National Cheng Kung University Hospital Online Medical Record Request Form
輸入畫面：
Fill-out the page		 (申請前請務必詳閱注意事項，以免無法取件)
Please read the following application carefully before applying,you will fail to receive the report if the inaccurate information was received. 
                                                網路申請病歷影本 請輸入以下資訊 Please fill out the following information online
病患身分證字號（或居留證號）：
Patient's National Identity Card,
Residence ID Card or Passport		  
  病患出生年月日 Birth date： 年 月 日    ex (073)年(05)月(25)日
  申請類別 ：
type of application		  
   
     
     
  申請目的：(單選)
Purpose of request
(singular choice)		          
  申請期間：
Duration of request		 年 月 日 ~ 年 月 日  
  病患姓名：
Name of patient		 (必填 Must fill in)  
  病患連絡電話：
phone numbrt of patient		 (必填 Must fill in)  
  申請人姓名 ：
Name of applicant		 (必填 Must fill in)  
  申請人連絡電話：
phone number of applicant		 (必填 Must fill in)  
  取件人姓名：
Name of consignee		 (必填 Must fill in)  
  取件人連絡電話：
Phone number of consignee		 (必填 Must fill in)                       
  請輸入圖形驗證碼
 

注意事項：

1、務必確認所須的項目及日期，如不確定有無做檢查，請勿全部勾選，應註明於「其他」。

       Please make sure all required items and date are correct. If the items you are requesting do not exist on the form, please stated in the other box.

2、網路申請後，本院會與病人(或法定代理人)電話連繫，確認影印範圍、預估金額及交件時間。

   After applied online, the hospital will contact the patient(or legal representative) to ensure the information on the application is correct. In addition, the hospital will provide the estimate cost and date of the report will be ready.  

3、務必親自至櫃台取件，並出示病人及申請人雙方身份證件正本(兒童請出示戶口名簿正本)，以及病人(或法定代理人)委託同意書，若資料不齊全，為保護病患隱私，欠難交件。

   To protect the patient’s privacy, you must come to the hospital to pick up the report in person. Please provide both patient(or legal representative), authorized person IDs and letter of authorization (for child please provide household register) if you are not the patient. We will not be able to give the report if you are not able to present correct documentation.  

4、取件地點：門診大樓1樓 批價11、12號櫃台 取件時間：週一至週五 8：00-17：00。

   Pick-up location: outpatient building 1 F No.11,No.12 cashier counter.  Pick-up time: 8am-5pm on Monday to Friday 

5、申請費用：基本費200元，加上影印病歷之頁數費用(5元/頁)，中文病歷摘要(650元/份)，

    若須影印全本病歷則須先匯款。

   Application fee: 200 NT dollars application fee. There will be additional charge for copying report (5 NT dollars per page). Medical Record summary in Chinese () 650 NT dollars per copy), In addition, you will need to pay in advance if you request for an entire medical record.

6、工作日數：受理後約2個工作天交件為原則(視病歷影本資料多少而定)， 如為出院病人，建議出院3日後再申請出院病歷摘要。

   Processing time: After we accept your request, you should have your report within 2 working days. For discharged patient and needs discharge medical

   record summary, we suggest you wait for 3 days after discharged to apply for the report.  

7、單純複製檢查報告(限6個月內)，請至門診大樓1樓11、12號批價櫃台辦理。

   Obtaining copies of inspection report (limited to records within the last 6 months) , please visit the outpatient building 1F, No.11, No.12 cashier counter. 

8、曾經使用網路申請病歷影本而未取件之病歷，將停止網路申請權利。

   You will not be able to apply the record on-line again, if you don't pick up the previous report you have applied online. 

9、如有任何疑問請洽(06)2353535-2736李小姐。

   If you have any questions please contact Ms. LEE at 06-2353535 ext: 2736. 


成大醫院 醫療事務室 敬啟
113年12月修訂