Intercollegiate Athletics Policy Manual

4.00 Camp Policy Manual

APPENDIX - Medical 15.30.13 HIPAA Camp Staff

THE UNIVERSITY OF TEXAS AT AUSTIN

University Sponsored Summer Sports Camps

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION TO CAMP STAFF

This authorizes The University of Texas at Austin physicians, medical personnel and camp sponsors to release information concerning the medical status, medical condition, injuries, prognosis, diagnosis and related personally identifiable health information of __________________________ (Participant) to camp staff.  This information includes injuries or illnesses relevant to participation in the above named camp at The University of Texas at Austin.

The reason for this disclosure is to advise camp staff of the nature, diagnosis, prognosis or treatment concerning any medical condition and any injuries or illnesses Participant may have so that they make decisions regarding Participant’s ability and suitability to participate in camp activities.  I understand that the entities that receive the information are not health care providers or health plans covered by federal privacy regulations, and that the information described above may be redisclosed publicly and that the information will no longer be protected by those regulations.

I understand that The University of Texas at Austin will not receive compensation for its use/disclosure of the information.  I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment.  I may inspect or copy any information used/disclosed under this authorization.

I understand that I may revoke this authorization in writing at any time by notifying in writing the Departments of Intercollegiate Athletics for Men and Women, but if I do, it will not have any effect on actions The University took in reliance on this authorization prior to receiving the revocation. This authorization expires one year from the date it is signed.

 

Signature of Camper Date

   

Signature of Parent/Legal Guardian  Date

(If camper is under 18 years of age)

Camper’s Date of Birth:

Camp

 

last updated: February 11, 2009