PERMIT NO. ___________________
OUT OF STATE YES NO
MEDICAL INFORMATION WAIVER
Chapter 134, Hawaii Revised Statutes
I, ___________________________________, do freely and in compliance with sections 134-2 and 134-7
(PLEASE PRINT NAME)
of the Hawaii Revised Statutes, authorize the Chief of Police in the City and County of Honolulu access
to any and all records which have a bearing on my mental health for the strict purpose of determining
my qualification to acquire, own, possess, or have under my control, a firearm.
Name of physician/facility: ___________________________________________________________________
__________________________________________________________________________________________
DOCTOR'S ADDRESS DOCTOR'S TELEPHONE NO.
_______________________________ ______________________________________________________
DATE SIGNATURE OF APPLICANT
___________________________________________________ ______________________ ____________
WITNESS DATE TIME
HPD-89 (R-05/13)
