Bsa Camper Under 18 Medical Records Authorization/permission Hipaa Form printable pdf download

PIKES PEAK COUNCIL

BOY SCOUTS OF AMERICA

CAMPER UNDER 18 MEDICAL RECORDS

AUTHORIZATION/PERMISSION HIPAA FORM

I _________________________as parent or guardian of ________________________________Give

permission for Camp Alexander Pikes Peak Council Medical and Management Staff to share my son

or daughters medical information with any Doctor, medical facility/hospital deemed necessary in case

of illness or injury. This information will be used for medical treatment and will not be given to

anyone other than proper medical personnel.

I also give permission for the adult leaders of troop #________to have knowledge of the medication

that my son or daughter takes. This information will be used only for the time period that the above is

in the care of the adult leaders.

THIS INFORMATION AND PERMISSION IS GIVEN IN KEEPING WITH CURRENT

HIPAA FEDERAL REGULATIONS AND WILL BE KEPT IN ACCORDANCE WITH THE

PIKES PEAKS COUNCIL BSA RISK MANAGEMENT GUIDELINES.

NAME:___________________________RELATIONSHIP:__________________________

(PRINT)

SIGNATURE:______________________________DATE:___________________________

THIS FORM TO BE ATTACHED TO THE SCOUTS CLASS III MEDICAL FORM

CA/HIPAA PERMISSION FORM/05/CAMPER