1.This authorization applies to all Health Information about me that is now (or, during the period covered by this authorization, may be) in the possession, custody or control of the persons or entities (or classes of persons or entities) identified below. As used in this authorization: "Health Information" means all information relating to my past, present or future physical or mental health or condition or medical record (including, but not limited to, my electronic medical record), including, but not limited to, all information relating to any injury, sickness, disease, condition, medical history, laboratory report or x-ray or other imaging test result, laboratory result and data (including, but not limited to, information relating to any test result or vaccination related to COVID-19), screening, medical or clinical status, diagnosis, treatment or prognosis, and "Health Care Provider" means any physicians, hospitals, laboratories, clinics, diagnostic testing companies or other testing providers, trainers, therapists, and/or any other health care professionals or organizations (including, but not limited to, any such persons or entities conducting any examination of me in connection with the 2024 NBA G League Local Player Tryout (the "Local Tryout" but not including any of such health care professionals or organizations in their capacity as participants in the National Basketball Players Association Mental Health and Wellness Program.
2.I authorize Health Care Providers to collect, store and/or use, and/or disclose to any Health Care Provider any of the Health Information about me that is (or, during the period covered by this authorization, may be) in their possession, custody or control for the following purpose (the "Purpose"): any purpose relating to my participation in a Local Tryout or my employment (or potential employment) as a player in the National Basketball Association ("NBA") or the G League ("G League"), and/or my participation in an NBA-approved summer league ("Summer League"), including, but not limited to, for any purpose relating to player health and fitness.
3.During the period covered by this authorization, the G League (but only with respect to G League players, which include, for purposes of this authorization, players participating in a Local Tryout), the NBA, NBA teams for which I have played (or may play) (including, but not limited to, in connection with my Summer League participation), G League teams for which I have played (or may play) (but only with respect to G League players, which include, for purposes of this authorization, players participating in a Local Tryout), and the physicians, owners, general managers, coaches, trainers, therapists, and counsel and other team personnel of the NBA or G League team(s) for which I have played (or may play) (including, but not limited to, in connection with my Summer League or Local Tryout participation) (collectively "Team Personnel") may, for the Purpose, collect, store, and/or use my Health Information. During the period covered by this authorization, the G League (but only with respect to G League players, which include, for purposes of this authorization, players participating in a Local Tryout), the NBA, NBA teams for which I have played (or may play) (including, but not limited to, in connection with my Summer League participation), G League teams for which I have played (or may play) (but only with respect to G League players, which include, for purposes of this authorization, players participating in a Local Tryout), Team Personnel, and Health Care Providers may, for the Purpose, disclose my Health Information to: (a) any Health Care Provider; (b) the NBA (including, but not limited to, its medical experts); (c) the G League (but only with respect to G League players, which include, for purposes of this authorization, players participating in a Local Tryout); (d) NBA teams, G League teams for which | have played (or may play) (but only with respect to G League players, which include, for purposes of this authorization, players participating in a Local Tryout), or the ), or Team Personnel of any such NBA or G League team(s) for which I have played (or may play) (including, but not limited to, in connection with my Summer League or Local Tryout participation);; (e) in the event of any contemplated assignment of my playing contract to another NBA or G League team, or the potential signing of a playing contract with an NBA or G League team, the Team Personnel of such other team(s); (f) any other NBA or G League team or Team Personnel as designated by the NBA or G League; (g) any entity from which any NBA or G League team seeks to procure, or has procured, any insurance policy covering my life or any disability, injury or illness I may suffer or sustain; (h) any entity from which the NBA or G League or NBA or G League team receives Health Information services (including, but not limited to, services related to the electronic collection, storage and processing of Health Information); (a) my certified player agent or representative; and/or (b) at the direction of the NBA or the G League (but only with respect to G League players, which include, for purposes of this authorization, players participating in a Local Tryout), the media or public.
4.| understand that my Health Information disclosed pursuant to this authorization may be redisclosed by the recipient and no longer be protected by local, state or federal health information privacy laws or regulations.
5.| understand that my medical treatment will not be conditioned upon whether or not I sign this form, except in the case of health care that is solely for the purpose of creating Health Information for such disclosures as set forth in Paragraphs 2 and 3 of this authorization (including, but not limited to, in connection with or related to a Local Tryout