HIPAA Privacy Authorization Form Sports Medicine-Youth

Authorization for Use or Disclosure of Protected Health Information (Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164)

1. Authorization to Disclose
I authorize Salem Christian Athletics to use and disclose to Salem Christian School/Salem Christian School Athletics (name of school/program) health information about my child obtained by Salem Christian Athletics in providing health services to my child during participation in sports programs (practices and games). The health information to be disclosed includes any information that is relevant to my child's ability to participate in practices, games, and other sports-related activities.

2. Purpose
The purposes of such uses and disclosures may include communicating with my child's coaches, administrative staff, athletic trainers, school nurses, guidance counselors and other individuals that are affiliated with the Program about my child's: (i) prognosis and recommended activities following an injury;(ii) ability to participate in training, practices, games and other team activities; and (iii) other health-related matters related to my child's activity with the Program.

3. Refusal to Sign
I understand that I may refuse to sign this authorization. Salem Christian School Athletic Trainers may not refuse to treat my child based on my refusal to sign this Authorization.

4. Expiration of Authorization
This Authorization shall be in force and effect for as long as my child participates in the Program. This Authorization will expire when my child is no longer in the Program. After this Authorization expires, the Program may no longer use or disclose my child's health information for the purposes listed in this Authorization unless I sign a new Authorization. However, materials that were created prior to the expiration of this Authorization may continue to be used or disclosed for the purposes listed in this Authorization.

5. Revocation of Authorization
I understand that I may revoke this authorization at any time, in writing, except to the extent that the Program has already relied on it in making a disclosure. If I wish to revoke this Authorization, I will send a written request to:

Salem Christian School8031
Salem Bible Church Rd
Macungie, PA 18062

6. Further Disclosure
I understand that my child's health information is protected by a federal law known as HIPAA for as long as that information is maintained by the Program. If I permit the Program to disclose my child's health information by signing this Authorization, that health information will no longer be protected by HIPAA. The recipient of my child's health information (the Program) might re-disclose the health information it receives, but would not be required to comply with privacy laws prior to any such re-disclosure.

Child's Name *

Date of Birth *

Child's Sport *

Relationship to Child *

Parent or Legal Guardian Printed Name *

Parent or Legal Guardian Signature *

HIPPA PRIVACY AUTHORIZATION FORM

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