REQUEST TO RESTRICT ELECTRONIC

ACCESS TO HEALTH INFORMATION

All information you provide will remain strictly confidential and will be used solely to carry out your request. KanHIT staff will contact you directly if additional information or clarification is required to fulfill your request.

You will receive confirmation from KanHIT once your request has been implemented. If you do not receive confirmation, contact 785-296-0461, as soon as possible.

For your protection, all requests are subject to verification procedures. If you fail to provide all information necessary to verify your request, it may result in its delay or even denial. Electronic access to health information will be restricted as soon as practical.

Please check the appropriate radio button, below. KanHIT cannot process your request if no radio button is selected. KanHIT can fulfill your request only if one of the following statements is true.

I am the person for whom the request is being made.

I am making the request as the parent or legal guardian of a minor and that minor does not have the legal authority to consent to his/her own medical treatment.

(Use this option if making the request for a minor)

I have been appointed by a court of proper jurisdiction to act on behalf of the individual for whom I am making the request as his/her legal guardian.

I have been formally appointed by the individual for whom I am making the request as his/her durable power of attorney and/or durable power of attorney for health care and that individual has an impairment that prevents him/her from making decisions on his/her own behalf.

I direct that no health information relating to the person identified below be electronically accessible to any person or entity for any purpose through an approved health information organization ("HIO"), except as necessary by a properly authorized individual in the event of an emergency when consent cannot be obtained or to report specific information to a government agency as required by law (for example, reporting of certain communicable diseases or suspected incidents of abuse).

I understand and accept the risks associated with denying health care providers access to health information through electronic health information exchange. I understand I can revoke this restriction at any time upon request to KanHIT.

By submitting this request, I certify under penalty of perjury that (1) all information I have provided on this form is true and accurate to the best of my knowledge; and (2) I have the authority to make this request.

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