RELEASE OF INFORMATION FOR

THERAPY SERVICES AND SPORTS MEDICINE

Authorization for Disclosure of Health Information   Page 1of 2

 

I hereby authorize Gibson Area Hospital Therapy Services and Sports Medicine to disclose information related to sports injury and/or physical rehabilitation from the health records of:

 

Patient Name:                                                                             Date of Birth:                                     

                        Last                  Middle              First                                          (Mo/Day/Yr)

 

Address:                                                            City:                               Zip Code:                 

 

Home Phone:    (           )                                     Emergency phone:      (           )                      

 

Emergency Contact Name:                                              Name of School:                                

 

THIS INFORMATION IS TO BE DISCLOSED TO THE FOLLOWING INDIVIDUALS (COACHES NAMES) FOR THE PURPOSE OF COORDINATING SPORTS PARTICIPATION, REHABILITATION, AND PROGNOSIS OF RECOVERY FROM A SPORTS INJURY.

 

SPORT (please check applicable boxes)                 Names of Coaches (please list)

□  Volleyball coaches                                                                                                                             □  ALL

 

□  Football coaches                                                                                                                               □  ALL

 

□  Cross Country Coaches                                                                                                                    □  ALL

 

□  Soccer Coaches                                                                                                                                  □  ALL

 

□  Basketball Coaches                                                                                                                           □  ALL

 

□  Wrestling Coaches                                                                                                                            □  ALL

 

□  Softball Coaches                                                                                                                               □  ALL

 

□  Baseball Coaches                                                                                                                               □  ALL

 

□  Track Coaches                                                                                                                                   □  ALL

 

□  Cheerleading                                                                                                                                      □  ALL

 

□  Other Coaches or Staff to whom information is to be released:                                  

 

□  Please do not disclose medical information to any coaches or staff.

RELEASE OF INFORMATION FOR

THERAPY SERVICES AND SPORTS MEDICINE

Authorization for Disclosure of Health Information   Page 2 of 2

 

Emergency Department and Radiology release authorization.

 

 

I hereby authorize Gibson Area Hospital Therapy Services and Sports Medicine staff to access information related to the athlete’s sports injury from the emergency department and/or radiology department at Gibson Area Hospital and Health Services. This information is to be used for medical follow up and communication to the approved coaching staff and school administration.

 

□  I give permission to GAH sports medicine staff to view ED and radiology records related to my

    son/daughter’s sports injury.

 

□  I DO NOT want the GAH sports medicine staff to view ED and radiology records related to my

    son/daughter’s sports injury.

 

 

I understand that I have the right to revoke this authorization at any time.  I understand that if I revoke this authorization I must do so in writing and present my written revocation to the Gibson Area Hospital Medical Records Department.  I understand that the revocation will not apply to information that has already been released in response to this authorization.  I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy.  Unless otherwise revoked, this authorization will expire at the end of each school year.  The current school year is                                                     to                                                    .

If I fail to specify a school year, this authorization will expire in six months after the date the form was signed.

 

I understand that authorizing the disclosure of this health information is voluntary.  I can refuse to sign this authorization.  I need to sign this form in order to enable communication between my child’s coach(es) and athletic trainer.  I understand that I may inspect or copy the information to be used or disclosed, as provided in CFR 164.524.  I understand that any disclosure of information carries with it the potential for an unauthorized redisclosure and the information may not be protected by federal law confidentiality rules.  If I have questions about disclosure of my health information, I can contact Candy Underwood, Chief Privacy Officer / Health Information Services Director at Gibson Area Hospital and Health Services.

 

 

 

 

SIGNED:                                                                                                                  DATE:                                 

                                STUDENT ATHLETE (signature optional unless over 18 years old)

 

 

 

SIGNED:                                                                                                                  DATE:                                 

                                PARENT / GUARDIAN (signature is mandatory for communication to occur)

 

Revised 10/07