Fill and Sign the Student Athlete Permission to Treat and Release Medical Form

STUDENT ATHLETE PERMISSION TO TREAT AND RELEASE MEDICAL RECORDS I, , as parent/guardian of hereby grant permission for to proceed with any necessary medical treatment on the aforementioned ch ild athlete in the event that I cannot be first contacted. I understand and request that every effort be made to contact me in the most expeditious manner possible in the event of an emergency or any situation that may require the attention of a medical profe ssional. Any medical procedure performed shall at all times be done in the best interest of said child athlete. Further, I hereby give the aforementioned pers on/entity permission to obtain any and all medical records necessary as they may pertain to any injury or condition incurred by participating in any activity associated with the aforementioned. I understand that every attempt will be made to inform me of the necessity of obtaining medical records. HIPAA Release Authority. My agent shall be tr eated as I would be with respect to my rights regarding the use and di sclosure of my child’s individually identifiable health information or other medical records. This release authority applies to any information governed by the Health Insu rance Portability and Account ability Act of 1996 (HIPAA), 42 U.S.C. 1320d and 45 CFR 160 through 164. I authorize any physician, health care professional, dentist, health plan, hospital, clinic, laboratory, pharmacy, or other covered health care provider, any insurance company, and the Me dical Information Bureau, Inc. or other health care cl earinghouse that has provided treatment or services to my child, or that has paid for or is seeking payment from me for such services, to give, disclose and release to my agent, without restriction, all of my child’s individually identifiable health information and medical records regarding any past, present or future medical or mental health condition, including all informati on relating to the diagnosis of HIV/AIDS, sexually transmitted diseases, mental illness, and drug or alcohol abuse. The authority given my agent shall supersede any other ag reement that I may have made with my child’s health care providers to restrict access to or disclosure of my child’s individually identifiable health information. The authority given my agent has no expiration date and shall expire only in the event that I revoke th e authority in writing and deliver it to my child’s health care provider. Name of Parent/Guardian _____________________ Signature of Parent/Guardian Date PERMISSION GRANTED BY CHILD ATHLETE TO RELEASE MEDICAL INFORMATION TO PARENTS/G UARDIAN OR MEDICAL STAFF I hereby give permission to release any medical records/information to my parent/guardian or attending medical staff as is necessary. I understand that an attempt will be made to inform me of any release of medical records/information. _____________________ Student Athlete Signature Date