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Medical History, Treatment Permission and Release

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MEDICAL FORM
WINSTON-SALEM DASH YOUTH BASEBALL ACADEMY
MEDICAL HISTORY, TREATMENT PERMISSION AND RELEASE

Note: This form is required prior to participation in The Winston-Salem Dash Youth Baseball Academy. Participation will not be permitted until this form has been completed and signed and is on file with the training academy.

PLEASE PRINT USING BLACK OR BLUE INK

PARTICIPANT INFORMATION:

NAME: AGE: DATE OF BIRTH:

HOME ADDRESS:

FATHER/GUARDIAN NAME:

ADDRESS:

PHONE: Home () Work () Cell ()

MOTHER/GUARDIAN NAME:

ADDRESS:

PHONE: Home () Work () Cell ()

OTHER/EMERGENCY CONTACT:

ADDRESS:

PHONE: Home () Work () Cell ()

Please continue to the next page.

FAMILY PHYSICIAN: PHONE: ()

INSURANCE COMPANY: ID NUMBER:

MEDICAL HISTORY (Please use notes section at the end of this form if necessary)

DATE OF LAST TENTANUS BOOSTER:

Is the participant under the care of a provider for a medical and/or psychological problem?

If yes, please explain:

Is the participant taking medication prescribed by a health care provider?

If yes, please explain:

ALLERGIES → If yes, please list the allergy and provide additional information if necessary.

Insect Bites/Stings

Medications

Food

Other

RELEASE OF LIABILITY: I hereby release and discharge, indemnify and hold harmless the Winston-Salem Dash, and their members officers, agents, employees, and any other persons or entities acting on their behalf, and the successors and assigns for any and all of the aforementioned persons and entities. Against all claims, demands, cost and expenses, and causes of action whatsoever, either in law or equity, arising out of or in any way connected with any property loss and/or bodily injury and/or disability, rising from my child’s participation in the youth training academy.

CONSENT FOR INJURY: I hereby give my permission to a academy certified athletic trainer to supervise on-site first aid for minor injuries. In the event of injury such as broken limb, sprain, contusion, laceration, concussion, ect,. or illness requiring medical diagnosis or treatment, I hereby give my consent for training academy staff to secure the proper medical care; including transportation and hospitalization, if necessary. Every attempt will be made to contact the parent or guardian to inform you of the need for any medical attention beyond minor first aid, if necessary.

PHYSICAL EXAMINATION WITHIN ONE YEAR: I certify that within the past 12 months my child has had a physical examination by a physician and that he/she is physically able to participate in the training academy.

ASSUMPTION OF FINANCIAL RESPONSIBILITY: I hereby acknowledge that I am responsible for medical charges incurred during training academy participation. I further understand that the training academy carries an excess medical insurance policy for sports injuries to the participant that may result from training academy activities. The training academy insurance has limits and exclusions and any secondary charges not covered under this plan will be my responsibility. This policy may only be utilized after my primary insurance company has processed the claims and issued an explanation of benefits.

Please continue to the next page.

IMPORTANT: MY SIGNATURE BELOW INDICATES THAT I HAVE READ AND UNDERSTAND THESE TERMS
PRINT NAME:
DATE:

SIGNATURE:

RELATIONSHIP TO PARTICIPANT:

ADDITIONAL INFORMATION:

NOTES:

THIS FORM IS NOW COMPLETE. PLEASE PRINT AND BRING THIS FORM WITH YOU ON THE FIRST DAY OF BASEBALL ACADEMY.

FORMS MUST BE COMPLETED TO PARTICIPATE!

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What this Medical History, Treatment Permission and Release does

The Medical History, Treatment Permission and Release is a combined clinical form that documents a patient’s relevant medical history, records consent to specified treatments or procedures, and includes a release authorizing the provider to act and exchange pertinent health information. It typically collects demographic data, current medications, allergies, past diagnoses, and emergency contacts, and it clarifies the scope and duration of treatment permission. Facilities use it to confirm informed consent, to communicate care limitations, and to support medical record accuracy while meeting documentation and privacy obligations.

Why a consolidated medical history and permission form matters

Combining medical history, treatment permission, and release into a single form reduces fragmentation, speeds clinical decisions, documents explicit consent, and creates a clear record for continuity of care while supporting privacy and audit requirements.

Why a consolidated medical history and permission form matters

Who completes and signs this form

Typical users and signers vary by setting and patient status.

  • Patients or legal guardians who must provide consent and disclose medical history for treatment.
  • Clinic staff and treating providers who collect, review, and rely on the information for care.
  • Schools, camps, or research teams when parental permission and medical details are required for participation.

Identify the legally authorized signer (patient, parent, guardian, or court-appointed representative) before submitting the document.

Step-by-step: completing the form before care

Follow these practical steps to ensure the form is complete, legible, and legally effective.

  • 01
    Gather records: Collect meds, prior reports, and IDs.
  • 02
    Fill fields: Complete all required entries accurately.
  • 03
    Review permissions: Confirm scope, duration, and recipients.
  • 04
    Sign and submit: Sign in the requested manner and give to provider.

Common questions and clarifications

Answers to frequent practical and legal questions about signatures, minors, revocation, and privacy when using this form.


