Welcome to the University of South Florida and its Intercollegiate Athletics Program. Prior to your Tryout it is necessary for us to gather pertinent medical information in order to determine if you are medically eligible to participate in intercollegiate athletics. Enclosed, you will find a packet of forms that require your attention. When completing these forms, please answer all questions to the best of your knowledge. Below is a list of forms followed by a brief description. If you have any questions, please feel free to contact one of the athletic training staff members via the numbers listed below. You are required to have completed in a comprehensive physical exam given by a qualified general medical physician. The physical form must be stamped by the clinic you receive your physical from. Unstamped physical forms will not be accepted as a valid physical. 9 UNIVERSITY OF SOUTH FLORIDA ATHLETICS TRYOUT CLEARANCE FORM 9
HEALTH INSURANCE INFORMATION FORM: A photocopy of both sides of all insurance cards (medical, dental, vision, prescription) must be attached to the completed form.
9
STUDENT-ATHLETE PERSONAL INFORMATION FORM: This form provides contact information in the event of an emergency.
9
MEDICAL HISTORY: This will inform us of any previous medical problems and hopefully prevent any further problems from occurring.
9
BIOLOGICAL TESTING CONSENT FORM: By signing this form, you are indicating your understanding of the program and your agreement to be screened for banned substances. Screening takes place randomly throughout the year for all athletes. Participation in athletics is contingent upon adherence to the program and the signing of the consent form.
9
INFORMATION RELEASE AUTHORIZATION FORMS: These forms gives the athletic training staff permission to release your medical history to team physicians, coaches, athletic staff members, student athletic trainers, parent(s)/ guardian(s), teammates, and professional scouts. These forms are required to be completed only once during your athletic career at USF.
9
NCAA AND USF POLICY REGARDING LIABILITY: This form allows us to provide emergency medical care to you and terminate participation for health reasons at any time.
9
NOTICE OF PATIENT INFORMATION PRIVACY PRACTICES: This form is informative and may be kept for your records. The notice explains your rights as a patient and how the USF Sports Medicine staff may use your medical information. Please return the acknowledgement page.
Note: if you are not under 18 years of age it is not necessary for a parent or guardian to sign these forms.
If you have any questions please feel free to contact one of us at in the Athletic Training room at (813) 974-0514.
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University of South Florida Athletics Tryout Clearance Form I, _________________________________________, understand that there are risks in trying out for the sport of __________________________. I am voluntarily assuming the responsibility for any such risks and I will be liable for any injury that I may incur during or as a result of my participation in this tryout. I assume full financial and legal responsibility for any injury/ or injuries suffered by me during any tryout(s). There is no health related reason(s) or problem(s) which preclude or restrict my participation in this tryout. I also consent to receive any emergency medical treatment deemed necessary by the Sports Medicine staff at the University of South Florida and agree that the Sports Medicine staff may terminate my participation in the tryout for any time and for any reason. I waive and release the University of South Florida, the Board of Trustees, and the officers, agents, employees, and any students acting on behalf of either the University of South Florida or the Board of Trustees, and their heirs, assigns, or successors in interest of any and each of them from any and all Liability which may result or arise from my participation in any tryout(s) or from any emergency treatment I may receive during the tryout(s). If any portion of this Release is held to be illegal, unenforceable, or in conflict with any laws of the State of Florida by any Court of competent jurisdiction, the remaining portions of this release shall not be affected.
_________________________ Signature
______________________________ Sports Medicine Approval
_________________________ Print Name
______________________________ Signature of Parent/Guardian if Participant is under 18 years of age
Enrolled Full Time?
Yes
No
Degree Seeking Student?
Yes
No
The above named student is approved to tryout for a maximum of seven (7) days without further approval.
