Daytona State College
Sports Medicine Department
INDIVIDUAL CONSENT FOR THE USE OR DISCLOSURE
OF PROTECTED HEALTH INFORMATION
By signing this form, you consent to our use and disclosure of protected health information
about you for treatment, payment, and practice operations as described in our Notice of Privacy
Practices. You have the right to revoke this consent, in writing, except where we have already
made disclosures or used your information based upon your prior consent.
Consent Related to HIV/AIDS Information
The information we use or disclose as described in our Notice of Privacy Practices may include
information about Acquired Immunodeficiency Syndrome (AIDS), or tests for or infection with the
Human Immunodeficiency Virus (HIV). You consent to the use or disclosure of this health
information for treatment, payment, or practice operations as described in our Notice.
Consent Relating to Mental Health or Substance Abuse
The information we use or disclose as described in our Notice of Privacy Practices may contain
information regarding psychiatric conditions, alcohol or substance abuse. You consent to the
use or disclosure of this health information for treatment, payment, or practice operations as
described in our Notice.
I consent to the use and disclosure of all of my health and medical information between
the Daytona State College Sports Medicine team (physicians, athletic trainers, coaches),
parents, hospitals, physical therapists, other healthcare providers and insurance
companies related to my past and present medical conditions, injuries, or illnesses, as
described in the Notice of Privacy Practices and in the paragraphs above. By signing
below, I also acknowledge receipt of said Notice.
Athlete Printed Name: _______________________ Sport: _________________________
Athlete Signature: __________________________ Date: _________________________
Parent/Guardian Signature: __________________ Date: _________________________
(if under 18)
Parent/Guardian Printed Name: _______________
Witness Signature: _________________________ Date:
_________________________
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