I hereby authorize Big Bend Community College the Certified Athletic Trainers, physicians, sports medicine staff and other medical personnel representing Big Bend Community College to release information concerning my medical status, medical condition, injuries, prognosis, diagnosis, and related personally identifiable health information to the coaches, assistant coaches, other athletics staff, my parents/guardians. This information includes, but is not limited to, injuries or illnesses relative to past, present or future participation in athletics at Big Bend Community College.
I understand that my protected health information is protected by federal regulations under either the Health Information Portability and Accountability Act (HIPAA) or the Family Educational Rights and Privacy Act of 1974 (the Buckley Amendment) and may not be disclosed without either my authorization under HIPAA or my consent under the Buckley Amendment. The reason for this disclosure is to advise my coaches and the athletics staff about the diagnosis or treatment concerning my medical condition so that they may make decisions regarding my athletic ability to compete while I am a student athlete. This disclosure is also used to advise my parent/guardian of the diagnosis or treatment concerning my medical condition so that they may assist me in making healthcare decisions while I am a student athlete.
In certain circumstances, this disclosure is also to advise print, radio, television and other media of the nature and treatment concerning my medical condition so that they may report on it while I am a student athlete. I understand that the entities that receive the information may not be health care providers, and that the information described above may be re-disclosed publicly and, at that point, the information will no longer be protected by these regulations.
I understand that my protected health information and any personal identifiers will be encrypted while being transmitted from my institution and, to the extent kept by the NWAC, that all such data will be stored securely within industry standards. I further understand that neither the NWAC nor its agents or contractors will identify me personally in any publication or disclosure of research results.
I understand that Big Bend Community College will not receive any compensation for its use of this information. I may inspect or copy any information used under this authorization. I understand I may revoke this authorization at any time by notifying the Director of Athletics in writing. This authorization expires two years from the date it is signed.
I hereby authorize Big Bend Community College and the athletic department’s secondary insurance agent to inspect or secure copies of case history records, laboratory reports, diagnosis, x-rays, and any other data covering this and/or previous confinements and/or disabilities. A photocopy of this form shall be deemed as effective and valid as the original. We authorize that the College or its insurance agent pay the medical vendors direct for any bills incurred from the accidents that are covered under the policy purchased by the College.
I understand that my signing of this authorization/consent is voluntary and that my institution will not condition or withhold any health care treatment or payment, enrollment in a health plan or receipt of any benefits (if applicable) on whether I provide the consent or authorization requested for this disclosure. However, I also understand that by choosing not to sign this document, I will not be able to participate in intercollegiate athletics at Big Bend Community College.