HIPAA Content Form

Student's FULL Name(*)
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Phone Number(*)
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Email Address(*)
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Student's Social Security Number(*)
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Date of Birth(*)
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Other than the above mentioned release, your personal healthcare information will NOT be released to others, including your parent(s), unless listed below.
Indicated by entering below, I give permission to provide information to the following:
Parent/Legal Guardian FULL NAME(*)
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Parent/Legal Guardian Phone Number(*)
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(FOR ATHLETES ONLY) By checking this box, I give permission to release my healthcare information to our SAU Athletic Training Staff and/or Program Director
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Others: FULL NAME
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Others Phone Number
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Today's Date
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Electronic Signature, Please Initial to Verify
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Secure your Submission(*)
Secure your Submission
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