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NYACK COLLEGE SPORTS MEDICINE DEPARTMENT
HIPAA ATHLETIC FORMS
Please read each statement carefully and initial each box then sign at the end of this form.
Parent/guardian initials & signature is required if the student-athlete is covered by medical insurance
through the parent/guardian &/or they are claim as a dependant even if they are over 18 years of age.
This document covers you for the entire length of your eligibility at Nyack College, along with the
summary waiver signed yearly by the returning athletes.
THIS FORM IS CONFIDENTIAL!
ATHLETES
INITIAL
PARENT’S
INITIAL
INSURANCE AUTHORIZATION TO RELEASE INFORMATION AND TO AUTHORIZE THE
INSURANCE COMPANIES TO PAY MEDICAL BILLS
I.
I hereby authorize Nyack College Athletics to release/obtain personal medical insurance data about me, my son/daughter for
the purpose of certification and payment of medical bills incurred as a result of injury, illness, physical examinations and
other legitimate reasons related to health coverage. In accordance with FERPA* and HIPAA**, this information is to be
released on the condition that Nyack College will not permit any other party access to the information without the written
consent of myself or other legally responsible party.
II.
I hereby authorize the student athlete’s insurance companies to release insurance information regarding medical history,
treatment, or benefits payable for claims incurred during intercollegiate sports pertaining to athletic injuries and illnesses, to
the athletic training staff, team physician(s), and area medical facilities.
III.
I authorize the student athlete’s insurance companies to pay insurance benefits to team physicians, student health services,
area medical facilities, or any other provider of medical services.
IV.
In acknowledgement of financial duty, I understand that the student athlete and/or policy holder agree that should a student
athlete’s claim be paid directly to the student athlete or policy holder, they will make payment to the hospital, physician
and/or any other provider of services who have rendered care to the athlete for the described injury or illness.
Failure to do so is a breach of duty. Nyack College will make no payments on this claim.
ATHLETES
INITIAL
PARENT’S
INITIAL
AUTHORIZATION TO OBTAIN AND RELEASE MEDICAL INFORMATION
I.
I hereby authorize Nyack College Athletics to release/obtain personal medical records in the event of an emergency to the
hospital, team physician, physicians, athletic trainer, or other provider of medical services in order to maintain
my/son/daughter’s well-being. In accordance with FERPA* and HIPAA**, this information is to be released/obtained on the
condition that Nyack College Athletics will not permit any other party access to the information without the express written
consent of myself or other legally responsible party.
II.
I authorize the Nyack College team physician, other physicians, hospitals, the Nyack College Health Services Department, or
any other provider of medical services to release medical information acquired in the course of my examination or treatment
to the Nyack College Athletic Trainer for the purpose of advising medical status, care of, and eligibility for returning to
sports.
III.
I acknowledge and authorize that any protected health information released to/obtained by the Nyack College Athletic
Trainer(s) can be disclosed within Nyack College Athletics, Nyack College Coaching Staff, Team Physician, Nyack College
Health Services, or any other provider of medical services for treatment purposes only within a year from date of injury and
in accordance with FERPA* and HIPAA** guidelines.
IV.
I acknowledge that Nyack College Athletics is not authorized to release any medical information to the media, sport
information personal and/or any other non-covered entity in accordance with FERPA* and HIPAA** guidelines unless a
signed authorization form is obtained first. I realize that I may withdraw my consent at any time in writing.
V.
I acknowledge and accept that the release of my/son/daughter’s protected health information is a prerequisite for
participation in Nyack College Athletics. I acknowledge and accept that I do have a right to revoke my authorization in
writing and in doing so I choose not to participate in Nyack College Athletics in accordance with the guidelines set by
FERPA* and HIPAA**.
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ATHLETES
INITIAL
PARENT’S
INITIAL
ATHLETIC PARTICIPATION MEDICAL EXAM AND MEDICAL CONSENT
I.
