"The copies of records for which this certification is made are true and complete reproductions of the original or microfilmed medical records which are housed in (name of health care facility). The original records were made in the regular course of business at or near the time of the matter recorded. This certification is given pursuant to 42 Pa.C.S. Ch. 61 Subch. E (relating to medical records) by the custodian of the records in lieu of his personal appearance."
Copies shall be separately enclosed and sealed in an inner envelope or wrapper bearing the legend "Copies of Medical Records."
42 Pa.C.S. § 6152