UPMC/UNIVERSITY OF PITTSBURGH MEDICAL CENTER (UPMC) Authorization for Release of Protected Health Information
RELEASE OF PROTECTED HEALTH INFORMATION
• I authorize UPMC to provide information related to my care to family/school/team physicians, school nurses, coaches, athletic directors, school principals, EMS personnel, and such other persons as is necessary needed for them to provide consultation, treatment, establish a plan of care or determine whether the Athlete may resume participation in school or sports activities.
• I authorize UPMC to use my billing information for UPMC internal departmental reporting purposes.
• I authorize UPMC (including its hospitals, other entities and programs) to use medical or other information maintained on electronic information systems or stored in various forms in connection with my care, health care operations, or payment for treatment and services.
• I understand that the health record(s) released by UPMC may be re-disclosed by the facility/person that receives the record(s) and therefore (1) UPMC and its staff/employees has no responsibility or liability as a result of the re-disclosure and (2) such information may no longer be protected by federal or state privacy laws.
• I understand that this Authorization is in effect for a period of one year from the date signed by the Athlete.
• I understand that this Authorization is in effect if I am treated for an injury during off-season workouts; however, no time frame specified shall go beyond one year from the date of signature.
• I understand that I have the right to revoke this Authorization form at any time by sending a written request to UPMC at the location where the Authorization was provided.
• I understand that my decision to revoke the Authorization does not apply to any release of my health record(s) that may have taken place prior to the date of my request to revoke the Authorization.
• I understand that I am entitled to a copy of this completed Authorization form.
Print Athlete’s First and Last Name
Parent /Guardian Signature (If Athlete is a Minor)