Law Enforcement Request for Protected Health Information Suspects, Fugitives, Material Witnesses, and Missing Persons

 

Kansas Bureau of Investigation

 

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) allows medical providers to cooperate with law enforcement in the investigation of crimes and the protection of victims pursuant to 45 C.F.R. 164.512(f).

 

As a law enforcement officer authorized to receive Protected Health Information (PHI), I am making an official request to obtain permitted disclosure of PHI for _________________________________________________________ (patient/victim).

 

Only the following information is sought in order to identify and locate the person named, who is a suspect, fugitive, material witness, or missing person:

 

A.                 Name and address;

B.                 Date and place of birth;

C.                Social Security Number;

D.                ABO blood type and rh factor;

E.                 Type of injury;

F.                 Date and time of treatment;

G.                Date of time of death, if applicable; and

H.                 A description of distinguishing physical characteristics, including height, weight, gender, race, hair and eye color, presence or absence of facial hair (beard or moustache), scars, and tattoos.

 

 

 

___________________________________ _____________________

Special Agent Date

Kansas Bureau of Investigation