Restrict Electronic Access to Health Information

All information provided 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 the request.

You will receive confirmation from KanHIT once your request has been implemented. If you do not receive confirmation, contact kanhit@ks.gov.

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 select the appropriate option below to proceed with the submission process.

I direct that no health information relating to the person identified 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.