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Pre-participation Physical Examination Name: ___________________________________ Date of Birth: ____ / ____ / ____
Date: ________________________ Sport: ________________________
Height: ________ (inches) Weight: ________ (lbs.) Vision: R 20/ ____ L 20/ ____ Corrected: Y / N Pupils: Equal / Unequal
B.P. _____ / _____ Pulse: ________ Glasses/Contacts SAC Result: ____/30
NORMAL
ABNORMAL FINDINGS
General Appearance Eyes Ears Nose Throat/Mouth Neck Heart Lungs Abdomen Hernia G.U. Other
Optional Dental: Cleared? Y / N Dental Physician: _____________________________ Recommendations: __________________________________________________________________________ General Medical Clearance: Cleared to Participate? Yes / No Further Evaluation Needed? Yes / No
Evaluating Physician: _________________________________ Explain: ___________________________________________ ___________________________________________________ ___________________________________________________
Reviewing Physician: _________________________________ Last printed 8/6/2010 8:40 AM
Pre-participation Physical Examination Name: ___________________________________ Date of Birth: ____ / ____ / ____
NORMAL
Date: ________________________ Sport: ________________________
ABNORMAL FINDINGS
Neck Back Shoulder/Arm Elbow/Forearm Wrist/Hand/ Fingers Hip/Groin Thigh Knee Lower Leg Ankle Foot
Orthopaedic Clearance: Cleared to Participate? Yes / No Further Evaluation Needed? Yes / No
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Evaluating Physician: ________________________________ Explain: ___________________________________________ ___________________________________________________ ___________________________________________________
University of South Florida Sports Medicine Athlete Medical History Name __________________________________ Date of Birth ____ / ____ / ____
Date
___________________
Sport _______________________________
Family History Does anyone in your family have a history of medical problems? Y / N If yes, explain: __________________________________________________________________ Mother: ________________________________________________________ Living: Y / N Age of Death: __________ Cause of Death: ________________________________________ Father: _________________________________________________________ Living: Y / N Age of Death: __________ Cause of Death: ________________________________________ Brother(s): ______________________________________________________Living: Y / N Age of Death: __________ Cause of Death: ________________________________________ Sister(s): ________________________________________________________Living: Y / N Age of Death: __________ Cause of Death: ________________________________________ Has anyone in your family ever been diagnosed with: Y/N
Sudden unexplained death Relationship: ____________________________ Explain: __________________________________________________________ Y / N Alcohol/Substance Abuse Relationship: ____________________________ Explain: __________________________________________________________ Y / N Asthma Relationship: ____________________________ Explain: __________________________________________________________ Y / N Cancer Relationship: ____________________________ Explain: __________________________________________________________ Y / N Diabetes Relationship: ____________________________ Explain: __________________________________________________________ Y / N Heart Disease (of any kind) Relationship: ____________________________ Explain: __________________________________________________________ Y / N High Blood Pressure Relationship: ____________________________ Explain: __________________________________________________________ Y / N Marfan Syndrome Relationship: ____________________________ Explain: __________________________________________________________ Y / N Migraines/Severe Headaches Relationship: ____________________________ Explain: __________________________________________________________ Y / N Osteoporosis/Bone Disorder Relationship: ____________________________ Explain: __________________________________________________________ Y / N Seizures/Epilepsy Relationship: ____________________________ Explain: __________________________________________________________ Y / N Sickle Cell Disease/Trait Relationship: ____________________________ Explain: __________________________________________________________ Last printed 8/6/2010 8:40 AM
Current Medical Conditions: Y/N
Are you currently under medical supervision for an injury/illness? If yes, explain: __________________________________________________________________
Y/N
Do you have a current ongoing or chronic illness? If yes, explain: __________________________________________________________________
Surgery/Hospitalization: Y/N
Have you ever had surgery? Date: ________________ Date: ________________ Date: ________________
Surgery: ______________________________ Surgery: ______________________________ Surgery: ______________________________
Y/N
Have you ever been hospitalized for a reason other than surgery? Date: ________________ Reason: _______________________________ Date: ________________ Reason: _______________________________
Y/N
Have you ever been advised to have a surgery not yet performed? If yes, explain: _________________________________________________________________
Medications: Y/N
Do you regularly use any prescription medication? If yes, explain: _________________________________________________________________
Y/N
Do you regularly use non-prescription medication? If yes, explain: _________________________________________________________________
Y/N
