Student Athlete Authorization/Consent for Disclosure of Protected Health Information


I, , hereby authorize Brandeis University and its physicians, athletic trainers, sports medicine staff and other health care personnel to disclose my protected health information and any related information regarding any injury or illness during training for or participation in intercollegiate athletics to the Brandeis University Sports Medicine staff and its employees or agents.


I understand that my protected health information will be used by the Brandeis University Sports medicine staff for the purpose of managing athlete injury or illness.


I understand that my injury/illness information is protected by federal regulations under either the Health Information Portability and Accountability Act (HIPPA) and the Family Educational Rights and Privacy Act of 1974 (the Buckley Amendment), and may not be disclosed without either my authorization under HIPPA or my consent under the Buckley Amendment. I understand that my signing this authorization/consent is voluntary and that my institution will not condition or withhold any healthcare treatment on whether I provide the authorization requested for this disclosure. I also understand that I am not required to sign this authorization in order to be eligible for participation in NCAA athletics.


I understand that by signing this authorization/consent form, I am allowing the medical staff associated with Brandeis University’s athletic programs (athletic trainers, physicians, etc.) to disclose medical information regarding an injury/illness to appropriate individuals to expedite my care. This may include but is not limited to, x-ray reports, MRI reports, surgical notes, and faxed information. At all times, only necessary information will be shared and privacy and confidentiality of records will be adhered to. Medical information will be stored in filing cabinets in a locked room in the athletic training room.


This authorization/consent expires 380 days from the date of my signature below, but I have the right to revoke it in writing at any time by sending written notification to the athletic director at my institution. I understand that a revocation is not effective takes effect on its request date and does not affect any action taken prior to that date. A new authorization/consent form must be completed every year of athletic participation.


NAME:  

EMAIL:

LAST FOUR DIGITS OF SAGE STUDENT ID#:

DATE (MM/DD/YYYY):

BY CHECKING THE FOLLOWING BOX, I ACKNOWLEDGE THAT I HAVE READ, UNDERSTAND AND VOLUNTARILY AGREED TO THE ABOVE STATEMENTS: