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Parental Permission For Release Of Medical Information

PARENTAL PERMISSION FOR RELEASE OF MEDICAL INFORMATION

To the Physician:

Your patient participates in a Fairfax County Public Schools (FCPS) athletic program and

thereby has contact with a certified athletic trainer (ATC). The FCPS Athletic Training

Program consists of athletic trainers certified by the National Athletic Trainers

Association (NATA) Board of Certification (BOC) and licensed by the Commonwealth

of Virginia’s Board of Medicine. ATC’s provide injury prevention programs, injury

evaluation, treatment, and rehabilitation services to FCPS student athletes.

Sound communication between and among all health care providers is key to providing

the best care to an injured athlete. This release is provided to encourage communication

between the treating medical physician and the athletic training staff at this athlete’s

school.

****** RELEASE ******

As parent or legal guardian of ______________________________, I grant permission

for the office of ______________________________ to release information pertinent to

the health care of my student athlete son/daughter to the athletic training staff at

____________________ High School.

I understand that the release of information may be in the form of personal

communication over the telephone, electronic form, letters or documents, reproductions

of originals of written material including X-Ray, MRI, or in person.

_________________________________

______________

Parent/Guardian Signature

Date

Any and all information shared will be considered confidential in nature, every effort

will be made to maintain confidentiality.

Parental Permission For Release Of Medical Information