Do you regularly take any dietary supplements? If yes, explain: _________________________________________________________________
Y/N
Have you ever taken supplements or vitamins to help you gain/lose weight in order to improve your performance? If yes, explain: _________________________________________________________________
Alleriges: Are you allergic to any of the following: Y / N Aspirin Y / N Food (specify) __________________________ Y / N Dust/pollen Y / N Insect stings (specify) _____________________ Y / N Penicillin Y / N Sulfa Drugs Y / N Novocaine Y / N Other Drugs (specify) _____________________
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Illnesses: Have you had any of the following illnesses: Y / N Chicken Pox Date: _______________ Y / N Diabetes Date: _______________ Y / N Hepatitis Date: _______________ Y / N Measles Date: _______________ Y / N Mononucleosis “Mono” Date: _______________ Y / N Pneumonia Date: _______________ Have you ever had any of the following: Y / N Anemia Y / N Sickle Cell Disease/ Sickle Cell Trait Y / N Eye injury or other eye problem Y / N Hearing loss Y / N Severe tooth or gum trouble Y / N Severe skin problems (rash, acne, burns, etc.) Do you have loss or seriously impaired function of any paired organ? Y / N Ear Y / N Eye Y / N Kidney Y / N Ovary Y / N Testicle Y / N Lung Cardiovascular System: Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N
Do you get more fatigued (tired) during exercise, or get fatigued earlier during exercise than your teammates? Do you become more short of breath during exercise than your teammates? Have you ever fainted or passed out during or after exercise? Have you ever had chest pains during or after exercise? Have you ever been told that you have high blood pressure (hypertension)? Have you ever been told that you have a heart murmur? Have you ever been told that you had high cholesterol (hyperlipidemia)? Has a physician ever ordered heart testing (for example: EKG, Echo, stress test, holter monitor)? If yes, please explain:____________________________________________________________ Y / N Have you ever been diagnosed with any type of heart disease (hypertrophic cardiomyopathy, coronary artery abnormality, heart infection, heart valve disease, Marfan’s Syndrome, etc)? If yes, please specify: ____________________________________________________________ Y / N Have you ever been told that you need to take medication before seeing a dentist? Y / N Have you ever had a racing heart or skipped heart beats? Y / N Has anyone in your family died of heart problems or sudden death before the age of 50? If you answered yes to any of the above questions, please explain: ____________________________ __________________________________________________________________________________________________ ________________________________________________________________________
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Respiratory System: Y/N Y/N Y/N
Y/N Y/N
Do you cough, wheeze, have difficulty breathing, or get short of breath during exercise? If yes, how often? _______________________________________________________________ Have you ever been diagnosed with asthma? If so, is your asthma well controlled? Please check one: I have symptoms from my asthma: daily_____ More than twice per week_____ Less than twice per week _____ Hardly ever _____ Do you use an inhaler? If yes, what kind? _______________________________________________________________ Do you have seasonal allergies that require medical treatment or medication?
Neurological System: Y/N
Have you ever had a head injury or a concussion? Date: ___________________ Explain: _________________________________ If so, how many concussions? __________________________________________
Y/N
Have you ever been knocked out, unconscious, or lost your memory? Date: ___________________ Explain: _________________________________
Y/N
Have you ever had a seizure? Date: ___________________ Explain: _________________________________
Y/N
Have you ever had a stinger, burner, or pinched nerve? Date: ___________________ Explain: _________________________________
Heat Illnesses: Y/N Y/N Y/N Y/N Y/N
Have you ever had heat stroke or heat exhaustion? If so, please explain: _____________________________________________________________ Have you ever had muscle cramps caused be the heat? How often? _______________________ Have you ever been dizzy or fainted in the heat? How often? ____________________________ Have you ever been confused in the heat? How often? _________________________________ Have you ever been hospitalized for a heat related condition?
Nutrition: Y/N Y/N Y/N
Do you want to weigh more or less than you currently do? Do you frequently lose weight or gain weight to meet the requirements of your sport? Would you be interested in seeing a sports nutritionist?
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Women Only: What was the date of your last menstrual period? ____________________________________________ When was your first menstrual period? ____________________________________________________ How many periods have you had in the last year? ____________________________________________ What was the longest time between periods in the last year? ____________________________________ My periods are now (circle one): Regular ⇒ every 24-35 days Irregular ⇒ every 36 days or more Absent ⇒ no periods for the past three months Y/N Y/N Y/N Y/N
Are you currently taking a form of birth control? If yes, what kind? _______________________________________________________________ Is there a history of osteoporosis in your family? Is there a history of repeated fracture in anyone in your family? Have you had repeated fractures or repeated stress fractures before?
