Non-Funded Injured Athlete 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 regarding your injury, medical process, and wellbeing will be used to work directly with your insurance company and medical bills.

Non-Funding Injured Athlete / Patient Information

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

1. Injured Athlete / Patient Information
A. Patient Information
Patient Name*
First Middle Last
Phone*
Email*
Date of Birth
Last 4 of Social Security Number
Todays Date
MM slash DD slash YYYY
B. Authorization of Release of Protected Health Information
2. Authorization to Release and Disclose Injured Athlete /Patient Information The Road 2 Recovery Foundation
Are you the legal guardian of the Injured Athlete / Patient?
- Yes
- No
Relationship to Athlete:*
Patient or Legal Guardian Full Name
Signature of Parent/Guardian

By typing your name, you are certifying this is a legal signature.
Parent/Guardian Home Address:*
Street Address City State / Province / Region ZIP / Postal Code Country
Injured Athlete / Patient Home Address:*
Street Address City State / Province / Region ZIP / Postal Code Country
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

Save and Continue Later

Non-Funding Injured Athlete / Patient Information

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

1. Injured Athlete / Patient Information

A. Patient Information

B. Authorization of Release of Protected Health Information

2. Authorization to Release and Disclose Injured Athlete /Patient Information The Road 2 Recovery Foundation

C. Revocation

D. Not Restriction on Treatment

E. Further Disclosures

F. Road 2 Recovery Hold Back

3. Injured Athlete / Patient Insurance Information

Athlete Insurance Information

Emergency Contact Information

Hospital Information

Athlete Injury Information and Questionnaire

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