Athlete/Industry Professional Memorial Fund Intake Form

Please complete this form to the best of your ability, the more detailed you can be the better. All personal information provided is private protected information and will not be shared with any outside source. The provided information will be used to work directly with insurance company, medical bills, and to create the Memorial Fund.

Athlete / Industry Professional Memorial Fund Intake Form

Step 1 of 2 - Authorization to Release and Disclose Patient Information The Road 2 Recovery Foundation

1. Athlete / Industry Personnel Memorial Fund Information
A. Patient Information
Legal Name of Athlete / Industry Personnel Memorial Fund is Under*
First Middle Last
Date of Birth
Last 4 of Social Security Number

Only if funds will be used to pay for medical bills or any bills under Athlete/Industry personnel's name.
Home Address:*
Street Address City State / Province / Region ZIP / Postal Code Country
Todays Date
MM slash DD slash YYYY
B. Authorization of Release of Protected Health Information
2. Authorization to Release and Disclose Deceased Athlete/Industry Personnel Information The Road 2 Recovery Foundation
Are you the legal guardian?
- Yes
- No
Relationship to Deceased*
Full Name of Responsible Decision Maker
Email*
Phone*
Home Address:*
Street Address City State / Province / Region ZIP / Postal Code Country
Signature of Parent/Guardian

By typing your name, you are certifying this is a legal signature. That you the information provided is accurate and that you have legal approval to start a memorial fund for the deceased.
List full names and best form of contact for top three approved decision makers for fund allocation.*
I hereby authorize The Road 2 Recovery Foundation full access; use and disclose my complete health record, including records relating to any mental healthcare, communicable diseases (e.g. HIV or AIDS) and treatment of alcohol or drug abuse, health information in compliance with state and federal law. This authorization shall be in force and effect for one year, unless I specify a different expiration here, in which case this authorization expires upon the occurrence of that event or date.*
- Check this box to authorize
Full Access Expiration Date:
Signature*

By typing your name you are certifying this is a legal signature.
Today's Date*
Month
Day
Year
C. Revocation
I understand that I have the right to revoke this authorization in writing at any time. I understand that a revocation shall not be effective to the extent that any person or entity has already acted in reliance on my authorization.*
- Check this box to authorize
D. Not Restriction on Treatment
I understand that my ability to obtain treatment will not be conditioned on whether I sign this authorization.*
- Check this box to authorize
E. Further Disclosures
I understand and acknowledge that Road 2 Recovery Foundation may re-disclose my protected health information described above in accordance with state and federal law and that Road 2 Recovery Foundation cannot prevent re-disclosure of my protected health information described above by the person or organization who may receive my protected health information from Road 2 Recovery Foundation. By signing this authorization, I release Road 2 Recovery Foundation from any and all liability resulting from a re-disclosure by the recipient. I understand and acknowledge that my signature indicates that I have read and understand this form, and authorize release of my protected health information as described above.*
- Check this box to authorize
F. Road 2 Recovery Hold Back

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Athlete/Industry Professional Memorial Fund Intake Form

Athlete / Industry Professional Memorial Fund Intake Form

Step 1 of 2 - Authorization to Release and Disclose Patient Information The Road 2 Recovery Foundation

1. Athlete / Industry Personnel Memorial Fund Information

A. Patient Information

B. Authorization of Release of Protected Health Information

2. Authorization to Release and Disclose Deceased Athlete/Industry Personnel Information The Road 2 Recovery Foundation

C. Revocation

D. Not Restriction on Treatment

E. Further Disclosures

F. Road 2 Recovery Hold Back

3. Athlete / Industry Personnel Insurance Information

Athlete Insurance Information

Hospital Information

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