Intercollegiate Athletics Policy Manual

Section 15.00 - Sports Medicine

15.08.2f Release of Medical Information to Professional Teams and Representatives

DIVISION OF ATHLETIC TRAINING/SPORTS MEDICINE
INTERCOLLEGIATE ATHLETICS • THE UNIVERSITY OF TEXAS AT AUSTIN
Post Office Box 7399 • Austin, Texas 78713-7399
Men: (512) 471-5513 • Women: (512) 471-4916

AUTHORIZATION – RELEASE OF MEDICAL INFORMATION TO PROFESSIONAL TEAMS AND THEIR REPRESENTATIVES

STUDENT-ATHLETE: SPORT:

This authorizes the athletic trainers, team physicians and athletics staff including coaches representing The University of Texas at Austin to release information concerning my medical status, medical condition, injuries, prognosis, diagnosis and related personally identifiable health information to professional athletics teams, their scouts, athletic trainers, physicians, servants, or employees.  This information includes injuries or illnesses relative to past, present or future participation in athletics at The University of Texas at Austin.

The reason for this disclosure is to advise those professional teams and their representatives of the nature, diagnosis, prognosis or treatment concerning my medical condition and any injuries or illnesses so that they may make decisions regarding my prospects as a professional athlete.  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 Director of Division of Athletic Training/Sports Medicine, 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 six years from the date it is signed.

 
 
Signature of Student-Athlete Date

 
Signature of Parent/Legal Guardian Date
(If student-athlete is under 18 years of age)

 

 

last updated: February 11, 2009