(Name of the Agency and Jurisdiction: e.g., Oklahoma
of the
Case No.
RELEASE TO LAW ENFORCEMENT*
The HIPAA Privacy Rule at 45 C.F.R. §164.512(f) permits a covered entity to disclose protected health
information in response to a law enforcement official’s request for such information about an individual (1) for
purposes of identifying and locating the individual (2) who is or is suspected to be a victim of a crime. The
University may disclose the protected health information if the law enforcement official signs the following
acknowledgment:
I,
Name and Rank), Badge No.
(Law Enforcement Officer’s
City Police Department) represent that I am conducting an ongoing investigation regarding potential criminal
activity. I am making an official request for the protected health information of
(name of individual):
(1) Who is suspected to be the victim of a crime:
I represent that the individual or individual’s authorized representative is unable or unwilling to authorize
the disclosure, or it is otherwise impractical for me to seek authorization. I represent that the information requested
is needed to determine whether a violation of law by a person other than the victim has occurred. Such information
is not intended to be used against the victim. I also represent that immediate law enforcement activity that depends
upon this disclosure would be materially and adversely affected by waiting until the individual or the individual’s
representative is willing or able to agree to the disclosure.
Or
(2) Whose identity and location I am trying to determine:
I am entitled to the following:
a. name a
nd address e. type of injury
b. date an
d place of birth f. date and time of treatment
c. social s
ecurity number g. date and time of death, if applied
d. ABO blood ty
pe and rh factor h. distinguishing physical characteristics
I am n
ot entitled to any information related to DNA, DNA analysis, dental records, or typing/samples/analyses of
bodily fluids or tissue.
Law Enforcement Official Requesting Disclosure Date
BASED UPON THIS REPRESENTATION BY THE ABOVED-NAMED LAW ENFORCEMENT
OFFICIAL, THE UNIVERSITY HEALTH PLAN HAS DETERMINED IT IS IN THE BEST INEREST OF
THE MEMBER TO RELEASE THE PROTECTED HEALTH INFORMATION TO THE LAW
ENFORCEMENT OFFICIAL.
*For use when no court order; court-issued summons or subpoena; administrative subpoena or summons; or
individual Authorization is presented. Consult the Office of Legal Counsel or Privacy Official if you have any
questions (271-2033).
Updated: 9/2014 © 2014