Protective Devices: Y/N Y/N Y/N Y/N
Do you wear contacts? Do you wear glasses? Do you wear orthotics in your shoes? Do you wear any corrective braces or supports? If yes, what? ___________________________________________________________________
Musculoskeletal System: Have you ever injured any of the following extremities that caused you to miss a week or more participation in your sport? Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N
Hip Groin Thigh Knee Shin/Calf Ankle Foot/Toes Skull/Face Teeth/Jaw Neck Back Shoulder Upper Arm Elbow Forearm Wrist Hand/Fingers
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Left / Right Left / Right Left / Right Left / Right Left / Right Left / Right Left / Right Left / Right Left / Right Left / Right Left / Right Left / Right Left / Right Left / Right Left / Right Left / Right Left / Right
Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date:
__________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________
Explain: Explain: Explain: Explain: Explain: Explain: Explain: Explain: Explain: Explain: Explain: Explain: Explain: Explain: Explain: Explain: Explain:
______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________
Other Medical Conditions: Y/N
Have you ever been told, for any reason, that you should not participate in sports? If yes, explain: __________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Y/N
Do you know of, or believe, there is any reason that should prevent you from participating in intercollegiate athletics? If yes, explain: __________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
I certify that the answers to the preceding questions are correct and true to the best of my knowledge. I understand that passing the physical exam does not necessarily mean that I am physically qualified to engage in intercollegiate athletics, but only that the examiner did not find medical reason to disqualify me from participation.
_______________________________________ Signature of Student-Athlete
_______________________ Date
_______________________________________ Signature of Parent/Guardian if under 18 years of age
_______________________ Date
MEDICAL CONSENT Permission is hereby granted to the attending physician, USF Sports Medicine Staff, or other medical personnel to proceed with medical treatment, minor surgical treatment, and x-ray examination. In the event of serious injury or illness, I understand that an attempt will be made by the appropriate medical personnel to contact my parents or legal guardian. If medical personnel are not able to communicate with the responsible party, the treatment necessary for my health will be provided. _______________________________________ Signature of Student-Athlete
________________________ Date
_______________________________________ Signature of Parent/Guardian if under 18 years of age
________________________ Date
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Student-Athlete Health Insurance Information Form Dear Parent/Guardian: We have an established athletic insurance policy providing medical coverage for your son/daughter for injuries that occur while participating in Intercollegiate Athletics. This medical coverage is secondary to medical/dental/vision insurance provided by the parent/guardian. After primary benefits are considered, USF will process the remaining balance for payment. Please complete this form entirely. Please attach copies of all insurance cards, front and back. Athlete______________________________________SS#________________________DOB_________________ Father/Guardian_____________________________________________SS#________________DOB____________ Address_____________________________________________________________________________________ Employer_________________________________________________Work.Phone__________________________ Employer.Address_____________________________________________________________________________ Mother/Guardian___________________________________________SS#_________________DOB____________ Address_____________________________________________________________________________________ Employer________________________________________________Work.Phone___________________________ Employer.Address_____________________________________________________________________________
Medical Insurance
Covered by Father/Mother/Uninsured (circle)
Insurance.Company_________________________________________ Customer.Service#_____________________ Claims.Address________________________________________________________________________________ Member#______________________________________Policy#____________________Group#_______________ PPO or HMO____________ Primary Care Physician_______________________Phone#_______________________
Prescription Insurance
Covered by Father/Mother/Uninsured (circle)
Insurance.Company_________________________________________Customer.Service#_____________________ Claims.Address________________________________________________________________________________ Member#_____________________________________Policy#_____________________Group#_______________
Dental Insurance
Covered by Father/Mother/Uninsured (circle)
Insurance.Company_________________________________________Customer.Service#_____________________ Claims.Address________________________________________________________________________________ Member#_____________________________________Policy#_____________________Group#_______________ PPO or HMO___________Primary Dentist_____________________________Phone#________________________
Vision Insurance
Covered by Father/Mother/Uninsured (circle)
Insurance.Company__________________________________________Customer.Service#____________________ Claims.Address________________________________________________________________________________ Member#_____________________________________Policy#_____________________Group#_______________
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STUDENT ATHLETE PERSONAL INFORMATION Name: ________________________________________________________________ (last)
(first)
USF I.D. #: _________________________
(middle initial)
Birthdate: _______________ (month / day / year)
Year in school: F S J S 5th
Sport: _____________________________
Local Address: _________________________________________________________ (Street / Box #)
(Apt #)
_________________________________________________________ (city / state / zip code)
Local Phone Number: (____) ____________________ Cell Phone Number: (____) _____________________
IN CASE OF EMERGENCY CALL: Name: ____________________________
Relationship: ________________
Address: ______________________________________________________________ (Street / Box #)
(Apt #)
______________________________________________________________ (city / state / zip code)
Home Phone #: (____) _________________ Work Phone #: (____) _________________ Cell Phone #:
(____) _________________
I acknowledge receiving the University of South Florida’s intercollegiate athletic medical policy. I understand the university’s responsibility to a student athlete who becomes injured or ill as a result from participation in intercollegiate athletics. Student Athlete’s Signature: _______________________________
(date)
_________
Parent / Guardian Signature: _______________________________
(date)
_________
(If under 18)
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University of South Florida Intercollegiate Athletics Biological Specimen Testing Consent Form 1. I hereby consent to be tested to determine if I have utilized any substance on the University of South Florida list of banned drug classes as set forth in the University of South Florida’s Substance and Abuse Policy, by providing a biological specimen as requested by the director of intercollegiate athletics or designee. 2. I agree to provide such biological specimens at the time and location and under conditions for collection, as determined by the director of intercollegiate athletics or designee, at various times throughout the year, with or without prior notice. 3. I hereby authorize the director of intercollegiate athletics or designee to send my samples to the laboratory of the university’s choice for actual testing and authorize the director of intercollegiate athletics or designee to receive test results. 4. I hereby authorize the director of intercollegiate athletics or designee to release all information and records, including test results, that may be made or received relating to the screening and testing of my biological specimens to the university’s respective head coach and associate athletic director for sports and program services, or their designees, for their use in supervision and administration of the university’s athletic program. I acknowledge that while certain medical information may be released to the media by virtue of my participation in USF Intercollegiate Athletics, the results of drug tests will not be released or reported. I further acknowledge and agree that my parent/ guardian will be notified of the results of any positive test result(s). 5. I acknowledge that I have read a copy of the University of South Florida Drug Abuse Policy and Procedures, including the University of South Florida Banned Drug Class List, and that I have had an opportunity to ask questions regarding them. I understand the provisions therein and I agree to abide by those provisions including those specifically related to possible penalties for positive test results. 6. I hereby release and discharge the University of South Florida and the Board of Trustees of the State University System of South Florida, their officers, employees and agents from all claims and causes of action created by or arising out of any act or omission related to the implementation of the University of South Florida Drug Abuse Policy and procedures. 7. I have read this Consent Form, understand the terms in it, their legal significance and sign voluntarily. 8. I understand that I may revoke my consent to participate at any time in the University of South Florida Drug Abuse Policy. In doing so, I understand and agree that I will immediately be banned from participation in intercollegiate athletics at University of South Florida and will immediately forfeit any related athletic scholarships or financial aid.
_______________________________________
____________________________
Student Athlete Name (Print)
USF ID Number
_______________________________________ Student-Athlete Signature
______________________________ Date Birth Date
___________________________________________ Parent / Guardian (if under 18 years of age)
______________________________ Date
_____________________________ Sport
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INFORMATION RELEASE AUTHORIZATION I, _____________________, Give consent for my medical records to be released to any USF Team physician involved in the care of my illness or injury; or to a physician appointed by the USF Athletic Training Staff.
Athlete’s Signature: _________________________
Date: ___/___/___
I also give consent for the USF Athletic Training Staff to release medical information to the sports information department, media, or a scout/ representative of any professional or amateur athletic organization seeking such information. I acknowledge that this type of information may be reported in the media as a result of my participation in USF Intercollegiate Athletics, except that no results of drug tests will be released or reported. ( Body part affected by injury or illness ( Nature of the injury (sprain, fracture, etc.) ( Status of the athlete for same day and future competition
Athlete’s Signature: _______________________
Date: ___/___/___
***This release remains valid until revoked in writing and delivered to the Assistant Director of Athletics for Sports Medicine. For purposes of this authorization, medical information can include but not be limited to, information concerning illness, injury, treatment, rehabilitation, physicians’ names or referrals, and/or prognosis.
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Supplement/Medication Waiver I will not consume any nutritional supplement* other than those provided or having written approval from Athletic Department Sport Performance staff, Sports Dietitian, Coach McKeefery (Assistant AD/Head Strength & Conditioning Coach) or Steve Walz (Assistant AD/Director of Sports Medicine). I will notify Sports Medicine staff and Team Physicians of any current prescription medications I am presently taking prior to receiving any OTC* and Prescription medications* from Sports Medicine staff. *Nutritional supplement is any product (powder, pill, liquid, beverage, tablet, etc.) designed to supplement the diet which includes one or more of the following ingredients: vitamins, minerals, herbs, botanicals, amino acids, calorie boosters, constituents, extracts, or any combination of these ingredients. *OTC medications are medications that can be purchased over the counter from retailers such as drug stores, pharmacies, grocery stores and convenience stores. A prescription is not needed for these medications. Typical OTC medications include Tylenol, aspirin, ibuprofen, cough and cold formulas, and medications for allergies, constipation, diarrhea and nausea. *Prescription medications are generally more potent than those sold over-the-counter (OTC) and may have more serious side effects if inappropriately used. Therefore, these medications are only sold under a doctor’s direction.
All supplements must be approved by the three individuals listed above. Please list supplements/medication you are currently taking or have taken in the past 3 months:
1. 2. 3. 4. 5. 6. Print Name:__________________ Signature:___________________ Date:_________
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University of South Florida Liability Waiver
I, ___________________________, understand that there are risks in participating in the sport of _________________________. I am voluntarily assuming the responsibility for any such risks. Therefore, I consent to receive any emergency medical treatment deemed necessary by the Sports Medicine staff at the University of South Florida and agree that the Sports Medicine staff may terminate my participation at any time and for any reason. I waive and release the University of South Florida, the Board of Trustees (or any other entity designated by Florida law to manage, operate, and/or oversee the University of South Florida) and the officers, agents, employees, and any students acting on behalf of either the University of South Florida or the Board of Trustees, and the heirs, assigns or successors in interest of any and each of them from any and all Liability which may result or arise from either my athletics participation or any medical treatment I may receive. If any portion on this Release is held to be illegal, unenforceable, or in conflict with any laws of the State of Florida by any Court of competent jurisdiction, the remaining portions of this release shall not be affected.
_____________________________ Signature of Participant
________________________ Date
_____________________________ USF ID Number
________________________ Date of Birth
_____________________________ Signature of Parent/Guardian if Participant is under 18 years of age
________________________ Date
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AUTHORIZATION FOR THE RELEASE OF MEDICAL INFORMATION AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION TO ATHLETIC TRAINING STUDENTS AND OTHER STUDENT MEMBERS OF THE SPORTS MEDICINE STAFF This authorizes the athletic trainers, team physicians, and sports medicine staff representing the University of South Florida to release information concerning my medical status, medical condition, injuries, prognosis, and diagnosis and related personally identifiable health information to the student athletic trainers and other students who are participating in the provision of sports medicine healthcare. This information includes injuries or illnesses relative to past, present or future participation in athletics at the University of South Florida. The reason for this disclosure is to allow such student athletic trainers and other students participation in the delivery of sports medicine healthcare to assist and participate in the provision of healthcare to me while I am a student athlete. I understand that the entities that receive the information are not health care providers or health plans covered by federal privacy regulations, and that the information described above may be re-disclosed publicly and that the information will no longer be protected by those regulations. I understand that the University of South Florida will not receive compensation for its use/disclosure of the information. I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain medical treatment. I may inspect or copy any information used/disclosed under this authorization. I understand that I may revoke this authorization in writing at any time by notifying in writing the Assistant Athletic Director for Athletic Training, but if I do, it will not have any effect on actions the University of South Florida took in reliance on this authorization prior to receiving the revocation. This authorization expires six years from the date it is signed. ______________________________ Printed Name of Student-Athlete
________________________ Sport
______________________________ Date of Birth ______________________________ Signature of Student-Athlete
________________________ Date
______________________________ Signature of Parent/Legal Guardian (If Student-Athlete is under 18 years of age)
________________________ Date
I have reviewed the above statements but I do not wish to authorize this release. _____________ Initials
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AUTHORIZATION FOR THE RELEASE OF MEDICAL INFORMATION AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION TO TEAMATES
This authorizes the athletic trainers, team physicians and athletics staff including coaches representing the University of South Florida to release information concerning my medical status, medical condition, injuries, prognosis, diagnosis, and related personally identifiable health information to my teammates. This information includes injuries or illnesses relevant to past, present or future participation in athletics at the University of South Florida. The reason for this disclosure is to advise my teammates of the nature, diagnosis, prognosis or treatment concerning my medical condition and any injuries or illnesses so that they will be aware of limitations that I may be under while I am a student athlete. I understand that the entities that receive the information are not health care providers or health plans covered by federal privacy regulations, and that the information described above may be re-disclosed publicly and that the information will no longer be protected by those regulations. I understand that the University of South Florida will not receive compensation for its use/disclosure of the information. I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain medical treatment. I may inspect or copy any information used/disclosed under this authorization. I understand that I may revoke this authorization in writing at any time by notifying in writing the Assistant Athletic Director for Athletic Training, but if I do, it will not have any effect on actions the University of South Florida took in reliance on this authorization prior to receiving the revocation. This authorization expires six years from the date it is signed.
______________________________ Printed Name of Student-Athlete
________________________ Sport
______________________________ Date of Birth ______________________________ Signature of Student-Athlete
________________________ Date
______________________________ Signature of Parent/Legal Guardian (If Student-Athlete is under 18 years of age)
________________________ Date
I have reviewed the above statements but I do not wish to authorize this release. _____________ Initials
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AUTHORIZATION FOR THE RELEASE OF MEDICAL INFORMATION AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION TO COACHES AND ATHLETICS STAFF This authorizes the athletic trainers, team physicians and athletics staff including coaches representing the University of South Florida to release information concerning my medical status, medical condition, injuries, prognosis, diagnosis, and related personally identifiable health information to the coaches, assistant coaches and other athletics staff. This information includes injuries or illnesses relevant to past, present or future participation in athletics at the University of South Florida. The reason for this disclosure is to advise the coaches and athletics staff of the nature, diagnosis, prognosis or treatment concerning my medical condition and any injuries or illnesses so that they may make decisions regarding my athletic ability and suitability to compete while I am a student athlete. I understand that the entities that receive the information are not health care providers or health plans covered by federal privacy regulations, and that the information described above may be re-disclosed publicly and that the information will no longer be protected by those regulations. I understand that the University of South Florida will not receive compensation for its use/disclosure of the information. I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain medical treatment. I may inspect or copy any information used/disclosed under this authorization. I understand that I may revoke this authorization in writing at any time by notifying in writing the Assistant Athletic Director for Athletic Training, but if I do, it will not have any effect on actions the University of South Florida took in reliance on this authorization prior to receiving the revocation. This authorization expires six years from the date it is signed. ______________________________ Printed Name of Student-Athlete
________________________ Sport
______________________________ Date of Birth ______________________________ Signature of Student-Athlete
________________________ Date
______________________________ Signature of Parent/Legal Guardian (If Student-Athlete is under 18 years of age)
________________________ Date
I have reviewed the above statements but I do not wish to authorize this release. _____________
Initials
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AUTHORIZATION FOR THE RELEASE OF MEDICAL INFORMATION AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION TO PARENTS OR GUARDIAN This authorizes the athletic trainers, team physicians and athletics staff including coaches representing the University of South Florida to release information concerning my medical status, medical condition, injuries, prognosis, diagnosis, and related personally identifiable health information to my parents/guardian. This information includes injuries or illnesses relevant to past, present or future participation in athletics at the University of South Florida. The reason for this disclosure is to advise my parent/guardian of the nature, diagnosis, prognosis or treatment concerning my medical condition and any injuries or illnesses so that they may make decisions regarding my athletic ability and suitability to compete while I am a student athlete. I understand that the entities that receive the information are not health care providers or health plans covered by federal privacy regulations, and that the information described above may be re-disclosed publicly and that the information will no longer be protected by those regulations. I understand that the University of South Florida will not receive compensation for its use/disclosure of the information. I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain medical treatment. I may inspect or copy any information used/disclosed under this authorization. I understand that I may revoke this authorization in writing at any time by notifying in writing the Assistant Athletic Director for Athletic Training, but if I do, it will not have any effect on actions the University of South Florida took in reliance on this authorization prior to receiving the revocation. This authorization expires six years from the date it is signed. ______________________________ Printed Name of Student-Athlete
________________________ Sport
______________________________ Date of Birth ______________________________ Signature of Student-Athlete
________________________ Date
______________________________ Signature of Parent/Legal Guardian (If Student-Athlete is under 18 years of age)
________________________ Date
I have reviewed the above statements but I do not wish to authorize this release. _____________
Initials
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NOTICE OF PATIENT INFORMATION PRIVACY PRACTICES Effective 4/1/03 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED OR DISCLOSED AND HOW YOU CAN GET ACCESS TO INFORMATION. PLEASE REVIEW IT CAREFULLY. The Health Insurance Portability & Accountability Act of 1996 (“HIPAA”) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, to be kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. HIPAA provides penalties for covered entities that misuse personal health information. As required by HIPAA, the University of South Florida has prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information. We participate in this notification, and will share protected health information (PHI), as necessary, to carry out treatment, payment, or healthcare operations. USES AND DISCLOSURES OF HEALTH INFORMATION The University of South Florida may use and disclose your protected health information for treatment, obtaining payment for treatment, and healthcare operations necessary to sustain our business. ¾
Treatment means providing, coordinating, or managing health care and related services by one or more health care providers. An example of this would be: o A physical examination or assessment.
