… Permission to the University of Tennessee team physicians, athletic trainers, coaches, and/or media relations staff to disclose my protected health information concerning any illness or injury relative to my participation in intercollegiate athletics to the media. This includes, but is not limited to: TV, radio, newspapers, magazines, University-sponsored websites, and other informational media outlets (here forth referred to as "the media").
I understand that my protected health information will be provided to the media for the purpose of PROVIDING ACCURATE INFORMATION regarding my health status and involvement in intercollegiate athletics.
I understand that my injury/illness information is protected by federal regulations under either the Health Information Portability and Accountability Act (HIPAA) or the Family Educational Rights Privacy Act of 1974 (FERPA) and by State law; furthermore, this information may not be disclosed without either my authorization under HIPAA or my consent under FERPA and State law. I understand that my authorization/consent is voluntary and that the University of Tennessee will not condition any health care treatment or payment, enrollment in a health plan, or receipt of any benefits (if any) on whether I provide the consent or authorization requested for this disclosure. I also understand that I am not required to give this authorization/consent in order to be eligible for participation in any University-sponsored intercollegiate athletics, Southeastern Conference Athletics, or NCAA-sanctioned athletics.
I understand that the media is not covered by HIPAA, FERPA, or State law and that these regulations will not apply to the media’s use or disclosure of my injury/illness information.
This authorization/consent expires four hundred fifty (450) days from the date of my signature below, but I have the right to revoke it in writing at any time by sending written notification to the Athletic Director or Director of Sports Medicine. I understand that the revocation will take effect when the University of Tennessee Athletic Department receives it, except to the extent that the University of Tennessee Athletic Department or others have already relied upon it.
I have been advised that I am entitled to a copy of this authorization.
I understand I cannot participate in athletics without signing and agreeing to the above release.