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.
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At least one radio button must be selected above.
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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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