I authorize the University of Tennessee ("UT") team physicians, athletic trainers, consultants, and/or their medical assistants to release and share protected health information concerning any injury or illness relative to my participation in intercollegiate athletics to UT coaches, administrators, the academic counseling staff, professors/lecturers, researchers approved by the UT IRB, and/or the NCAA for legitimate educational purposes, related to my past, present, or future participation in athletics at the University of Tennessee.
I also authorize any medical institution which might render medical treatment to me during this period, or may have rendered medical care to me previously, to release all records to the University of Tennessee Head Team Physician, Director of Sports Medicine, or University of Tennessee’s Medical Claims Coordinator, in order that they will be better informed of my medical condition, capabilities, and/or limitations while I participate in athletic competition for the University of Tennessee.
The University of Tennessee Athletic Department and many other individuals and organizations such as physicians, hospitals and health insurance plans are required by law to keep your health information confidential. If you have authorized the disclosure of your health information to someone who is not legally required to keep it confidential, it may no longer be protected by state or federal confidentiality laws.
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 understand that I am entitled to receive a copy of this authorization upon request. A photostatic copy of this authorization shall be considered as effective and valid as the original.
I understand I cannot participate in athletics without signing and agreeing to the above release.