Pickens High School Sports Medicine Student Athlete Authorization
Purpose: This form is used to authorize Pickens High School Sports Medicine to use or disclose your Personal Health Information (PHI) to the individual(s) or class(es) of persons you designate and for the Sports Medicine Department to disclose your PHI for the purposes stated on the completed form.
Section A: Individual authorizing use and/or disclosure -Complete information.
This authorization is good for one year from the date it is signed.
Athelete's Name *
Your answer
Section B: The Use and/or Disclosure Being Authorized
The PHI to be disclosed will be injury and/or illness information that directly affects your participation in high school athletics. It is important for the student to understand that this authorization is all or none. Ifyou give permission to disclose PHI, you give permission to disclose any PHI to any of the parties indicated below within the discretion of the Certified Athletic Trainer.

I hereby authorize Pickens High School Sports Medicine to disclose personal health information about me to the following entities

Please Check each that Apply *
Required
Access to PHI
I understand that it is necessary for head coaches, assistant coaches, & medical providers to have access to my PHI if I am to participate in high school athletics. Accordingly, I acknowledge that if I do not give permission for my PHI to be shared with these persons, I will not be allowed to participate in high school athletics at Pickens High School.
Right to Revoke: I understand that I may revoke this authorization at any time by giving written notice to the ATC. I also understand that by revocation of this authorization, it may affect my ability to participate in high school athletics at PHS.
Media Disclosure: You are not required to give PHI to the media as a condition for participation in athletics at PHS. PHI disclosed to the media will be done on a case by case and will require written permission by the athlete per injury/ illness
Section C: Individual's signature
I have had full opportunity to read and consider the contents of this authorization, and I understand that by signing this form, I am confirming my authorization of the use and/or disclosure of my PHI as described on this form.
Signature *
Your answer
Date *
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