This is a multi-purpose form that informs the student-athlete of the inherent risk associated with participating in any athletic activities within the intercollegiate athletic department at an NCAA member institution. The subsequent sections allow the sports medicine staff to evaluate and treat any injury that might occur during an intercollegiate activity as well as allowing the sports medicine department to disclose information about those injuries to the individuals listed on the form and only those people. This form also includes an NCAA HIPAA form that allows the NCAA member institution to keep medical file on a secure server at the NCAA Headquarters as well as allows the NCAA to perform random drug testing to any student-athlete.
General Authorization For Release Of Information
State:
Multi-State
Control #:
US-01717BG
Format:
Word;
Rich Text
Instant download
Description
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How to fill out Sports Medicine General Pre-Participation Form, Assumption Of Risk, Consent To Receive Medical Care, And HIPAA Release?
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Valid HIPAA Authorizations: A ChecklistNo Compound Authorizations. The authorization may not be combined with any other document such as a consent for treatment.Core Elements.Required Statements.Marketing or Sale of PHI.Completed in Full.Written in Plain Language.Give the Patient a Copy.Retain the Authorization.
Elements of a release formPatient information. Naturally, the release should require the patient's information so it's clear who the form refers to.Receiving party's information.Information to be shared.Purpose of the release.Expiration of authorization.Disclaimers.Date and signature.
Your authorization allows the Health Plan (your health insurance carrier or HMO) to release your protected health information to a person or organization that you choose.
The core elements of a valid authorization include:A meaningful description of the information to be disclosed.The name of the individual or the name of the person authorized to make the requested disclosure.The name or other identification of the recipient of the information.More items...
A description of the information that will be used/disclosed. The purpose for which the information will be disclosed. The name of the person or entity to whom the information will be disclosed. An expiration date or expiration event when consent to use/disclose the information is withdrawn.