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Before taking ImPACT test please review and agree to the terms below.
UNIVERSITY OF PITTSBURGH MEDICAL CENTER (UPMC)
Authorization for Release of Protected Health Information
- I am 18 years or older, or
- under 18 years of age and have parent/guardian supervision
in taking this ImPACT test
- under 18 years of age and taking the ImPACT test under the supervision of a certified athletic trainer (below form is already signed and returned by parent/guardian)
- I authorize UPMC to provide information related to
my care to be provided to the family/school/team physician, school
nurse, coaches,
athletic directors, school principals, EMS personnel, and such persons as needed
for
them to provide consultation, treatment, and establish a plan of care.
- I
give authorization to UPMC to use my UPMC billing information for
UPMC departmental internal reporting only.
- I give authorization to
UPMC (including hospitals, other entities
and programs) to access medical or other information maintained on
electronic information systems or stored in various forms at individual
UPMC affiliates
related to treatment/or services provided to me by UPMC and/or any
affiliate in connection with my care, health care operations, or payment
for treatment
and services. I also authorize information related to my care to be
provided to my family/team/school physician and such persons as necessary
for
them to provide consultation, treatment, and/or services to me.
- I give authorization
to UPMC to access medical or other information maintained on electronic
information systems or stored in various forms
used in the evaluation and follow-up care from ImPACT concussion testing.
I also authorize information related to my ImPACT concussion testing to be provided
to my family/team/school
physician and such persons as necessary for them to provide consultation,
treatment,
and/or services to me.
- I understand that my health record(s) will not
be released or obtained by UPMC unless permission is provided for herein
as evidenced
by the signature on this Authorization for Release of Protected Health Information
(Authorization)
- I understand that the release of my health record(s)
will be for the purpose stated on this form.
- I understand that the
health record(s) released by UPMC may possibly be re-disclosed by the
facility/person that receives the record(s)
and therefore (1) UPMC and its staff/employees have no responsibility or liability
as a result
of the re-disclosure and (2) such information would no longer be protected
by the Privacy Rule.
- I understand that this Authorization is in effect
for a period of the current scholastic sport season (fall, winter,
or spring as
designated by the school), or beyond in the event of the continued treatment
of
an injury from that designated sports season; however, no time frame specified
shall
go beyond one year from the date of signature.
- I understand that this
Authorization is also in effect if I am treated for an injury during
off-season workouts; however, no time
frame specified shall go beyond one year from the date of signature.
- I understand
that I have the right to revoke this Authorization form at any time
by sending a written request to UPMC where the Authorization
was provided.
- I understand that my decision to revoke the Authorization
does not apply to any release of my health record(s) that may have
taken
place prior to the date of my request to revoke the Authorization.
- I understand
that I am entitled to a copy of this completed Authorization form.
By
clicking the link below to the ImPACT test, you agree to the terms and
conditions listed above. If you disagree, you will be unable to take
the ImPACT baseline test. ImPACT
Baseline Concussion Testing for UPMC Affiliated Schools
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