Medical Information Release Form printable pdf download

Medical Information Release Form

Western Connecticut State University

Medical Information Release Form

Name (Print)_______________________________

Date of birth_______________

I understand that communication and records relating to a person’s identity, diagnosis,

prognosis or treatment is confidential under the general statutes of the State of Connecticut. I

hereby authorize the WCSU Athletic Department, the WCSU Health Service, and the WCSU

Recreation Department to disclose any medical information which may impact my academic

activities and participation in the intercollegiate or club sports programs. I understand that this

authorization is for the release of general protected health information. In this reciprocal

agreement, my medical information may be disclosed interdepartmentally, as well as to other

healthcare professionals who are participating in my care. The sharing of information will be

limited to the information that is essential for the optimal provision of care.

By signing this authorization, I release the WCSU Athletic Department, the WCSU Health

Service, the WCSU Recreation Department, and WCSU from any liability resulting from the

release of this information.

I understand that this authorization will expire one year from the date signed, but may be

withdrawn by me at any time through a written, signed, and dated request.

Athlete’s Signature: ______________________________________

Date: __________

Parent/Guardian’s Signature: _______________________________

Date: __________

(if under 18 years of age)

(WCSU HS 11/2014)

Medical Information Release Form