(1) UPMC Authorization for Release of Protected Health Information

As part of a contractual agreement with UPMC Sports Medicine, certified athletic trainers may aide in the prevention, recognition, evaluation, and tre...

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__________________________________________ Print Athlete’s Name

__________________________________________ Print Athlete’s Sport

As part of a contractual agreement with UPMC Sports Medicine, certified athletic trainers may aide in the prevention, recognition, evaluation, and treatment of athletic injuries. Please note that the forms below have no relationship to your health insurance plan and in no way, influence your choice of medical care. UPMC must have these forms completed to comply with privacy and standard consent to treat laws.

(1) UPMC Authorization for Release of Protected Health Information • I authorize UPMC to provide information related to the athlete’s care to family/school/team physicians, school nurses, coaches, athletic directors, school principals, EMS personnel, and such other persons as is necessary needed for them to provide consultation, treatment, establish a plan of care or determine whether the athlete may resume participation in school or sports activities. • I authorize UPMC to use the athlete’s medical information for UPMC internal departmental reporting purposes. • I authorize UPMC (including its hospitals, other entities and programs) to use medical or other information maintained on electronic information systems or stored in various forms about the athlete’s care, health care operations, or payment for treatment and services. • I understand that the health record(s) released by UPMC may be re-disclosed by the facility/person that receives the record(s) and therefore (1) UPMC and its staff/employees has no responsibility or liability because of the re-disclosure and (2) such information may no longer be protected by federal or state privacy laws. • I understand that this Authorization is in effect for a period of one year from the date signed by the athlete. • I understand that this Authorization is in effect if the athlete is treated for an injury during off-season workouts; however, no time frame specified shall go beyond one year from the date of signature. • I understand that I have the right to revoke this Authorization form at any time by sending a written request to UPMC at the location where the Authorization was provided. • I understand that my decision to revoke the Authorization does not apply to any release of my health record(s) that may have taken place prior to the date of my request to revoke the Authorization. • I understand that I am entitled to a copy of this completed Authorization form.

Page 1 of 2 UPMC Forms Rev Feb 2018

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__________________________________________ Print Athlete’s Name

__________________________________________ Print Athlete’s Sport

(2) UPMC Consent for Treatment and Healthcare Operations I consent to the provision of care. I understand that this care may include medical treatment, special tests, exams, evaluation, treatment, and rehabilitation of athletic injuries. I acknowledge that no guarantees have been given to me as to the outcome of any examination or treatment and all results of any examination and/or treatment are kept confidential. I understand and agree that others may assist or participate in providing care. This may include, but may not be limited to team physician, school nurse, and licensed physical therapists. Under the direction of a certified athletic trainer, college/university athletic training students and high school student aides may also provide care. I acknowledge that no guarantees have been given to me as to the outcome of any examination or treatment. In the event of ImPACT baseline testing, I understand the ImPACT baseline testing provided by UPMC Sports Medicine is not intended to prevent, diagnose, or treat a concussion and is not to be administered following a possible concussion. If the athlete suffers a concussion, the administration of an ImPACT post-test is generally conducted at the discretion of the concussion specialist at their facility.

(3) UPMC Privacy Practices I understand that copies of the UPMC Notice of Privacy Practices document are available at the school, can be sent in the mail upon my request or viewed at http://www.upmc.com/patients-visitors/privacyinfo/Pages/default.aspx. I give UPMC and its designees permission to use my information as described in the UPMC Notice of Privacy Practices. By signing below, I am acknowledging the above (1) Authorization for Release of Protected Health Information, (2) Consent for Treatment and Healthcare Operations, and (3) Notice of Privacy Practices. __________________________________________ Athlete signature

___________________ Date

__________________________________________ Parent or guardian signature/relationship

___________________ Date

__________________________________________ Parent or guardian signature/relationship

___________________ Date

For Office Use Only: Sign here if patient failed to acknowledge receipt of Notice of Privacy Practices: ____________________ Reason given by patient for failure to acknowledge receipt of the Notice of Privacy Practices: _____________________________________________________________________________________

Page 2 of 2 UPMC Forms

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