Consent For Release Of Medical Information Form (Hipaa) printable pdf download

CONSENT FOR RELEASE OF MEDICAL INFORMATION FORM (HIPAA)

Students Name ____________________________ Date of Birth ___________________

1. I authorize the use or disclosure of the above named individual’s health information including

the Initial and Interim Pre-Participation History and Physical Exam information pertaining to a

student’s ability to participate in South Dakota High School Activities Association sponsored

activities. Such disclosure may be made by any Health Care Provider generating or maintaining

such information.

2. The information identified above may be used by or disclosed to the school nurse, athletic

trainer, coaches, medical providers and other school personnel involved in the care of this

student.

3. This information for which I am authorizing disclosure will be used for the purpose of

determining the student’s eligibility to participate in extracurricular activities, any limitations on

such participation and any treatment needs of the student.

4. I understand that I have a 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 school

administration. 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.

5. This authorization will expire on July 1, 20_____.

6. I understand that once the above information is disclosed, it may be redisclosed by the recipient

and the information may not be protected by federal privacy laws or regulations.

7. I understand authorizing the use or disclosure of the information identified above is voluntary.

However, a student’s eligibility to participate in extracurricular activities depends on such

authorization. I need not sign this form to ensure healthcare treatment.

__________________________________

_____________________

Signature of Parent

Date

This form must be completed annually and must be available for inspection at the school

Revised 7/10

PHYS - #5

Consent For Release Of Medical Information Form (Hipaa)