PATIENT AUTHORIZATION FORM

To Permit Use and Disclosure of Health Information

 

 

Patient Name:_____________________________________________________________ Date of Birth ___/___/___

 

By signing this form I authorize _________________________________________________ to disclose

                                                            Person authorized to disclose the information

 

to the NC State University Department of Athletics Sports Medicine Office, its trainers and staff,  (collectively, “Sports Medicine”) the following

protected health information (check all that apply):

 

[   ] history and physical

[   ] diagnosis

[   ] operative reports

[   ] laboratory test results

[   ] films and reports of x-rays, ultrasounds, scans, etc.

[   ] medication schedules

 

The purpose of this use or disclosure is (check all that apply):

 

[   ] at the request of the patient

[   ] to determine eligibility to participate in an athletic event(s)

[   ] to provide physical therapy

[   ] other __________________________

 

I understand that I have the right to revoke this authorization, in writing, at any time by sending written notification to the Director of Sports Medicine, NC State University Department of Athletics. I understand that a revocation is not effective to the extent that information has already been used or disclosed in reliance on this Authorization.  Sports Medicine will not condition my treatment or payment for my treatment on whether I provide authorization for the requested use or disclosure unless health care services are provided to me solely for the purpose of creating protected health information for disclosure to a third party. However, Sports Medicine may condition my participation in practice or an athletic event upon receipt of a signed authorization.

 

I understand that information used or disclosed pursuant to this Authorization may be used or disclosed by the recipient and may no longer be protected by federal or state law.

 

This authorization expires one year from the date below.

 

 

______________________________                                    _____________________________

Patient Signature                                                                    Parent Signature (if under 18)

 

___________________                                                          ______________________

Date                                                                                        Date