Request to Access or Disclose Personal Health Information

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Information on this form is collected under authority of Prince Edward Island’s Freedom of Information and Protection of Privacy Act and Health Information Act, and will be used to respond to your request. If you have questions regarding your personal health information and privacy, visit www.healthpei.ca/yourprivacy or speak with your health care provider.

Identification

Enter details of the individual whose information is being requested.

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

Date of Birth

Does the individual whose information is being requested have a PEI Health Card?

Personal Health Number (PHN)

Enter the 8-digits from the individual's PEI health card.

Does the individual have an out-of-province Health Card?

Out-of-Province Health Card Number

Which Health PEI facility does your request relate to?