If this document is not completed, it is assumed that authorization is NOT given. Authorization is effective until it is revoked by a parent or guardian, or until Student is no longer enrolled at the school.

The purpose of this authorization is to permit disclosure of Student’s protected health information (PHI) among health care professionals, coaches, athletic training staff, insurance personnel, and academic counselors and administrators. This disclosure allows athletic medical staff and School to make certain decisions about Student’s health and ability to participate in certain athletic programs sanctioned by School in accordance with the Health Information Portability and Accountability Act (HIPAA). HIPAA protects personal injury and illness information from disclosure without authorization under HIPAA. Student’s PHI includes, but is not limited to, information involving the nature and treatment of an injury or illness, medical history and status, prognosis, diagnosis, athletic participation status, insurance coverage, and copies of hospital and medical records.

Pursuant to this signed authorization, athletic training staff, including trainers, coaches, or other qualified personnel of Two Rivers Public Schools are authorized to disclose Student’s PHI verbally or in writing, as necessary and appropriate for the purpose of health care treatment or exchanging information regarding Student’s health as permitted or required under the law (e.g. determining Student’s ability and eligibility to participate in athletic programs sanctioned by School, evaluating injuries and other medical conditions which Student reports while engaging in athletic programs sanctioned by School, etc.).

The Student's PHI may be disclosed to:
1. School’s coaches, athletic director, or other members of School’s administrative staff or their designees;
2. Student’s parents and guardians; and
3. Emergency medical personnel, hospitals, or other health care professionals who evaluate, diagnose or treat an injury, illness, or other condition incurred by Student while participating in athletic programs sanctioned by School, as necessary to:
(a) Evaluate Student's eligibility to participate in School activities, including but not limited to interscholastic or intramural sports programs and physical education classes;
(b) Document and evaluate first aid treatment and athletic treatment modalities provided;
(c) Evaluate treatment alternatives; and
(d) Resolve disputes that arise with regard to the above.

4. Encrypted Sway Mobile App that student athletes will download on their personal mobile devices and/or provided mobile devices.

Signing this authorization/consent is voluntary, and authorization may be revoked at any time by a written revocation sent to both School’s athletic department and athletic training staff. However, authorization may be required in order for Student to participate in an athletic program. Any revocation will not apply to information that has already been released. Student and Student’s parents and guardians reserve the right to review all records and to obtain a copy of all records released at any time upon request. In the event that Student’s PHI is re-disclosed by a person who receives it under this authorization, it will no longer be covered by this authorization.