct ascendant, direct descendant)
1. Recipient’s ID
2. Family relation certificate or verification form
3. Authorization Form* download
Authorized Person other than direct relatives
(e.g. Insurance company, friend, sibling)
1. Recipient’s ID
2. Copy of patient’s ID
3. Authorization Form* download