(Agency letterhead)

 

D R A F T

 

HIPAA DOCUMENTATION FOR

LAW ENFORCEMENT PURPOSES

 

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) allows medical providers to cooperate with law enforcement in the investigation of crimes and protection of victims.   45 C.F.R. §164.512(f)(1)-(6)  Pursuant to that authorization, this is an investigatory demand for information regarding _______________________________________ (Name or description).                

 

1.      This person has authorized the blood test requested pursuant to K.S.A. 8-1001.

 

            ___________________________________________________     __________

            Signature of Consent                                                                                    DATE

 

2.      This person is unconscious or dead.  As such, consent for the test is created through K.S.A. 8-1001(a).

 

            ___________________________________________________     __________

            Signature of Officer                                                                                       DATE

 

The officer, being of lawful age and upon my oath does solemnly state as follows:

 

  1. The information sought is relevant and material to a legitimate law enforcement inquiry.

 

  1. The officer is making a specific request and it will be limited in scope to the extent reasonably practicable in light of the purpose for which the information is sought.

a.                  The specific request for information is as follows:

______________________________________________________________

 

______________________________________________________________

 

______________________________________________________________

 

  1. De-identified information cannot reasonably be used.

 

            ________________________________________                  ________________

            Officer signature, Radio Number.                                       Date

 

This documentation may be provided to the person regarding whom information is sought in compliance with HIPAA.  45 CFR §164.501

 

If you have any questions, please contact the Kansas Highway Patrol Legal Office at (785) 296-6800.