We request that the following Authorization be signed before any claims may be filed to your Insurance Carrier:
I hereby authorize the Sports Medicine Department to have medical claims filed on my behalf to my current medical/prescription drug/dental/vision insurance policy(ies) for any illnesses and/or athletic injuries sustained during my participation in intercollegiate sport at the University of Tennessee.
I also authorize the Athletic Department to pay medical providers directly for remaining balance of claims that are approved as detailed in the Sports Medicine Dept. Medical Claims Payment policy.
I hereby grant permission to the University of Tennessee team physicians, athletic trainers, consultants, and/or their medical assistants to provide any treatment, medical care, or surgical care they deem necessary for my health and well-being.
I also authorize the University of Tennessee athletic trainers, under the direction and guidance of the team physicians and their consultants, to render any preventative, first aid, rehabilitative, or emergency treatment which the athletic trainers deem necessary for my health and well-being.
This signed medical consent also authorizes the above named members of the University of Tennessee sports medicine staff to select other health care providers, including hospitals, to render this same appropriate medical care.
I understand I cannot participate in athletics without signing and agreeing to the above release.
I understand that there are inherent dangers and potential for injury during participation in intercollegiate athletics while at the University of Tennessee. I am also aware that intercollegiate athletic participation, even when all reasonable precautions are taken, carries a risk of serious injury or illness – including, but not limited to, paralysis and death – due to the nature of sport. I also understand that the risks of participation in intercollegiate athletics may result not only in serious injury or illness but also in impairment of my future ability to earn a living and/or my quality of life.
Shared Responsibility for Sports Safety
The rules of play, safety guidelines, equipment standards, and training are designed to protect athletes from injury, but cannot guarantee that I will not be injured. I acknowledge that I have a responsibility to wear the required equipment and clothing, obey the rules of my sport, utilize proper techniques, follow my coaches’ and athletic trainers’ instructions, and avoid activities for which I have not trained or for which I do not feel qualified to perform. Furthermore, if I am currently taking dietary supplements, other performance-enhancing drugs, or prescription medications on my own, I am aware of and understand the possible risks associated with their ingestion. These risks include, but are not limited to: elevated heart rate, increased or decreased blood pressure, heat stroke, and death.
I accept responsibility for reporting all injuries and illnesses to the sports medicine staff, including any signs or symptoms of a concussion. These signs and symptoms may include, but are not limited to, headache, dizziness, nausea, visual changes, memory loss, or loss of consciousness.
Additional Information for the Sport of Football Only:
Do not use your helmet to butt, or spear an opposing player. This is in violation of all football rules and such use can result in severe head injury, paralysis or death to you, as well as inflicting possible injury to your opponent. No helmet can prevent all head or neck injuries that a player might receive while participating in football.
I have read and understnad the significance of the above statements. I voluntarily accept the risks of participation in intercollegiate sports. I also acknowledge that I have a shared responsibilty for injury prevention.
I understand I cannot participate in athletics without signing nad agreeing to the above release.
I authorize the University of Tennessee ("UT") team physicians, athletic trainers, consultants, and/or their medical assistants to release and share protected health information concerning any injury or illness relative to my participation in intercollegiate athletics to UT coaches, administrators, the academic counseling staff, professors/lecturers, researchers approved by the UT IRB, and/or the NCAA for legitimate educational purposes, related to my past, present, or future participation in athletics at the University of Tennessee.
I also authorize any medical institution which might render medical treatment to me during this period, or may have rendered medical care to me previously, to release all records to the University of Tennessee Head Team Physician, Director of Sports Medicine, or University of Tennessee’s Medical Claims Coordinator, in order that they will be better informed of my medical condition, capabilities, and/or limitations while I participate in athletic competition for the University of Tennessee.
The University of Tennessee Athletic Department and many other individuals and organizations such as physicians, hospitals and health insurance plans are required by law to keep your health information confidential. If you have authorized the disclosure of your health information to someone who is not legally required to keep it confidential, it may no longer be protected by state or federal confidentiality laws.
This authorization/consent expires four hundred fifty (450) days from the date of my signature below, but I have the right to revoke it in writing at any time by sending written notification to the Athletic Director or Director of Sports Medicine. I understand that the revocation will take effect when the University of Tennessee Athletic Department receives it, except to the extent that the University of Tennessee Athletic Department or others have already relied upon it. I understand that I am entitled to receive a copy of this authorization upon request. A photostatic copy of this authorization shall be considered as effective and valid as the original.
… Permission to the University of Tennessee team physicians, athletic trainers, coaches, and/or media relations staff to disclose my protected health information concerning any illness or injury relative to my participation in intercollegiate athletics to the media. This includes, but is not limited to: TV, radio, newspapers, magazines, University-sponsored websites, and other informational media outlets (here forth referred to as "the media").
I understand that my protected health information will be provided to the media for the purpose of PROVIDING ACCURATE INFORMATION regarding my health status and involvement in intercollegiate athletics.
I understand that my injury/illness information is protected by federal regulations under either the Health Information Portability and Accountability Act (HIPAA) or the Family Educational Rights Privacy Act of 1974 (FERPA) and by State law; furthermore, this information may not be disclosed without either my authorization under HIPAA or my consent under FERPA and State law. I understand that my authorization/consent is voluntary and that the University of Tennessee will not condition any health care treatment or payment, enrollment in a health plan, or receipt of any benefits (if any) on whether I provide the consent or authorization requested for this disclosure. I also understand that I am not required to give this authorization/consent in order to be eligible for participation in any University-sponsored intercollegiate athletics, Southeastern Conference Athletics, or NCAA-sanctioned athletics.
