Dear Student-Athlete: We are pleased to have you as an athlete at Huntington University. We hope that you will have a successful and injury-free year. At the beginning of EACH YEAR you must complete an athletics packet that includes medical history, athletic physical completed by a physician, insurance information including a photo copy of your insurance card, concussion/cardiac arrest education, and a variety of other waivers that must be signed. All of the forms that must be completed and returned follow this letter on pages 3-19. For your convenience there is a checklist on pg 2 to ensure nothing has been missed. The ENTIRE athletic packet must be completed and processed before athletes will be allowed to participate in practices and/or games. ALL ATHLETES must complete the athletic packet by August 1, 2018. This deadline is in place to ensure that all forms are filled out completely and correctly. You WILL NOT be allowed to practice until all forms are completed correctly. It is certainly a privilege to work with you and we look forward to a good year. You can reach us by email with any questions. Sincerely, Chris J. Burton, MS, ATC, LAT Beth A. Herrell, MS, ATC, LAT, CSCS Athletic Trainer Athletic Trainer Huntington University Huntington University 2303 College Avenue 2303 College Avenue Huntington, IN 46750 Huntington, IN 46750 cburton@huntington.edu bherrell@huntington.edu Quinn Wiley, MPM, ATC, LAT Athletic Trainer Huntington University 2303 College Avenue Huntington, IN 46750 qwiley@huntington.edu

1

Huntington University Athletics Packet Checklist

1. _____Physical Exam Medical History (Pg 3-5)

Filled out and Signed by Athlete

2. _____Physical Exam Form (Pg 6)

Completed and Signed by Physician (MD, DO, PA, or NP only)

Physician must also check the box for “No Restrictions” at the bottom of

Pg 6.

3. _____Insurance Paperwork (Pg 7)

Must also include a Photo Copy of the Front and Back of Insurance card.

4. _____HU Consent for Voluntary Athletic Participation Form (Pg 8)

5. _____HU Assumption of Risk Form (Pg 9)

6. _____ Parkview Sports Medicine Consent to Treat/Release of Info. Form (Pg 10-12)

7. _____Concussion/Acute Cardiac Arrest Consent Form (Pg 13)

Please mail completed forms to: Huntington University Athletic Training

2303 College Ave

Huntington, IN 46750

Pg 14-16 Concussion and Cardiac Arrest Education Information (Does not need returned)

Pg 17-19 Parkview Notice of Privacy (Does not need returned)

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2018-2019 Huntington University Physical Examination for Athletic Participation

___________________________________________________________________

Medical History Questionnaire to be completed by the Student-Athlete Name: _____________________________________________________ Sport: ____________________________________ Last First MI Date of Birth: ____________________ Social Security #: ____________________ Student ID#:____________________________________ Student-Athlete's Address: _____________________________________________

City, ST Zip: _____________________________________________

Student-Athlete’s Home Phone: _________________________________________

Student Athlete’s Cell Phone: ___________________________________________

In case of Emergency Person to notify:

Name:___________________________________ Relationship:___________________

Home Phone:_____________________ Cell Phone:________________________ Work Phone:_____________________

Name:___________________________________ Relationship:___________________

Home Phone:_____________________ Cell Phone:________________________ Work Phone:_____________________

Personal Signs and Symptoms

   No  Yes  Date     No  Yes  Date     No  Yes  Date 

Abdominal Pain           Frequent Urination           Nose Bleeds          

Apnea           Hypertension           Numbness/tingling          

Blackouts           Increased Thirst           Painful Joints          

Chest Pain w/Exercise           Infrequent Periods           Painful Urination          

Chest Tightness           Kidney Trouble           Persistent Cough          

Chronic Cough           Loss of Balance           Ringing in Ears          

Digestive Problems           Loss of Consciousness           Shortness of Breath          

Dizziness           Loss of Memory           Significant Wt. Gain          

Easily Bruised           Loss of Sensation           Significant Wt. Loss          

Fainting Spells           Migraines           Skin Problems          

Fainting w/Exercise           Nausea/Vomiting           Sleep Walking          

Frequent Headaches           Nerve Damage          Wheeze/Cough after exercise          

Please Explain Yes Answers___________________________________________________________________________________

Freshman Physical

Sophomore Physical

Junior Physical

Senior Physical

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Name:_______________________________

