Consent To Treat

This form outlines the medical responsibilities, authorizations, and privacy considerations required for participation in Vincennes University Athletics.
Good Samaritan Hospital Sports Performance is the chosen medical contractual and athletic training provider of Vincennes University Athletics. Completion of this form is a condition of participation in athletic practices and events sponsored by Vincennes University.
Title
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Consent To Treat/Disclosure of Protected Health Information
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Student Athlete Information

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Acknowledgments & Consent

Please read carefully & understand before you complete the acknowledgment
Please read carefully & understand before you complete the acknowledgment
Please read carefully & understand before you complete the acknowledgment (required)
Please read carefully & understand before you complete the acknowledgment
Please read carefully & understand before you complete the acknowledgment
Please read carefully & understand before you complete the acknowledgment (required)
Please read carefully & understand before you complete the acknowledgment
Please read carefully & understand before you complete the acknowledgment
Please read carefully & understand before you complete the acknowledgment (required)
Please read carefully & understand before you complete the acknowledgment
Please read carefully & understand before you complete the acknowledgment
Please read carefully & understand before you complete the acknowledgment (required)
Please read carefully & understand before you complete the acknowledgment
Please read carefully & understand before you complete the acknowledgment
Please read carefully & understand before you complete the acknowledgment (required)
Please read carefully & understand before you complete the acknowledgment
Please read carefully & understand before you complete the acknowledgment
Please read carefully & understand before you complete the acknowledgment (required)
Please read carefully & understand before you complete the acknowledgment
Please read carefully & understand before you complete the acknowledgment
Please read carefully & understand before you complete the acknowledgment (required)
Please read carefully & understand before you complete the acknowledgment
Please read carefully & understand before you complete the acknowledgment
Please read carefully & understand before you complete the acknowledgment (required)
Please read carefully & understand before you complete the acknowledgment
Please read carefully & understand before you complete the acknowledgment
Please read carefully & understand before you complete the acknowledgment (required)
Please read carefully & understand before you complete the acknowledgment
Please read carefully & understand before you complete the acknowledgment
Please read carefully & understand before you complete the acknowledgment (required)
Please read carefully & understand before you complete the acknowledgment
Please read carefully & understand before you complete the acknowledgment
Please read carefully & understand before you complete the acknowledgment (required)
Please read carefully & understand before you complete the acknowledgment
Please read carefully & understand before you complete the acknowledgment
Please read carefully & understand before you complete the acknowledgment (required)
Responsibility to Report Health
I acknowledge that I must be an active participant in my own healthcare. As such, I have the direct responsibility for reporting all injuries and illnesses to the sports medicine staff at Vincennes University (e.g. team physician, athletic trainer, and athletic health care provider).
Accuracy of Medical History
I understand that my true physical condition is dependent upon an accurate medical history and a full disclosure of any symptoms, complaints, prior injuries, and/or disabilities experienced. I hereby affirm that I have fully disclosed in writing (e.g. physical forms, etc.) any prior medical conditions and will disclose any future conditions to the sports medicine staff at Vincennes University.
Pre-Participation Medical Exam
I agree that, after July 1st and prior to the first practice for participation in intercollegiate athletics, I shall undergo a thorough medical examination and be approved for intercollegiate athletic competition by the sports medicine staff of Vincennes University. Superseding all other governing body rules and regulations, the physical examination shall be valid for thirteen (13) consecutive months to the date unless otherwise limited by the physician indicating the physical is only good for less than thirteen (13) consecutive months.
Consent for Medical Treatment
I hereby authorize Vincennes University, the Certified Athletic Trainers, physicians, sports medicine staff and other medical personnel representing Good Samaritan Hospital Sports Performance to provide medical treatment and similar relevant services for myself during the normal course of university-sponsored athletic activities.
Health Information Protection (HIPAA/FERPA)
I understand that my 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.
Medical Information Release to Staff & Media
I hereby authorize Vincennes University, the Certified Athletic Trainers, physicians, sports medicine staff and other medical personnel representing Good Samaritan Hospital Sports Performance to release information, via all forms of communication, concerning my medical status, medical condition, injuries, prognosis, diagnosis, and related personally identifiable health information to the Director of Athletics, Head Coach(es) of my sport, Assistant Coach(es) of my sport, other athletics staff, physicians, emergency medical technicians, and my parents/guardians, where applicable, to facilitate decisions about my participation in athletic activity or the need for further medical treatment. This information includes, but is not limited to, injuries or illnesses relative to past, present or future participation in athletics at Vincennes University. In certain circumstances, this disclosure is also to advise print, radio, television and other media of the nature and treatment concerning my medical condition so that they may report on it while I am a student athlete. I understand that the entities that receive the information may not be health care providers, and that the information described above may be re-disclosed publicly and, at that point, the information will no longer be protected by these regulations. 
No Compensation for Medical Information Use
I understand that Vincennes University will not receive any compensation for its use of stated medical information. I may inspect or copy any information used under this authorization. 
Right to Revoke Authorization
I understand I may revoke this authorization at any time by notifying the Director of Athletics in writing, except to the extent that action has been taken in reliance upon it.  If not previously revoked, this authorization will expire on July 31, 2026.  
Secure Data Transmission & Storage
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 applicable governing body, that all such data will be stored securely within industry standards. I further understand that neither the applicable governing body nor its agents or contractors will identify me personally in any publication or disclosure of research results. 
Authorization for Insurance & Records Access
I hereby authorize Vincennes University and the athletic department’s insurance agent to inspect or secure copies of case history records, laboratory reports, diagnosis, x-rays, and any other data covering this and/or previous confinements and/or disabilities. A photocopy of this form shall be deemed as effective and valid as the original. I authorize that the University or its insurance agent pay the medical vendors direct for any bills incurred from the accidents that are covered under the policy purchased by the University.
Consent for Anonymous Data Use (Balance Testing)
Good Samaritan Hospital Sports Performance requests to use, in anonymous group format, collected information from tests, normally performed in the pre-participation physical exam, to develop typical values for balance to compare athletic performance within a sport.  I understand that my decision is voluntary and that my institution will not condition or withhold any sport participation, physical exam, or medical treatment based on my decision.

Emergency Contact

Attestation
I certify, under penalty of perjury of the laws of the State of Indiana, that I have read the contents and warning of this acknowledgement; that I fully understand this acknowledgment; that I am in agreement with the terms of this acknowledgment; that I am signing this acknowledgement voluntarily, under no compulsion; that I have had an opportunity to ask questions and seek advice regarding this acknowledgement; that I am age 18 or over or, if not, that my parents/guardians hereby make these promises on my behalf; and that I choose to participate (or to permit my child or ward to participate) in the Vincennes University activity listed below of my own accord.
Acknowledgment & Consent
Clicking Submit signifies that you have thoroughly read and fully understand all the information presented in this form. This consent, waiver, indemnity and release is binding on me, my heirs, executors, administrators and assigns.This action is the equivalent of providing your handwritten signature and the current date.

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