Healthcare Sports Medicine Document

HEALTHCARE SPORTS MEDICINE DOCUMENT

Patient Information

Date of birth:

Male Female Non-binary Other:

Emergency Contact

Insurance Information

Subscriber date of birth:

Medical History

Asthma Diabetes Heart disease Seizure disorder Hypertension Other:

Yes No

Sports Participation / Injury Information

Youth High school College Professional Club

Pain Swelling Instability Numbness/tingling Decreased range of motion

Consent for Evaluation and Treatment

I authorize the sports medicine clinician, athletic trainer, designees, and supervising physicians to perform a clinical evaluation, diagnostic testing procedures, therapeutic modalities, and treatment plans as deemed necessary for my care. I understand that assessment and treatment may include manual therapy, therapeutic exercise, joint mobilization, wound care, taping/brace application, local injection therapy performed by authorized providers, referral for imaging, and other procedures consistent with standard sports medicine practice.

I acknowledge that all medical procedures carry potential risks including but not limited to bleeding, infection, adverse reaction to treatment, increased pain, and, in rare cases, permanent injury. The expected benefits, risks, and alternatives have been discussed with me or are available upon request. I understand I may refuse any recommended treatment and may withdraw consent at any time, except where withdrawal would create immediate risk to my health.

By signing below I consent to evaluation and treatment by the sports medicine team and authorize communication of my relevant medical information to treating providers, coaches, and appropriate medical personnel for coordination of care.

HIPAA Authorization and Release of Information

I authorize disclosure of my protected health information to other health care providers, athletic staff, and insurers as necessary for treatment, payment, and healthcare operations related to my sports medicine care. This authorization includes release of medical history, diagnostic results, treatment plans, and return-to-play clearance notes. I understand that this authorization is voluntary and that I may revoke it in writing at any time, except to the extent action has already been taken in reliance upon it.

Expires on:

Financial Responsibility and Assignment of Benefits

I authorize payment of medical benefits to the treating sports medicine provider for services rendered. I understand that I am financially responsible for charges not covered by insurance, including co-pays, deductibles, and services denied as not medically necessary. Submission of insurance claims is a service provided on my behalf and is not a guarantee of payment.

Return-to-Play and Concussion Acknowledgment

I acknowledge that returning to sport following an injury, particularly a head injury or concussion, carries risk if done prematurely. Clearance to return-to-play will be provided in writing by an authorized clinician following established protocols. I agree not to resume participation until I receive explicit written clearance. I understand that failure to follow clearance recommendations may increase the risk of further injury.

I have read and understand the foregoing statements, and I certify that the information I have provided on this form is true and complete to the best of my knowledge.

Additional Information

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