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Payment means such activities as obtaining reimbursement for services, confirmation coverage, billing or collection activities and utilization review. An example of this would be: o We may provide information to your insurance company as needed to receive payment for services rendered to you. This may include, but is not limited to, diagnosis and treatment codes, treatment notes, and copies of documentation relevant to obtaining payment. Your insurance company, health plan, health insurance issuer or HMO with respect to a group health plan, may disclose protected health information to the sponsor of the plan.
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Healthcare Operations includes the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost -management analysis, and customer service. An example of this would be: o We may use your personal information to contact you to remind you of an upcoming appointment, either by phone or by mail.
Some of the services we offer may be provided to you in a semi-private setting. For example, our Sports Medicine Clinic and Therapy Departments have an open gym area that allow athletic trainers and patients efficient access to equipment and modalities needed and shared by the department. The University of South Florida may use or disclose your protected health information without prior authorization for public health purposes, for auditing purposes, for research studies and for emergencies. We also provide information when required by law. We may also create and distribute de-identified health information by removing all references to individually identifiable information. In any other situation, the University of South Florida’s policy is to obtain your written authorization before disclosing your protected health information. An example of this would be a release to the media in regards to a specific injury or illness. If you provide us with a written authorization to release your information for any reason, you may later revoke that authorization to stop future disclosures at any time. Last printed 8/6/2010 8:40 AM
The University of South Florida may change its policy at any time. This amendment will affect all protected health information maintained by the University of South Florida. When changes are made, a new Notice of Patient Information Practices will be posted in the training room areas that will display the Effective Dates and any Revision Dates, and will be provided to you on your next visit. You may also request an updated copy of our current Notice of Patient Information Practices at any time. PATIENT’S INDIVIDUAL RIGHTS You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer: ¾ You have the right to review or obtain a copy of your protected health information at any time. ¾ You have the right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosure of family member, other relatives, close personal friends or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it. You may also request in writing that we not use or disclose your protected health information for treatment, payment and administrative purposes except when specifically authorized by you, when required by law or in emergency circumstances. The University of South Florida will consider all such requests on a case-by-case basis, but the practice is not legally required to accept them. ¾ You have the right to request that we amend your protected health information. ¾ You also have the right to request a list of instances where we have disclosed your protected health information for reasons other than treatment, payment or other related administrative purposes. ¾ You have the right to obtain a paper copy of this notice from us upon request.
CONCERNS AND COMPLAINTS If you are concerned that the University of South Florida may have violated your privacy rights or if you disagree with any decisions we have made regarding access or disclosure of your protected health information, please contact our Privacy Officer or Quality Assurance Department at the address listed below. It is our intent to protect and keep your protected health information confidential. Your alerting us of any concerns you may have is a necessary part of a continuous quality process we employ. You will, in no way, be retaliated against for filing a complaint. You may also send a written complaint to the US Department of Health and Human Services. For further information on the University of South Florida’s health information practices or if you have a complaint, please contact the following person:
University of South Florida Sports Medicine Privacy Officer: Steve Walz M.A., ATC, LAT Assistant Athletic Director Director of Sports Medicine University of South Florida ATH 100 (813) 974-3506
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By signing this form I acknowledge that I have read and received the Notice of Patient Information Privacy Practices from the University of South Florida Sports Medicine Staff.
I understand my rights as a patient and further understand that the University of South Florida Sports Medicine Staff may change their Notice of Privacy Practices at any time. If a change in this policy does occur, I understand that I will be notified in a timely manner.
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_________________________
Student-Athlete Name (Print)
Date
_______________________________ Student-Athlete Signature
_______________________________
_______________________
Parent/Guardian Signature (if under 18 years of age)
Date
Last printed 8/6/2010 8:40 AM
Concussion Management Protocol Agreement
I, ___________________________, have been presented educational material regarding concussion injuries. I have read and understand this material and am aware of the concussion management protocol in place at the University of South Florida. I agree to report fully and honestly any and all concussion signs and/or symptoms I experience as a result of an injury, whether sustained during athletic participation or outside of athletic participation, to the University of South Florida Sports Medicine staff.
I understand that withholding
information regarding my symptoms puts me at risk for further injury and prevents the USF Sports Medicine staff from accurately assessing and managing my injury. I agree to abide by the USF Concussion Management Protocol and any treatment/management plans set forth by the USF Sports Medicine Department and/or USF Team Physicians.
_____________________________ Signature of Participant
________________________ Date
_____________________________ USF ID Number
________________________ Date of Birth
_____________________________ Signature of Parent/Guardian if Participant is under 18 years of age
________________________ Date
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