Personal Disease/Illness History

   No  Yes  Date     No  Yes  Date     No  Yes  Date 

Anaphylaxis           Gas Reflux           Mononucleosis          

Anemia           Gout           Motion Sickness          

Appendicitis           Hay Fever           MRSA          

Arthritis           Head Injuries           Mumps          

Asthma            Hearing Loss           Neuro Disorder          

Attention Deficit Disorder           Heart Issues           Osteomyelitis          

Bladder Infection           Heart Murmur           Pacemaker          

Blood Disorder           Heat Illness           Pneumonia          

Cancer           Hepatitis           Pregnancy          

Cardiomyopathy           Hernia           Seizures          

Chicken pox           Impetigo           Sickle Cell          

Colitis           Influenza           Speech Impaired          

Concussions           Loss of a digit           Stroke          

Deafness           Lyme Disease           Thyroid Disease          

Dental Appliances           Malaria           Tuberculosis          

Diabetes           Marfan's Syndrome           Ulcer          

Epilepsy           Missing Organ                      

Please Explain Yes Answers___________________________________________________________________________________ ________________________________________________________________________________________________________________________

__________________________________________________________________________________________ Psychological History

   No  Yes  Date     No  Yes  Date     No  Yes  Date 

Anxiety Disorder           Depression           Insomnia          

Attempted Suicide           Drug Abuse           Substance Abuse          

Bipolar Disorder           Eating Disorder                      

Please Explain Yes Answers___________________________________________________________________________________ ___________________________________________________________________________________________________________ Surgery History

 Have you ever had surgery?  Date  Surgeon  Body Part  Type of Surgery 

             

              

              

              

If needed explain further_______________________________________________________________________________________

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Name:_______________________________ Orthopedic Injury History-General

   No  Yes  Right   Left  Date  Please Specify 

Skull Fracture                   

Hospitalized for Head Injury                   

Ruptured Disc (Neck or Back)                   

Whiplash                   

Pinched Nerve                   

Burner/Stinger                   

Osgood‐Schlatter's Disease                   

Chondromalacia                   

Bone Graft                   

Spinal Fusion                   

Stress Fracture                   

Do you wear any brace or protective equipment?                   

Do you have any pins, screws, or metal implants in your body?                   

Do you wear orthotics?                   

Orthopedic Injury History-Specific

   No  Yes  Right  Left  Date  Injury Type (Sprain, Strain, Fracture, Dislocation) 

Foot/Arch                   

Ankle                   

Shin/Low Leg                   

Knee                   

Thigh/Groin                   

Hip                   

Back                   

Shoulder                   

Elbow/Forearm                   

Wrist/Hand/Finger                   

Neck                   

General Medical Information

   Please Specify 

Are you Currently taking any Medication? List medication    

Do you have any Allergies?    

Are you currently being treated for any medical condition?    

All of this information is complete to the best of my knowledge. Student-Athlete’s Signature: X__________________________________ Date: ____________________

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Huntington University Physical Examination for Athletic Participation

Physical Examination to be completed by a Licensed Physician

Name:___________________________

Height: __________ in. Weight: __________ lbs. Blood Pressure: __________ mm HG Pulse: __________ BPM

Vision: Right: ________ Left: _______ Corrected: Contacts / Glasses Date of Birth:_______________________

ORTHOPEDIC SCREENING Normal Abnormal Specific Findings

Neck

Back

Shoulder

Elbow / Wrist / Hand

Hip / Thigh

Knee

Shin / Ankle / Foot

BODY SYSTEMS EVALUATION Normal Abnormal Specific Findings

Head

Ears, Nose & Throat

Eyes

Lung & Chest

Heart & Vascular

Abdominal

Neurological Upper Extremity

Lower Extremity

Genitalia / Hernia

Skin

Urinalysis / Laboratory findings: ____________________________________________________________________________ __________ NO RESTRICTION for collegiate athletic participation

__________ RESTRICTED PARTICIPATION to _________________________________________________________________

Physician Name: ________________________ Physician Signature: _____________________________ Date: ____________ Practice Name: ____________________________________________________ Address: _____________________________________________ Phone: ____________________________________ _____________________________________________

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Huntington University Athletic Department Insurance Information Form

