Athletic Training

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