NOTE: IF STUDENT ATHLETE IS 18 YEARS OR OLDER, HE/SHE MUST SIGN THIS AUTHORIZATION. IF THE STUDENT ATHLETE IS YOUNGER THAN 18, A PARENT OR GUARDIAN MUST SIGN THIS AUTHORIZATION. A STUDENT SHALL NOT BE CLEARED TO PARTICIPATE IN CERTAIN SCHOOL SPONSORED ACTIVITIES (INCLUDING BUT NOT LIMITED TO SPORTS PROGRAMS) IF THIS ACKNOWLEDGEMENT IS NOT SIGNED OR IF IT IS REVOKED.
By signing below, I hereby authorize Community, including its employees and agents, to disclose minimally necessary protected health information (PHI) of my child listed on this form as follows: Community may disclose 1) records of physical examinations performed to determine student athlete's eligibility to participate in School sponsored activities; 2) records of therapeutic evaluations; 3) records and reports of diagnosis and treatment of injuries or illness experienced by the student athlete while engaged in School sponsored activities, including but not limited to athletic program practice sessions, training and competition; and 4) other records as necessary to determine Student Athlete's physical fitness to participate in school sponsored activities.
I hereby authorize minimally necessary PHI to be disclosed for the purposes described above to the following School personnel (“School Personnel”): 1) principal or assistant principal, athletic director, coaches, teachers, school nurses or other members of the School's administrative staff or their designees, and 2) emergency medical personnel, hospitals or any other health care professional or provider who
evaluates, diagnoses or treats an injury, illness or other condition incurred by the Student Athlete while participating in a school sponsored activity, as necessary to:
· Evaluate the Student Athlete’s eligibility to participate in School sponsored activities, including but not limited to interscholastic or intramural sports programs, physical education classes or other classroom activities;
· Document the sports medicine services provided by Community and evaluate program outcomes;
· Resolve grievances; and
· Evaluate treatment alternatives.
I understand that Community has requested this Authorization to disclose PHI so that the school, together with Community, can make certain decisions about the Student's health and ability to participate in certain classroom and school sponsored activities in accordance with the Health Information Portability and Accountability Act (HIPAA). I also understand that the Student's participation in certain school sponsored activities is conditioned upon my signing this Authorization. I understand that I may revoke this Authorization by sending written notice to the athletic trainer, except that such revocation will not affect action previously taken by Community in reliance on this Authorization. I understand that the PHI released may be subject to re-disclosure by any recipient and no longer protected by federal and/or state privacy laws.