Form for Student Athletes

 

Office of Sports Medicine

Department of Athletics, North Carolina State University

 

 

GENERAL CONSENT FOR TREATMENT AND CONSENT TO USE AND DISCLOSE HEALTH AND MEDICAL INFORMATION FOR TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS

           

Welcome to the NC State University Sport’s Medicine Office. This handout summarizes important information that you should know about our services and provides us with your written consent for treatment/care by our licensed athletic trainers and other health care providers as well as your consent to our use and disclosure of your protected health information for treatment, payment for services, and health care operations.  We ask you to read it carefully, ask any questions that you may have, and then sign, date and return the form to us. 

 

I.  Services Offered

 

The Sports Medicine Office provides a variety of services related to the care, prevention and rehabilitation of injuries incurred by student athletes.  Under the direction of the team physician, licensed athletic trainers and staff will provide you with these services in the sports medicine facilities on campus.  The trainers in consultation with the team physician will determine if the care needed involves resources or competencies beyond the scope of our services, and will, with the administrative coordinator for sports medicine provide the appropriate referral, documentation, and follow-up.   

 

 

II.  Confidentiality

 

Your medical records on file at the sports medicine department are treated as confidential records and will only be released pursuant to your authorization or as otherwise permitted or required by law.  See NC State University Health Care Components Notice of Privacy Practices.  This Notice is posted on the Student Health Services web page at___________________.  You may also ask the Sports Medicine Insurance Coordinator for a printed copy of this notice.

 

 

III. Your Responsibilities

 

Student-Athletes are expected to honestly answer the Personal Information and Medical History questionnaire and provide a full and accurate medical history to our physicians at the time of their physical exam for participation in the intercollegiate athletic program at NC State University.

 

Passing the Medical Exam does not mean that the student athlete is physically qualified to engage in athletic activity but only that the examiner did not find a disqualifying medical condition.  The student-athlete has a continuing responsibility to report all injuries or illnesses immediately to their licensed trainer or a graduate assistant athletic trainer and to follow the direction of the physician, athletic trainer and coach concerning the prevention, treatment, and rehabilitation of injuries.

 

CONSENT FOR TREATMENT/CARE

 

I have read the above material regarding rights and responsibilities of the student athlete as it relates to the sports medicine office at North Carolina State University.  I understand its provisions, and agree to receive services under the above conditions and I consent to treatment/care, as determined to be necessary by the team physician, trainers and other professional sports medicine staff of the sports medicine office.

 

 

 

 

CONSENT FOR USE AND RELEASE OF INFORMATION

 

I give permission to NC State University Sports Medicine trainers and other staff to release any information about me, my health, the health services provided to me, or payment for my health services which may be necessary:

 

1. For my treatment – to any physician, or other health care providers or facilities which need the information for my continued care; I further authorize the NC State Department of Athletics, the Sports Medicine Staff, University Health Services, and consulting physicians to hospitalize and secure treatment for me for any athletic injuries. 

 

2. For payment purposes – to determine whether I am eligible for insurance coverage and if this treatment/care is authorized for payment by my insurance. This information may also be used to process an insurance claim, for billing and for collection purposes.

 

3. For the health care operations of the Sports Medicine Office – to operate its business more efficiently, and to assess and improve the quality of its health care.

 

 

Student Athlete Name (please print) ______________________________

 

Sport_________________________________

 

Date of Birth___________________________  Age________

 

Student ID: ______  ______  _______

 

____________________________________________                    ____/___/___

Signature of Student-Athlete                                                                     Date

 

________________________________________________________                             ____/____/____

Signature of Parent/Guardian                                                                    Date       

if student is considered a minor in North Carolina