PLEASE ATTACH A COPY OF FRONT AND BACK OF YOUR INSURANCE CARD A. Receipt of injury and Medical Policy I understand the University’s responsibility to an athlete injured as a result of participation in an intercollegiate sport at Huntington University. Athlete’s Name _________________________________________ Sport(s) _______________________________ Mailing Address _________________________________________ Cell Phone __________________________ Birth Date __________________________ Age _____________________ S.S.# ___________________________ B. Insurance Policy Holder Parent/Guardian _____________________________ S.S.#___________________ Phone (____)____________ Address ___________________________ City ____________________ State_________ Zip _______________ Employer____________________________________ Work Phone (____)_________________________________ Address ___________________________ City ____________________ State_________ Zip _______________ C. Parent/Guardian My son/daughter is covered under the following carrier. I authorize the claim procedures of Huntington University to be followed for any medical/dental expenses due to his/her participation in intercollegiate athletics at Huntington University for the current school year. Insurance Carrier _______________________________________________________________________________ Address ___________________________ City ____________________ State ________ Zip _______________ Group #__________________________ Policy # _______________ Phone (____)_________________________ D. Authorization I hereby authorize Huntington University to inspect or secure copies of case history records, laboratory reports, diagnostic x-ray and any other data covering this and/or previous confinements and/or disabilities. A photo static copy of this authorization shall be deemed as effective and valid as the original. This authorization shall be considered valid unless revoked in writing. I UNDERSTAND THAT I WILL NOT BE ALLOWED TO PARTICIPATE IN ANY PRACTICE OR CONTEST UNTIL THIS FORM AND THE PHYSICAL EXAM ARE COMPLETED AND RETURNED TO THE ATHLETIC DEPARTMENT. ________________________________________________ _________________________________ Student /Athlete Signature Date ________________________________________________ _________________________________ Parent/Guardian’s Signature Date (If under 18 years of age)

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Huntington University Consent for Voluntary Athletic Participation ASSUMPTION OF RISK AND RELEASE WAIVER

__________________________________________________________ I am aware that playing or practicing in any sport can be a dangerous activity involving MANY RISKS OF INJURY. I understand that the dangers and risks of playing or practicing in any sport include, but are not limited to, death, serious neck and spinal injuries which may result in complete or partial paralysis or brain damage, serious injury to virtually all bones, joints, ligaments, muscles, tendons, and other aspects of the musculoskeletal system, and serious injury or impairment to other aspects of my own body, general health or well-being.

Because of the dangers of participating in any sport, I recognize the importance of following the coach's instructions regarding playing techniques, training rules of the sport, other team rules, and to obey such instructions. All participants, voluntary or otherwise, have the responsibility to help reduce the chance of injury. Therefore, all volunteers, including but not limited to coaches, assistants, student-athletes, non-roster athletes, athlete recruits, other students, etc. who voluntarily participate in an athletic program or activity for Huntington University must obey all safety rules and regulations, report all physical problems to the coach and athletic trainer and follow a proper conditioning program, and inspect personal protective equipment daily. Proper execution of skill techniques must be followed for every sport, especially in contact sports.

As a volunteer, including but not limited to coaching, an assistant, student-athlete, non-roster athlete, athlete recruit, other student type, etc. who is voluntarily participating in athletic programs and activities in the Huntington University athletic program and by signing below, I voluntarily agree to assume and/or incur all risks of loss, impairment, damage or injury of whatever kind, including death, that may be sustained or suffered or associated by my participation in any athletic program or event whether or not the result is in whole or in part from acts or omissions, negligence or other unintentional fault of the events or activities of Huntington University.

In addition, I (including my heirs, assigns and personal representatives) agree to release, hold harmless, and indemnify Huntington University, the physicians, and other practitioners of the healing arts treating me from and against any and all liability, claims, demands of any kind and nature, actions, causes of action, lawsuits, expenses, or losses (including attorneys’ fees) of any kind and nature whatsoever arising by, or in connection with or on account of property damage or personal injury (including death) arising out of or attributable to the individual’s travel to/from or participation in any event(s)/activities in relation to Huntington University. I understand that Huntington University athletic insurance coverage is available to me if I am a rostered student athlete and representative of HU. Furthermore, I understand that Huntington University athletic insurance coverage is not responsible for pre-existing injuries/illness and injuries/illnesses not attributable to athletic participation.

This Assumption of Risk and Release Waiver applies to Huntington University and all of its trustees, officers, directors, managers, servants, agents, faculty, staff, students, volunteers, employees, advisors and/or representatives and remains in effect until such time as it is no longer valid.

