2022 Bermuda Short-Handed Return

GEORGE WASHINGTON MARITIME MEDICAL ACCESS RELEASE

Name*

First NameLast Name

Yacht Name*

READ BEFORE SIGNING

We have made arrangements with George Washington Maritime Medical Access (GWMMA) to provide standby telephonic medical support during the race.

GWMMA may not disclose your protected health information (“PHI”) without your written authorization, except as provided in their Notice of Privacy Practices. If you want GWMMA providers to share your PHI with the Bermuda Short Handed Return coordinators, you must individually authorize that by each participant completing and signing this form. This form is optional; GWMMA will not condition providing treatment to you on whether you complete this form.

I, {name} hereby authorize George Washington Maritime Medical Access (GWMMA) to share my HPI with the organizers of Bermuda Short Handed Return. I understand the purpose is to permit GWMMA to advise the Bermuda Short Handed Return coordinators about the necessity of care that was provided.

I understand that the following information may include (but are not limited to) treatment information, care options, facilities where testing or procedures will be done, and why certain medical decisions are made. This authorization will expire after July 3rd, 2022, unless otherwise specified below.

I further that I have the right to revoke this authorization by sending my written and signed request to GW MMA at GWMMA@gwmaritime.com. I understand that any revocation will not affect actions taken by GWMMA in reliance on this authorization before receiving the revocation.

Satellite Phone Number

Area CodePhone Number

Email*

example@example.com

Please list any known medical conditions.

Shoreside Emergency Contact Name*

First NameLast Name

Shoreside Emergency Contact Number (please list the best number to reach this person at any time)*

Please enter a valid phone number.

Signature

Date