Authorization To Disclose Health Records To A Law Enforcement Agency Form Utah
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1UTAH AUTHORIZATION TO DISCLOSE HEALTH RECORDS TO A LAW ENFORCEMENT AGENCY
(For Law Enforcement Use Only. Deliver in person, or if mailed/faxed, with cover letter on agency letterhead. Complete all sections.)
1. I authorize the health care provider(s) listed below to disclose protected health records of:
Name of Patient
_______________________________________
Date of Birth__________________________
(print)
Phone Number_(____)____________________
Soc. Sec.#
_______________________________________
(optional)
Address_________________________________________________________________________________________
City______________________________________________ State___________________ Zip ___________________
2. Record(s) Requested from:
Complete record(s) consisting of:
Between the dates of:
A. (ii)(Check all that apply)
A. (iii)
A. (i) (Physician/Facility Name and Location)
Inpatient record
_________ to_________
Outpatient record
Emergency record
Ambulance/transport record
Other________________________
(
B. (iii)
B. (ii)
Check all that apply)
B. (i) (
Physician/Facility Name and Location)
_________ to_________
Inpatient record
Outpatient record
Emergency record
Ambulance/transport record
Other________________________
C. I authorize my complete substance abuse treatment records to be disclosed from the following provider(s):
(i)_____________________________________________________from the dates of: (ii)________to _________.
(Physician/Facility Name and Location)
I understand, by initialing this box, that I am allowing the disclosure to law enforcement of my substance abuse
treatment records protected by Federal confidentiality rules (42 CFR part 2), and which are prohibited from redisclosure
without my written consent (or otherwise permitted by these rules). Records given to law enforcement by this
disclosure cannot be used to investigate or prosecute me for a criminal offense unless ordered by a court.
Patient initials:
(If the records requested are a minor’s, both the minor and the parent must sign and initial this form.)
3. Provide these records to the following Law Enforcement Agency: (Agency name, address, phone):
4. Unless
revoked (see 5. B below)
this aut
horization will remain in effe
ct until:
(check one)
1 year
from date signed
For one time disclosure only
Other event or time:
(Please specify)________________
____
5.
I un erstand:
d
A.
I may decide not to sign this authorization. The provider(s) listed above will not deny me treatment solely for that reason.
B.
If I do sign this authorization, I may revoke it at any time, unless the provider(s) have relied on my authorization and have already
disclosed the records. To revoke this authorization, I need to send a revocation in writing to the provider(s) above.
C.
The law enforcement agency that receives the records may redisclose them if permitted
by law. Only records protected by Federal
confidentiality rules 42 CFR part 2 (specified in Section 2. C above), are restricted from redisclosure unless I give
written consent,
unless redisclosure is permitted by these confidentiality rules, or if ordered by a court.
D.
If I wa
nt to know what is in these records, I can contact the provider(s) listed above for access to these records.
_______________________________________
_________________________
Signature of Patient
Date
________________________________________
________________________
Signature of Parent/Guardian [if applicable]
Relationship to Patient
6. I hereby v rify
e
the identity of the person(s) signing above and that these records will be used for law enforcement
purposes on
ly.
_
_________________________________
________________
________________________
Signature of Law Enforcement Officer
Badge or Attorney Bar #
Agency
_______________________________
__________________
_______________________
Print Officer’s Name
Agency Case Number
Dispatcher’s Phone (for verification)
Source: Utah HIPAA Preemption/Law Enforcement Task Force
Revision Date 06/6/2005
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Parent category: Medical