I, the parent or guardian of the above named athlete, a student athlete participating in interscholastic athletic sports, understand that the disclosure of the student-athlete’s protected health information is a condition of participation at O’Fallon Township High School-District 203
(“OTHS”).
I hereby authorize/consent for physicians covering OTHS 203 athletic events and Memorial Hospital’s Certified Athletic Trainer and other health-care personnel participating with the OTHS’s athletic program to release information regarding my student athlete’s protected health information (“PHI”) and related information regarding any injury or illness which may occur during the student athlete’s training for and participation in athletics at OTHS to any coach, athletic director or school official in connection with my student’s participation in interscholastic sports. This protected health information may concern the student-athlete’s medical status, medical condition, injuries, prognosis, diagnosis, athletic participation status and related personally identifiable health information. This protected information may be released to other health-care providers, hospital and/or medical clinics and laboratories, athletic coaches, athletic trainers, medical insurance coordinators, athletic and or school administrators, and officials of the student-athlete’s sport.
I understand that my student-athlete’s protected health information may be protected by federal regulations under the Health Information Portability and Accountability Act (HIPAA) and, if so, may not be disclosed without parent/legal guardian’s authorization.
I understand as parent or guardian of the student athlete:
- This authorization/consent is valid for the duration of the school year of the student athlete, unless Irescind my permission in writing to O’Fallon Township High School, District 203, 600 S Smiley St,O’Fallon, IL 62269.
- A revocation will not affect any uses or disclosures that the School, Southern Illinois Sports Medicine and Memorial Hospital’s Certified Athletic Trainer made before it received my student’s revocation.
- If I request it, I may see a copy of the PHI described on this form.
- The information that is used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by HIPAA. I have the right to seek assurances from the above named entities or individuals authorized to receive the information that they will not re-disclose information to any other party without my further authorization.