1) I authorize the use of disclosure of the above individual’s health information. Also if the student is involved in athletics/activities at Baltic School the Pre-Participation History and Physical Exam information pertaining to a student’s ability to participate in South Dakota High School Activites Association sponsored activities. Such disclosure may be made by any Heath Care Provider generating or maintaining such information.
2) The information identified above may be used by or disclosed to the school nurse, athletic trainer, coaches, medical providers and other school personnel involved in the care of this student.
3) This information for which I am authorizing disclosure will be used for the purpose of determining the student’s eligibility to participate in extracurricular activities, any limitations on such participation and any treatment needs of the student.
4) I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to the school administration. I understand that the revocation will not apply to the information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy.
5) I understand that once the above information is disclosed, it may be re-disclosed by the recipient and the information may not be protected by federal privacy laws or regulations. I understand authorizing the use or disclosure of the information identified above is voluntary.
6) However, a student’s eligibility to participate in extracurricular activities depends on such authorization. I need not sign this form to ensure healthcare treatment.
I understand authorizing the use or disclosure of the information identified above is voluntary. However, a student’s eligibility to participate in extracurricular activities depends on such authorization. I need not sign this form to ensure healthcare treatment.