National Cheng Kung University Hospital Online Medical Record Request Form
Fill-out the page
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
Patient's National Identity Card,
Residence ID Card or Passport
  病患出生年月日 Birth date: 日    ex (073)年(05)月(25)日
  申請類別 :
type of application
Purpose of request
(singular choice)
Duration of request
日 ~  
Name of patient
(必填 Must fill in)  
phone numbrt of patient
(必填 Must fill in)  
  申請人姓名 :
Name of applicant
(必填 Must fill in)  
phone number of applicant
(必填 Must fill in)  
Name of consignee
(必填 Must fill in)  
Phone number of consignee
(必填 Must fill in)                       



       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.


   After applied online, the hospital will contact the applicant and patient 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.  


   To protect the patient’s privacy, you must come to the hospital to pick up the report in person. Please provide both patient, authorized person IDs and letter of authorization (for child please provide household register) if you are not the patient. We will not 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號櫃台 取件時間:週一至週五 8:00-17:00。

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



   Application fee: 200 NT dollars application fee. There will be additional charge for copying report (5 NT per page). Medical report for discharge summary in Chinese is 650 NT 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.  


   For picking up of medical records applied online and obtaining copies of inspection report (limited to records within the last 6 months) , please visit the outpatient building 1F, No 13 cashier counter for expedited access. 


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


   If you have any questions please contact Mr. Guo at 06-2353535 x 2736. 

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