I have read and fully understand the voluntary athletic participation information above and I acknowledge that I agree to the contents and provisions in this document.

____________________________________________________________

Participant’s Name: _______________________________ Date: _____________________ (Please print)

Participant’s Signature: _______________________________________________________ Participant’s Address:______________________________________________

Participant’s S.S. # (last 4 #’s):____xxx-xx-___________ Date of Birth: _____________________

Signature of parent or guardian (required if participant is under 18 years old and single):

____________________________________________

Emergency Contact information in the event of an emergency: 1._Name & relationship:______________________________Phone:_________________________

2._Name & relationship:______________________________Phone:_________________________

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ASSUMPTION OF RISK ACKNOWLEDGEMENT

I understand that as a student athlete, I am required to have primary medical insurance. I understand that

the athletic activities can be dangerous and involve risks of being injured or hurt. I understand that I am

assuming all of the risks if I get hurt while participating in a workout, practice, or athletic competition

while a student at Huntington University.

I know that these risks and dangers may be caused by my own actions or inactions, the actions or

inactions of others participating in the event(s), the condition and layout of the premises and equipment,

or the negligence of other, including those persons responsible for conducting the event(s).

I understand that I am responsible for the first $1,500 of cost of medical care that may be needed if I

become hurt or injured while participating in a workout, practice, or athletic competition. The first

$1,500 could be covered by my primary medical insurance coverage. If the first $1,500 is not covered, I

am responsible for this cost.

I HAVE READ THE ABOVE ASSUMPTION OF RISK ACKNOWLEDGEMENT, UNDERSTAND

WHAT I HAVE READ, AND SIGN IT VOLUNTARILY.

__________________________________________ ________________________

Signature of Student Athlete Date

__________________________________________ ________________________

Signature of Parent/Guardian (for minor) Date

__________________________________________ _________________________

Printed Name of Athlete Age of Athlete

__________________________________________ __________________________

Signature of Witness Date

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Pa r k v i e w S p o r t s M e d i c i n e

Consent to Treat

I hereby authorize medical treatment for said athlete at _____________ (School Name) by the athletic trainers, physicians, and staff of Parkview Ortho Performance Center d/b/a Parkview Sports Medicine. A family member can be reached at ________________________ in the event additional treatment or information is required. I understand that if the said athlete is seen by a physician or other provider at Parkview Sports Medicine and my insurance requires prior approval, I will be responsible for notifying the appropriate party in order to obtain approval.

Student Name Student Signature

Mailing Address City/State/Zip

Date Student Date of Birth

Parent/Guardian Name Parent/Guardian Signature

***************************************************************************************************************************** **********************

Acknowledgement of Receipt or Declination of Notice of Privacy Practices

I acknowledge that Parkview Ortho Performance Center d/b/a Parkview Sports Medicine (PSM) has offered me a copy of its Notice of Privacy Practices. The Notice describes how Parkview may use and disclose my protected health information, certain restrictions on the use and disclosure of my health information, and rights that I have regarding my health information. I understand that I should read it carefully. By signing this Acknowledgement, I acknowledge that I have received a copy of the Notice.

The Notice of Privacy Practices is also available at the front desk at all PSM offices and on the PSM web site at www.parkviewsportsmedicine.com. Parkview reserves the right to change the Notice at any time. I understand that I can obtain any revisions to the Notice by accessing the PSM web site, calling PSM and requesting a copy of the Notice be mailed to me or asking for one at the time of my next appointment.

Student Name Student Signature

Parent/Guardian Name Parent/Guardian Signature

Date

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Pa r k v i e w S p o r t s M e d i c i n e

Authorization for Release of Medical Information I hereby authorize Parkview Ortho Performance Center d/b/a Parkview Sports Medicine, its physicians and providers (“PSM”) to release any and all information regarding medical treatment provided to __________________________________ (Student Name) related to any injury, illness or that otherwise concerns my physical condition and ability to participate in athletics at _______________________________ (School Name). PSM may disclose the information to the School, its administration, coaching and athletic staff for the purpose of informing them of my playing status. I expressly authorize PSM to discuss my condition with these individuals. If I am over 18: I also authorize PSM to release my medical information to my parent(s)/guardian(s). I understand that I may revoke this authorization at any time by notifying PSM, in writing, of the revocation. The revocation will not affect any action already taken in reliance on this authorization. If not previously revoked, this authorization will terminate one (1) year from the earliest date set forth below. I understand that information disclosed to the School, its administration, coaching and athletic staff pursuant to this authorization may be re-disclosed and no longer protected by federal privacy laws. PSM will not be responsible for any such further use or disclosure of the information. I understand that PSM will not condition the provision of treatment, payment, enrollment in a health plan or eligibility for benefits on whether I sign this Authorization. A photocopy of this authorization shall be considered as valid as the original.