Need help? Contact support

Security and compliance controls to note

Encryption at rest: AES-256
Encryption in transit: TLS 1.2/1.3
HIPAA support: BAA required
Audit trail: Timestamps and IP
Access controls: Role-based
Authentication options: Email, SMS, or advanced

Risks and legal consequences of improper forms

HIPAA violations: Civil and criminal exposure
Invalid consent: Treatment refusal or liability
Medical errors: Inadequate history increases risk
Privacy breaches: Regulatory fines possible
Insurance denial: Claims payment risk
Litigation exposure: Professional liability suits

Common preparation mistakes to avoid

  • Leaving required fields blank or entering partial names or incorrect dates, which can delay care or create identity verification problems.
  • Using vague permission language like 'any and all treatments' without specifying scope or time limits, which can cause disputes about provider authority.
  • Failing to disclose allergies, medications, or prior reactions, increasing the risk of adverse events during treatment.
  • Submitting unsigned or improperly signed forms, including unsigned electronic forms where consent requirements have not been met.

Essential parts of a professional medical history and release

A robust form balances clinical detail, clear authorization language, and privacy safeguards to support safe care and legal compliance.

Patient identification

Full legal name, DOB, contact details, and government ID where required to ensure correct record matching and billing.

Clinical history

Current conditions, medications, allergies, immunizations, and prior surgeries to guide safe treatment decisions and reduce adverse events.

Emergency contacts

Designated contact names, relationship, and phone numbers for urgent communication and care coordination.

Permission scope

Clear description of permitted treatments, any exclusions, duration, and named providers or institutions authorized to act.

Release language

Authorizes sharing of medical information and limits provider liability consistent with applicable law and facility policy.

Signature block

Designates signer, capacity (patient, guardian, agent), signature, date, and any witness or notarization requirements.

Where to submit the completed form

Routes depend on the setting; follow these typical submission pathways for processing and inclusion in the medical record.

  • In-person: Hand to registration or nursing staff.
  • Patient portal: Upload to the facility’s secure portal.
  • Email (secure): Use encrypted clinical email when allowed.
  • Electronic health record: Direct import into the provider EHR.

Digital signing and file requirements for e-submission

Electronic completion must meet legal, privacy, and technical requirements to be accepted by providers and auditors.

  • File formats: PDF, DOCX
  • Integrations: EHR and cloud storage
  • Authentication: Email or SMS code

Ensure the chosen platform supports HIPAA controls, audit trails, and required signer authentication before sending or storing forms.

How to configure an online workflow for this form

Set up fields, authentication, and storage so submissions meet clinical and legal requirements.

Field Configuration
Identity verification Email + SMS or KBA
Signature type Drawn, typed, or certified digital
Conditional fields Show allergies only if checkbox selected
Storage Encrypted cloud with access logs

Time-sensitive actions and response expectations

Some actions tied to the form have statutory or best-practice response windows; plan accordingly.

Effective Date:

Treatment permission is effective on the signature date unless a later date is specified.

Access Request:

HIPAA requires a response to record access requests, typically within 30 days (45 CFR §164.524(b)(2)).

Revocation Notice:

Revocation is effective upon written notice to the provider as described in the form.

Emergency Use:

Emergency treatment may proceed under implied consent where permitted by state law.

Record Updates:

Update medical history promptly after new diagnoses or medication changes to maintain safety.

How a treatment permission compares with a HIPAA authorization

These documents overlap but serve different legal and operational functions; compare their primary distinctions below.

Document Type Treatment Permission HIPAA Authorization
Primary Purpose authorize care authorize phi disclosure
Required Content consent scope specific phi and recipients
Revocation allowed per form allowed per hipaa rules
Typical Use procedures and treatment records release and third-party access

eSignature vendor comparison relevant to medical forms

Comparing common eSignature vendors on starting price, trial availability, bulk send, audit trail, HIPAA support, and envelope limits provides procurement context for secure medical workflows.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial Varies by vendor Varies by vendor Varies by vendor Varies by vendor
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No
Envelope Cap No envelope cap 100 envelopes/user/year Varies Varies Varies

Real-world examples of medical forms in use

Practical examples show how organizations use digital consent and release forms to streamline care and compliance.

Fertility Clinic

A regional fertility center consolidated intake and consents into a single digital workflow to reduce errors and accelerate scheduling.

  • Implementation focused on secure patient access and audit trails.
  • "The airSlate SignNow team has been exceptional, responsive, the API has been great, and we're extremely happy that we chose airSlate SignNow as a company."

Compliance-Focused Provider

A provider with strict regulatory needs deployed e-signature and retention workflows to meet audit requirements.

  • The project prioritized SOC 2 controls and ESIGN/UETA compliance.
  • "We felt most comfortable with airSlate SignNow given their SOC 2 certification and strict focus on ESIGN and UETA act compliance."

Key processing stages from submission to record inclusion

Track these numbered stages to monitor progress from form completion through retention and audit readiness.

01

1. Submission

Form received by registration or uploaded to portal; begins processing.

02

2. Verification

Staff verify identity, completeness, and required attachments.

03

3. Authorization

Provider documents acceptance or clarifies scope before treatment.

04

4. Record Integration

Signed form is attached to the EHR and retained per retention rules.

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