Student-Athlete Health Information Disclosure Authorization - HIPAA Form

Please print out two (2) “HEALTH INFORMATION DISCLOSURE AUTHORIZATIONS FORMS” - HIPAA FORMS.

Have one (1) form signed by a person legally authorized to sign for a minor student, or signature of the student if his/her age is 18 or greater.

Also initial on the form that you have printed out and read Bellin Health’s "Notice of Privacy Practices."

Download the HIPAA form HERE.