Adult - PATIENT AUTHORIZATION FOR THE RELEASE OF PROTECTED HEALTH INFORMATION (HIPAA Compliant)

PATIENT AUTHORIZATION FOR THE RELEASE OF PROTECTED HEALTH INFORMATION (HIPAA Compliant)

Students 18+
I hereby authorize Chaminade-Madonna College Preparatory, its agents, employees, and associates, to release the protected student health records that is described below to JOE DIMAGGIO CHILDREN’S HOSPITAL (“JDCH”), 11005 Joe DiMaggio Drive, Hollywood, FL 33021, its agents, and employees. I understand that JDCH requires my records so that JDCH understands the basis of my general health, potential health risks, limitation considerations, and/or need for additional clearance from a specialist before being cleared to return to a sport. I consent to allow JDCH team physicians to evaluate any injuries obtained by me while participating in Chaminade-Madonna College Preparatory activities or events.
The protected health information herein is specifically as follows:

Any and all documentation from Chaminade-Madonna College Preparatory, generated in connection with JDHC/U18 including but not limited to: reports, charts, files, correspondence, notes, memoranda, radiology studies and films of any kind or nature, test findings, statements, treatment of any kind or nature, including psychological and psychiatric records, and any and all records regarding: Student Name*.
This protected health information is to be used in and during the 2024-2025 school year.

This release may be revoked by a signed and properly dated written revocation. I understand that any such revocation does not apply to the extent that persons authorized to use or disclose my health information have already acted in reliance on this authorization.

This authorization will expire after the 2024-2025 school year.
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