SAMPLE FORM
REQUEST FOR PATIENT INFORMATION PURSUANT TO PHL SECTION 18


TO: (name and address of the health care provider from whom patient information is being requested.)

RE: (describe the patient information requested; include dates if pertinent)

Patient Name:__________________________________

I, the undersigned, hereby request a copy of the above-referenced patient information.

I further request that such copy of patient information be delivered to me in care of: (name and address, if applicable, of the third party to whom the copy of the patient information is to be delivered).

Date: ____________

Signature: ____________________________
(qualified person) (Print Name Below Signature)

Relationship to Patient: ______________________
(Some health care providers require the signature to be notarized.)