department of athletics policies & procedures - UNC Wilmington ...

FERPA Form for release of Student-Athlete
PHI among UNCW covered health care components
University of North Carolina Wilmington
Department of Athletic Training
Authorization for Release of Health Information
Student-Athlete Name
(First) (MI) (Last)
Sport(s) Men’s/Women’s
Date of Birth / / Age UNCW ID#
I hereby grant consent to the University of North Carolina Wilmington Student Health
Center, the University of North Carolina Wilmington Counseling Center, and the University
of North Carolina Wilmington Department of Athletic Training to disclose to each other and
their respective professional staff members all of my protected health information (except
psychotherapy information) for coordination of my health care at the University of North
Carolina Wilmington, and I authorize each unit and their professional staff members to use
such information for the purpose of such coordination in order to provide me with the best
possible health care while I am a student at the University of North Carolina Wilmington.
This information also may be used and further disclosed by each unit for purposes of my
treatment, to obtain payment for services rendered to me in connection with each unit’s
health care program and for each unit’s health care operations activities.
This consent expires for each of the identified units when I cease to be a student at the
University of North Carolina Wilmington. This consent expires for the sharing of
information with or by the University of North Carolina Wilmington Department of Athletic
Training when I cease to be a student-athlete at the University of North Carolina
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