Student Name ________________________ Student Signature _________________________________ Student Address Date

Parent/Guardian Name Parent/Guardian Signature

Relationship to the Student Date

You Are Entitled To A Copy Of This Authorization

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Pa r k v i e w S p o r t s M e d i c i n e

Interview/Photographic Release

I hereby authorize Parkview Ortho Performance Center d/b/a Parkview Sports Medicine and its

employees to interview, photograph and videotape ____________________ (Name of Athlete) while

participating in athletic events, practices and other functions associated with athletics at the above

identified School. I understand that the Athlete’s likeness and name may be used and displayed by

Parkview Sports Medicine on its website and on social media, such as Twitter. I understand that if the

Athlete provides an interview, information provided in the interview may also be included on the Parkview

Sports Medicine website or on social media. I hereby release Parkview Sports Medicine, its employees

and affiliates from any and all liability, claims, demands and causes of action connected with the use

and publication of the Athlete’s likeness and other identifying information on the Parkview Sports

Medicine website and social media.

Parent/Guardian Signature _____________________________ Date ___________________ Student Signature _____________________________________ Date ___________________

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January 2015

CONCUSSION and SUDDEN CARDIAC ARREST ACKNOWLEDGEMENT AND SIGNATURE FORM

FOR PARENTS AND STUDENT ATHLETES

Student Athlete’s Name (Please Print): _____________________________________________________

Sport Participating In (If Known): _______________________________ Date: ____________________

IC 20-34-7 and IC 20-34-8 require schools to distribute information sheets to inform and educate student athletes and their parents on the nature and risk of concussion, head injury and sudden cardiac arrest to student athletes, including the risks of continuing to play after concussion or head injury. These laws require that each year, before beginning practice for an interscholastic or intramural sport, a student athlete and the student athlete’s parents must be given an information sheet, and both must sign and return a form acknowledging receipt of the information to the student athlete’s coach.

IC 20-34-7 states that a high school athlete who is suspected of sustaining a concussion or head injury in a practice or game, shall be removed from play at the time of injury and may not return to play until the student athlete has received a written clearance from a licensed health care provider trained in the evaluation and management of concussions and head injuries.

IC 20-34-8 states that a student athlete who is suspected of experiencing symptoms of sudden cardiac arrest shall be removed from play and may not return to play until the coach has received verbal permission from a parent or legal guardian of the student athlete to return to play. Within twenty-four hours, this verbal permission must be replaced by a written statement from the parent or guardian.

Parent/Guardian - please read the attached fact sheets regarding concussion and sudden cardiac arrest and ensure that your student athlete has also received and read these fact sheets. After reading these fact sheets, please ensure that you and your student athlete sign this form, and have your student athlete return this form to his/her coach.

As a student athlete, I have received and read both of the fact sheets regarding concussion and sudden cardiac arrest. I understand the nature and risk of concussion and head injury to student athletes, including the risks of continuing to play after concussion or head injury, and the symptoms of sudden cardiac arrest.

____________________________________________________________ ___________________ (Signature of Student Athlete) (Date)

I, as the parent or legal guardian of the above named student, have received and read both of the fact sheets regarding concussion and sudden cardiac arrest. I understand the nature and risk of concussion and head injury to student athletes, including the risks of continuing to play after concussion or head injury, and the symptoms of sudden cardiac arrest.

_____________________________________________________________ ___________________ (Signature of Parent or Guardian if under 18) (Date)

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SUDDEN CARDIAC ARRESTA Fact Sheet for Student Athletes

FACTS Sudden cardiac arrest can occur even in athletes who are in peak shape. Approximately 500 deaths are attributed to sudden cardiac arrest in athletes each year in the United States. Sudden cardiac arrest can affect all levels of athletes, in all sports, and in all age levels. The majority of cardiac arrests are due to congenital (inherited) heart defects. However, sudden cardiac arrest can also occur after a person experiences an illness which has caused an inflammation to the heart or after a direct blow to the chest. Once a cardiac arrest occurs, there is very little time to save the athlete, so identifying those at risk before the arrest occurs is a key factor in prevention.

