Law Enforcement Request for Protected Health Information Crime Victims

 

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).

 

The person named may be unable to agree to consent due to incapacity or other emergency circumstance. The disclosure is needed to determine whether a violation of law by a person other than the victim has occurred, and such information is not intended to be used against the victim. Immediate law enforcement activity would be materially and adversely affected by waiting until the individual is able to agree to the disclosure. I believe that the disclosure is in the victim's best interest and may prevent further serious harm to them or other potential crime victims. As a law enforcement officer, I further believe that the health care provider should also find, in the exercise of professional judgement, that such disclosure is in the victim's best interest.

 

The PHI that is being sought is limited to:

________________________________________________________________________________________________________________________________________________________________________

 

 

 

 

_________________________________ ____________________

Special Agent Date

Kansas Bureau of Investigation