Fill and Sign the Sports Medicine General Pre Participation Form Assumption of Risk Consent to Receive Medical Care and HIPAA Release

Sports Medicine General Pre-Participation Form, Assumption of Risk, Consent to Receive Medical Care, and HIPAA Release Assumption of Risk I understand that although _______________________________________________ (Name of College or University) and its medical care providers take all possible precautions to safeguard your health and safety, serious and potentially debilitating injuries can and do occur while participating in any activity. I know that it is extremely important that all student-athletes and parents should thus consider and be ever mindful of the risks that are involved in such competition. I feel comfortable with and accept these risks that are associated with athletic practice and competition. Initial: ________ Consent to Receive Medical Care I give authorization to the Athletic Trainer and/or Team Physician to evaluate and treat any injuries that occur during my athletic participation at the _________________________________________________ (Name of College or University) (this includes immediate first aid and treatment, x -ray, physical exam, follow-up care, and rehabilitation). I understand that the ________________________________________ (Name of College or University) designated Team Physicians have the authority to prevent me from further participation because of an injury and/or because of an undue liability to the ________________________________________________ (Name of College or University) . Initial: _________ Health Insurance Portability and Accountability Act Release I hereby authorize the physicians, athletic trainers, sports medicine staff and other health care personnel representing the _____________________________________________ (Name of College or University) to release information regarding my protected health information and any related information regarding any injury or illness during my training for and participation in intercollegiate athletics. This protected health information may concern my medical status, medical condition, injuries, prognosis, diagnosis, athletic participation status, and related personally identifiable health information. This protected health information may be released to other health care providers, parents/guardians, hospitals and/or medical clinics and laboratories, athletic coaches, strength and conditioning coaches, medical insurance coordinators, insurance carriers, medical supply vendors and/or service companies, academic counselors, athletic and/or university administrators, chaplains and/or clergy members, NCAA Injury Surveillance System, sports information staff and members of the media. I understand that my authorization/consent for the disclosure of my protected health information is a condition for participation as an intercollegiate athlete for the _____________________________________ __________________ (Name of College or University) . I understand that my protected health information is protected by federal regulations under either the Health Information Portability and Accountability Act (HIPAA) or the Family Educational Rights and Privacy Act of 1974 (the Buckley Amendment) and may not be disclosed without either my authorization under HIPAA or my consent under the Buckley Amendment. I understand that once information is disclosed per my authorization/consent, the information is subject to re-disclosure and may no longer be protected by HIPAA and/or the Buckley Amendment. I understand that I may revoke this authorization/consent at any time by notifying in writing the Director of Sports Medicine, but if I do, it will not have any effect on actions ______________________________________________________ (Name of College or University) took in reliance on this authorization/consent prior to receiving the revocation. This authorization/consent expires one (1) year from the date it is signed. Signature of Student-Athlete _______________________________________ Date _________________________ Printed Name _______________________________________ Contract # ____________________________