WARNING SIGNS There may not be any noticeable symptoms before a person experiences loss of consciousness and a full cardiac arrest (no pulse and no breathing).

Warning signs can include a complaint of:

Chest Discomfort

Unusual Shortness of Breath

Racing or Irregular Heartbeat

Fainting or Passing Out

EMERGENCY SIGNS – Call EMS (911) If a person experiences any of the following signs, call EMS (911) immediately:

If an athlete collapses suddenly duringcompetition

If a blow to the chest from a ball, puckor another player precedes an athlete’scomplaints of any of the warning signsof sudden cardiac arrest

If an athlete does not look or feel rightand you are just not sure

How can I help prevent a sudden cardiac arrest? Daily physical activity, proper nutrition, and adequate sleep are all important aspects of life-long health. Additionally, you can assist by:

Knowing if you have a family history ofsudden cardiac arrest (onset of heartdisease in a family member before theage of 50 or a sudden, unexplaineddeath at an early age)

Telling your health care provider duringyour pre-season physical about anyunusual symptoms of chest discomfort,shortness of breath, racing or irregularheartbeat, or feeling faint, especially ifyou feel these symptoms with physicalactivity

Taking only prescription drugs that areprescribed to you by your health careprovider

Being aware that the inappropriate useof prescription medications or energydrinks can increase your risk

Being honest and reporting symptomsof chest discomfort, unusual shortnessof breath, racing or irregular heartbeat,or feeling faint

What should I do if I think I am developing warning signs that may lead to sudden cardiac arrest?

1. Tell an adult – your parent or guardian,your coach, your athletic trainer or your school nurse

2. Get checked out by your health careprovider

3. Take care of your heart4. Remember that the most dangerous thing

you can do is to do nothing

Developed and Reviewed by the Indiana Department of Education’s Sudden Cardiac Arrest Advisory Board

(1-7-15)

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CONCUSSION FACT SHEET FOR ATHLETES

CONCUSSION FACTS

• A concussion is a brain injury that affects how yourbrain works.

• A concussion is caused by a bump, blow, or jolt to thehead or body.

• A concussion can happen even if you haven’t beenknocked out.

• If you think you have a concussion, you should notreturn to play on the day of the injury and until ahealth care professional says you are OK to return toplay.

CONCUSSION SIGNS AND SYMPTOMS

Concussion symptoms differ with each person and with each injury, and may not be noticeable for hours or days. Common symptoms include:

• Headache• Confusion• Difficulty remembering or paying attention• Balance protblems or dizziness• Feeling sluggish, hazy, foggy, or groggy• Feeling irritable, more emotional, or “down”• Nausea or vomiting• Bothered by light or noise• Double or blurry vision• Slowed reaction time• Sleep problems• Loss of consciousness

During recovery, exercising or activities that involve a lot of concentration (such as studying, working on the computer, or playing video games) may cause concussion symptoms to reappear or get worse.

WHY SHOULD I REPORT MY SYMPTOMS?

• Unlike with some other injuries, playing or practicingwith concussion symptoms is dangerous and can lead toa longer recovery and a delay in your return to play.

• While your brain is still healing, you are much morelikely to have another concussion.

• A repeat concussion in a young athlete can result inpermanent damage to your brain. They can even befatal.

15

WHAT SHOULD I DO IF I THINK I HAVE A CONCUSSION?

DON’T HIDE IT. REPORT IT. Ignoring your symptoms and trying to “tough it out” often makes symptoms worse. Tell your coach, parent, and athletic trainer if you think you or one of your teammates may have a concussion. Don’t let anyone pressure you into continuing to practice or play with a concussion.

GET CHECKED OUT. Only a health care professional can tell if you have a concussion and when it’s OK to return to play. Sports have injury timeouts and player substitutions so that you can get checked out and the team can perform at its best. The sooner you get checked out, the sooner you may be able to safely return to play.

TAKE CARE OF YOUR BRAIN. A concussion can affect your ability to do schoolwork and other activities. Most athletes with a concussion get better and return to sports, but it is important to rest and give your brain time to heal. A repeat concussion that occurs while your brain is still healing can cause long-term problems that may change your life forever.

