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

PIKES PEAK COUNCIL

BOY SCOUTS OF AMERICA

CAMPER 18 AND OVER MEDICAL RECORDS

AUTHORIZATION/PERMISSION HIPAA FORM

I _________________________ ________________________________Give permission for Camp

Alexander Pikes Peak Council Medical and Management Staff to share my 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 I take. This information will be used only for the time period that the above is attending Camp

Alexander.

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 ADULTS CLASS III MEDICAL FORM

CA/HIPAA PERMISSION FORM/05/CAMPER ADULT