McCullough-Hyde Hospital & Union County High School

Release and Disclosure of Personal Health Information

I hereby authorize the release and disclosure of the personal health information of ___________________(the “Student”) to Union County High School (the “School”).

I understand that the School has requested this authorization to release or disclose the personal health information of the Student to make certain decisions about the Student’s health and ability to participate in certain school sponsored and classroom activities.

Personal health information of the Student includes, but is not limited to, records of physical examinations and other records used to determine the Student’s physical fitness and eligibility to participate in classroom or other School sponsored activities, such as, but not limited to, athletic practice sessions, training, and competition.

Personal health information of the Student may be released to the School’s principal, athletic director, coach, athletic trainer, physical education teacher, school nurse or other member of the School’s administrative staff as necessary to evaluate the Student’s eligibility to participate in school sponsored activities.

The personal health information of the Student may be released or disclosed to the School by any of the following:

• The Student’s personal physician or physicians;
• a physician or other health care professional retained by the School to perform physical examinations to determine the Student’s eligibility to participate in certain School sponsored activities;
• a physician or other health care professional retained by the School to provide treatment to students injured while participating in certain School sponsored activities; and
• any EMT, hospital, physician or other health care professional who evaluates, diagnoses or treats an injury or other condition incurred by the Student while participating in School sponsored activities.

I understand that the School is covered under federal regulations that govern the privacy of educational records, and that the personal health information of the Student disclosed under this authorization may be protected by those regulations.  I consent to the release of the Student’s records to the people identified in this document for the use described above.

I understand that the Student’s participation in certain school sponsored activities may be conditioned on the signing of this authorization.

I understand that the School is not a health care provider or health plan covered by the Health Insurance Portability and Accountability Act of 1996 and that Act’s implementing regulations (“HIPAA”).

I understand that personal health information of the Student that is disclosed under this authorization may be re-disclosed and may not continue to be protected by the federal HIPAA privacy regulations.

I understand that health care providers and health plans may not condition the provision of treatment or payment on the signing of this authorization.

I understand that I may revoke this authorization in writing at any time, except to the extent that action has been taken by a health care provider in reliance on this authorization, by sending a written revocation to the school principal (or designee) whose name and address appear below:

Name of Principal________________________

School Address ___________________________

This authorization will expire when the student is no longer enrolled as a student at the school.

NOTE: IF THE STUDENT IS UNDER 18 YEARS OF AGE, THIS AUTHORIZATION

MUST BE SIGNED BY A PARENT OR LEGAL GUARDIAN TO BE VALID.

IF THE STUDENT IS 18 YEARS OF AGE OR OLDER, THE STUDENT MUST SIGN

THIS AUTHORIZATIN PERSONALLY.

________________________________________________________________________

Student’s Signature                                                       Birth date of Student, including year

________________________________________________________________________

Parent/Guardian Name, if applicable

I am the Student’s (check one): _______Parent

                                                _______Legal Guardian (documentation must be provided)

_________________________________________________________________________

Parent/Guardian Signature, if applicable                                     Date

A copy of this signed form has been provided to the student or his/her parent/guardian.

THE STUDENT SHALL NOT BE CLEARED TO PARTICIPATE IN

INTERSCHOLASTIC ATHLETICS UNTIL THIS FORM HAS BEEN SIGNED

AND RETURNED TO THE SCHOOL.