Authorization Form for Disclosure of Protected Health Information

 

Kansas Bureau of Investigation

 

___________________________________________________________________________

(Hospital / Medical Provider Name)

___________________________________________________________________________

(Hospital / Medical Provider Address)

 

Patient Name: ____________________________________ Date of Birth:________________

 

Patient Address: ___________________________________________________________________

 

I hereby authorize the hospital (includes hospital/clinic administrative staff, examining physicians, nurses, and other allied health care personnel) or medical provider and its agents to disclose (disclose includes release of records/material, and to provide information/testimony) all medical records* and any related protected health information to any special agent/forensic scientist of the Kansas Bureau of Investigation, and/or any prosecutor and staff, and/or court/court personnel for the purpose of conducting a criminal investigation or subsequent prosecution of the reported crime or lesser included crime relating to or resulting from an examination(s) and/or treatment(s) received on and/or treatment based on the following examination dates: _______________________________ limited to and relative to the reported sexual assault or other violent crime.

 

(*All medical records includes inpatient/outpatient records, medical, dental, optical, psychiatric, alcohol/chemical/substance abuse, HIV/Aids, pharmaceutical, hospital or physician records, office notes, narrative summaries, telephone messages, correspondence to/from/about me, diagnostic testing results, bills, statements and invoices whether or not you created those records as long as the records are in your control or possession.)

 

         This authorization shall expire on ____________________________ (MM/DD/YY). [In Kansas, this date cannot exceed 1 year from the date below.]

         I understand that I have the right to revoke this authorization, in writing, at any time by sending a written notification to this hospital or medical provider.

         If I revoke this authorization, it will have no effect on actions already taken based on this form.

                I understand that information disclosed under this authorization may be further disclosed by the recipient and may no longer be protected by federal or state law.

         This hospital or medical provider will not condition examination or treatment on whether the individual signs this authorization form.

 

_____________________________________________ ____________________________

Signature of Patient or Patients Personal Representative Date of Signature

 

_________________________________________________________________________________

Personal Representatives Relationship / Capacity to Patient

 

_________________________________________________________________________________

Printed Name, Address & Telephone Number of Personal Representative