MEDICAL INFORMATION WAIVER Chapter 134, Hawaii …

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

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

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Transcription of MEDICAL INFORMATION WAIVER Chapter 134, Hawaii …

1 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.

2 _____ _____ DATE SIGNATURE OF APPLICANT _____ _____ _____ WITNESS DATE TIME HPD-89 (R-05/13)