MUSKINGUM UNIVERSITY SPORTS MEDICINE

NOTICE OF PRIVACY PROTECTION FOR ATHLETES

Muskingum University Sports Medicine strives to meet all guidelines for the privacy of your Personal Health Information (PHI). Our department is not considered an entity covered by HIPAA guidelines.

By signing this waiver below you are agreeing to the following stipulations:

1. You agree that the athletic training staff can converse about an injury, illness or condition you may have, treatment considered or rendered, medical history, or your health status, within the medical team rendering your care, the coaching staff of your sport, and the athletic director as necessary.

2. You also agree that the athletic training staff may converse and share information regarding any injury, illness, or health status with your parents, legal guardian, or other designee.

3. You also agree that we can converse with any third party insurance carrier with regard to care of an injury, condition, or illness to facilitate payment of medical bills.

4. You also agree that the release of height and weight can be made for the purpose of roster, media guide and general team releases. Release of PHI will not be made by the athletic training staff to the sports information office or media without your permission. We will report specific injuries (type and location) and game and practice status to the media when requested. The athletic training staff does not have jurisdiction over the release of information by the sports information office or coaching staff to the media.

5. We will not release any medical information to any legal or judicial entity, professional scout or team without your written permission.

6. You have the right to rescind this consent and refuse the release of any PHI to anyone at any time. If you do refuse release of information to the medical team caring for you and/ or your team coaches this may disqualify you from participation in intercollegiate athletics at Muskingum University.

7. You have the right to inspect the medical records kept on you by the athletic training staff. Arrangements to do so should be made through the athletic trainer assigned to your team.

8. You understand and agree that some information about your health history may be included in data for statistical research. If information about you is used it will be submitted and used in a manner where you cannot be personally identified.

9. This waiver is valid only through the 2013-14 school and athletic year. Your consent is assumed through the summer until if and when a new waiver is signed at the beginning of the new school year. If you discontinue participation in the athletic program any release of information to other schools, physicians or other entities must be approved by you.

10. The athletic training staff maintains records on a computer data base, hard copy files, and dead file storage in perpetuity. In addition to the professional staff, student aides may be used to enter data and file PHI. Emergency forms that travel with teams include PHI on all athletes for the purpose of relaying information to medical practitioners while away from campus. All necessary precautions are used to maintain privacy of records.

Athlete name (print)______

Athlete Signature______Date______

Athletic Trainer______