I understand that the media is not covered by HIPAA, FERPA, or State law and that these regulations will not apply to the media’s use or disclosure of my injury/illness information.
This authorization/consent expires four hundred fifty (450) days from the date of my signature below, but I have the right to revoke it in writing at any time by sending written notification to the Athletic Director or Director of Sports Medicine. I understand that the revocation will take effect when the University of Tennessee Athletic Department receives it, except to the extent that the University of Tennessee Athletic Department or others have already relied upon it.
I have been advised that I am entitled to a copy of this authorization.
I hereby acknowledge that I have received a copy of the University of Tennessee-Knoxville Substance Abuse Testing Policy and Procedures for Intercollegiate Student-Athletes, and I am aware that an online copy of the policy is available at:
I hereby consent to have a sample(s) of my urine, or other approved specimen, collected and tested for the presence of drugs, both illegal and prescription, and banned substances, in accordance with the provisions of the University of Tennessee-Knoxville Substance Abuse Testing Policy and Procedures.
I authorize the employees or agents of the University of Tennessee to send my urine or specimen sample(s) to a professional laboratory of the University’s choice for actual drug testing. I also authorize the employees or agents of the University of Tennessee to provide the results of all drug tests to the Chancellor, Athletic Director, Head Coach, Sport Administrator, Head Team Physician, Director of Sports Medicine, substance abuse counselor(s), and my parent(s) or legal guardian(s).
I hereby release the University of Tennessee, its Board of Trustees, its officers, employees, and agents from any and all liability that may result from the release of such information and records as authorized by this form.
I have read, understand, and agree to comply with the University of Tennessee-Knoxville Substance Abuse Testing Policy and Procedures for Intercollegiate Student-Athletes. I have also been given the opportunity to ask questions about the policy and procedures and have had my questions answered satisfactorily. I understand that signing this form is consideration for my being permitted to participate in intercollegiate athletics at the University of Tennessee- Knoxville.
Student-Athlete Authorization/Consent for
Disclosure of Protected Health Information
and its physicians, athletic trainers and health care personnel to disclose my protected healthinformation including, without limitation, any information regarding any injury, illness, treatment or participation related to or affecting my training for and participation in intercollegiate athletics to the National Collegiate Athletic Association (NCAA), and its designated employees, agents and/or contractors. I further authorize the NCAA to disclose, and/or use, such information as provided herein.
I understand that my participation and protected health information, including, without limitation, injuries or illnesses resulting from or affecting training for or participation in athletics, may be disclosed to, and/or used by, the NCAA, and any third party expressly authorized by the NCAA to receive such information for the purposes described in this paragraph. The information provides NCAA committees, athletics conferences and individual schools and NCAA-approved researchers with injury, relevant illness and participation information that does not identify individual student-athletes or schools. The data provide the Association and other groups with an information resource upon which to base and evaluate the effectiveness of health and safety rules and policy, and to study other sports medicine questions. Selected de-identified summary (aggregate) data also are made accessible to the general public as a service to further the general understanding of athletic injury patterns.
I understand that my protected health information is protected by federal regulations under either the Health Information Portability and Accountability Act (HIPAA) or the Family Educational Rights and Privacy Act of 1974 (the Buckley Amendment) and may not be disclosed without either my authorization under HIPAA or my consent under the Buckley Amendment. I understand that my signing of this authorization/consent is voluntary and that my institution will not condition or withhold any health care treatment or payment, enrollment in a health plan or receipt of any benefits (if applicable) on whether I provide the consent or authorization requested for this disclosure. I also understand that I am not required to sign this authorization/consent in order to be eligible for participation in NCAA athletics.
I understand that while HIPAA regulations may not apply to NCAA use or disclosure of my injury/illness information, the NCAA is committed to protecting my privacy. I understand that my protected health information and any personal identifiers will be encrypted while being transmitted from my institution and, to the extent kept by the NCAA, that all such data will be stored securely within industry standards. I further understand that neither the NCAA nor its agents or contractors will identify me personally in any publication or disclosure of research results.
This authorization/consent for transfer of protected health information expires 545 days from the date of my signature below but I have the right to revoke it in writing at any time by sending written notification to the director of athletics at my institution. I understand that a revocation takes effect on its request date and does not affect any action taken prior to that date.
PATIENT PRIVACY NOTICE ACKNOWLEDGEMENT
Designated Representatives: The following people may call to ask and receive medical information for me:
Notice of Financial or Investment Relationship
In order to provide you with the most comprehensive quality care, you may be referred to a facility in which your physician may have a ownership interest. They may include the following: Ft. Sanders West Outpatient Surgery Center, Tennova Ambulatory Surgery Center, U.T. Ambulatory Surgery Center, Advanced Family Surgery Center, Maryville Surgery Center, Knoxville Orthopedic Surgery Center, Ortho Tennessee Therapy, Imaging Centers, and Ortho Tennessee Orthotics. Some physicians are paid consultants to orthopedic manufactures of surgical implants and other orthopedic products that may be used in your treatment. In addition, some physicians have an interest in Joint Solutions of Tennessee, a distributor of surgical implants to the hospitals and ambulatory surgical centers.
1. This document serves as notice to you of the various investments and/or financial interest of the physicians of Ortho Tennessee Orthopedics.
2. You have the right to request services (PT, MRI, surgery centers) at the provider of your choice or request an alternative provider. Please advise your physician and you will be referred to another comparable facility. If you are to receive an orthopedic implant, your physician will be glad to discuss his/her choice with you.
3. You will not be treated differently by this practice or by your physician if you choose not to use the services recommended by your physician, in which he/she has a financial/investment interest.