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 Patient’s Personal Representative Date of Signature

_________________________________________________________________________________

Personal Representative’s Relationship / Capacity to Patient

_________________________________________________________________________________

Printed Name, Address & Telephone Number of Personal Representative

---