I understand that the NCAA requirement for eligibility to participate in Nyack College Athletics is having a report of a
physical exam on file in the Nyack College Sports Medicine Department. I hereby authorize the release of
my/son/daughter’s medical exam to the Nyack College Sports Medicine Department and the Nyack College Student
Health Services of the Student Development Office.
II.
I hereby authorize permission to Nyack College team physician and/or consulting physician to render me, my son/daughter
any treatment or medical or surgical care that they deem reasonably necessary to my/son/daughter health and well being. I
also hereby authorize the athletic trainers at Nyack College, who are under the direction and guidance of Nyack College
team physician, to render me, my son/daughter any preventative, first-aid, rehabilitative or emergency treatment that they
deem reasonably necessary to my/son/daughter health and well being.
ATHLETES
INITIAL
PARENT’S
INITIAL
ACKNOWLEDGEMENT OF MY INSURANCE RESPONSIBILITY AND THE NYACK
COLLEGE ATHLETIC INSURANCE POLICY
I.
I hereby acknowledge that I have read, accepted and understand the Nyack College Athletic Insurance Policy included in the
information package I have received or obtained online. If I did not receive an Explanation of the Nyack College Athletic
Insurance Policy I have requested and been given one before signing below.
II.
I realize that any personal insurance I have is the primary insurance carrier and I realize that it is my responsibility to first
follow the procedures of my insurance company to obtain treatment from medical facilities. I also realize that not following
these procedures may result in claims being denied by the Nyack College Athletic Insurance Policy, which is a secondary
policy. I realize that following these procedures may include obtaining pre-authorization prior to medical treatment (doctor
visits, etc.) and procedures (MRI’s, bone scans, x-ray, surgery, etc.) when required by my insurance company. If any bills
are not paid by the student’s primary insurance company due to failing to following proper procedures, Nyack College
Athletic Insurance Policy will not pay these bills. If this occurs I realize and accept that these bills are my responsibility and
Nyack College will not pay these bills.
III.
I realize and accept that the Nyack College Athletic Insurance Policy is secondary to my own insurance. The Nyack College
Athletic Insurance Policy provides coverage for up to 2 years from date of injury and does not cover any pre-existing
conditions.
IV.
I am also aware that the Nyack College Athletic Insurance Policy covers participation in Intercollegiate Athletics only. It
DOES NOT cover participation in other sport activities, intramurals, or classes open to the general student body. In addition,
this athletic insurance DOES NOT cover medical expenses related to an illness or disease unless it results from a Nyack
College intercollegiate athletic-related injury.
ATHLETES
INITIAL
PARENT’S
INITIAL
SPORTS MEDICINE DEPARTMENT POLICY
I.
I acknowledge that I have read, accepted and understand the Sports Medicine Department Policy that has been included in
the information package I have received or obtained online. If I did not receive a copy of the Sports Medicine Department
Policy, I have requested and been given one before signing below. I, the undersigned, understand this Sports Medicine
Department Policy statement and agree to abide by its rulings.
*FERPA- The Family Educational Rights and Privacy Act of 1974
**HIPAA- The Health Insurance Portability & Accountability Act of 1996
(http://www.oms.nysed.gov/medicaid/guidebook_6/HIPAA_FERPA_Guidebook_6.htm)
By initialing above and signing below, I acknowledge that I have read, accepted and understand, and will comply with all of the above
policies and procedures. I also acknowledge that if initially I did not understand, I have contacted the Nyack College Sports Medicine
Dept. to clarify any issues I did not understand and have had those issues clarified. This signed form is required prior to participation
in any intercollegiate athletics at Nyack College.
___________________
DATE
___________________
DATE
________________________________________
PRINTED ATHLETE’S
FULL NAME
________________________________________
PRINTED PARENT/GUARDIAN’S NAME
_______________________________________
SIGNATURE OF ATHLETE
_______________________________________
SIGNATURE OF PARENT/GUARDIAN***
***Parent/guardian signature is required if the student that is claimed as a dependant &/or if medical insurance is through the parent/guardian.
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