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성남시 분당구 대왕판교로 34번길 ***** 13549 길동 홍 A 병원 경기도 성남시 분당구 구미로 00 00000
진료정보교류에 관한 개인정보 제공 동의 철회서
접수일
2017-04-28 		접수기관
A 병원 		처리기간 10일 이내
동의주체 성 명 홍길동 전화번호 010-0000-1000
생년월일(주민등록번호) 19880101
주 소 경기도 성남시 분당구 대왕판교로 34번길 *****
철회내용 부분 의료기관 의료기관명(동의 철회 요구) A병원 B병원 C병원
기관 철회 사유
부분 진료과 진료과명(동의 철회 요구) 비뇨기과 산부인과 정신과 피부과
진료과 철회 사유
전체 전체 철회사유

개인정보보호법 등에 따라 위와 같이 요구합니다.
2016년 07월 04일
환자(대리인 또는 보호자) 이름: 홍길동 연락처: 010-0000-1000 환자와의 관계: 본인
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