Student-Athlete Health Information Disclosure Authorization - HIPAA Form
Please print out two (2) “HEALTH INFORMATION DISCLOSURE AUTHORIZATIONS FORMS”- HIPAA Forms. Have one (1) form signed by a person legally authorized to sign for a minor student, or signature of the student if his/her age is 18 or greater. Also initial on the form that you have printed out and read Bellin Health’s “Notice of Privacy Practices.” Return the signed form to the Athletic Trainer at your school and keep one (1) form for your personal records.
Download the form here: I understand what is being asked of me and agree to the instructions stated above.
Descarga el impreso aquí: Entiendo la información y lo que necesito hacer y acepto las instrucciones como se indica más arriba.
Physical Cards – to be filled out during Pre-Participation Exams
- Student Athlete Physical Card (English)
- Student-Athlete Physical Card (Spanish)
WIAA alternate year cards
- Student-Athlete Alternate Year Card (English)
- Student-Athlete Alternate Year Card (Spanish)
- Student-Athlete Alternate Year Card (Hmong)