Current Page 1 Page 2 Preview Personal information on this form is collected under section 31(c) of Prince Edward Island’s Freedom of Information and Protection of Privacy (FOIPP) Act as it relates directly to and is necessary for providing services under the Out-of-Province Travel Support Program. If you have any questions about this collection of personal information, call 902-368-5918. Identification First Name Middle Initial Last Name Address 1 Address 2 City, Town, or Community Province Postal Code For example C1B 0X1 or 12345 Country Telephone Number For example 902-555-5555 Email Address Personal Health Number (PHN) Please enter the 8-digits from your PEI health card. Medical Reason Diagnosis that requires out-of-province service. Location of Service - Select -Nova ScotiaNew Brunswick Is an essential escort requested? An eligible essential escort is either a) one parent/guardian or designate for a child less than 18 years of age; or b) a person who is required to accompany a patient for medically necessary reasons for safe patient transport. A physician note is required. - Select -YesNo Upload a copy of Physicians Note One file only.1 MB limit.Allowed types: jpg, jpeg, txt, pdf, doc, docx, xls, xlsx.