“IT’S BETTER TO MISS ONE GAME, THAN THE WHOLE SEASON.”

JOIN THE CONVERSATION AT www.facebook.com/CDCHeadsUp

TO LEARN MORE GO TO >> WWW.CDC.GOV/CONCUSSION

Content Source: CDC’s Heads Up Program. Created through a grant to the CDC Foundation from the National Operating Committee on Standards for Athletic Equipment (NOCSAE).

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Parkview Ortho Hospital, Parkview SurgeryONE and Parkview Sports MedicineParkview Ortho Hospital, Parkview SurgeryONE and Parkview Sports MedicineNotice of Privacy PracticesNotice of Privacy PracticesEffective October 1, 2007, and revised Effective April 10, 2017

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

When this Notice refers to “we” or “us,” it is referring to Orthopedic Hospital at Parkview North, LLC, Parkview Ortho Center, LLC, and Parkview Ortho Performance Center, LLC. It is also referring to contracted providers of anesthesiology, emergency medicine, hospitalists, pathology, radiology, and other direct and indirect services.

This Notice describes how we will use and disclose your health information. The policies outlined in this Notice apply to all of your health information generated by us, whether recorded in your medical record, invoices, payment forms, videotapes or other ways. These policies also apply to the health information gathered from other organizations by any health care professional, employee or volunteer who participates in your care.

Uses and Disclosures of Your Health InformationUses and Disclosures of Your Health Information1. In some circumstances we are permitted or required to use or disclose your health information without obtaining your

prior authorization and without offering you the opportunity to object. These circumstances include:

a. Uses or disclosures relating to treatment, payment and health care operations: (1) Treatment. We may use and/or disclose your health information to provide, or to allow others to provide, treatment

to you. An example would be if your primary care physician discloses your health information to another doctor for a consultation. Also, we may contact you with appointment reminders or information about treatment options or other health-related benefits and services that may be of interest to you.

(2) Payment. We may use and/or disclose your health information for the purpose of allowing us, as well as other organizations, to secure payment for the health care services provided to you. For example, we may inform your health insurance company of your diagnosis and treatment in order to assist the insurer in processing our claim for the health care services provided to you.

(3) Health Care Operations. We may use and/or disclose your information for the purposes of our day-to-day operations and functions. We may also disclose your information to another covered entity (health care provider, health plan or health care clearinghouse) to allow it to perform its day-to-day functions, but only to the extent that we both have a relationship with you. For example, we may compile your health information, along with that of other patients, in order to allow a team of our health care professionals to review that information and make suggestions concerning how to improve the quality of care provided at this facility.

We participate in a community health record and in information exchanges enabling access to your health information by your other health care providers.

We may also participate in organized health care arrangements with other providers and facilities. If we do, we may use, or disclose to other covered entities also participating in the organized health care arrangements, your health information for any health care operations activities of the organized health care arrangements.

b. To create materials that originally had any identifying information concerning you deleted from the final materials;

c. When required by law;

d. For public health purposes;

e. To disclose information about victims of abuse, neglect, or domestic violence as required by law;

f. For health oversight activities, such as audits or civil, administrative or criminal investigations;

g. For judicial or administrative proceedings;

h. For law enforcement purposes;

i. To assist coroners, medical examiners or funeral directors with their official duties;

j. To facilitate organ, eye or tissue donation;

k. For certain research projects that have been evaluated and approved through a research approval process that takes into account patients’ need for privacy;

l. To avert a serious threat to health or safety; 17

m. For specialized governmental functions, such as military, national security, criminal corrections, or public benefit purposes; and

n. For workers’ compensation purposes, as permitted by law.

2. We may also use or disclose your health information in the following circumstances. However, except in emergency situations, we will inform you of our intended action prior to making any such disclosures and will, at that time, offer you the opportunity to object.

a. Directories. We may maintain a directory of patients that includes your name and location within the facility, your religious designation, and information about your condition in general terms that will not communicate specific medical information about you. Except for your religion, we may disclose this information to any person who asks for you by name. We may disclose all directory information to members of the clergy.

b. Notifications. We may disclose to your relatives or close personal friends any health information that is directly related to that person’s involvement in the provision of, or payment for, your care. We may also use and disclose your health information for the purpose of locating and notifying your relatives or close personal friends of your location, general condition or death, and to organizations that are involved in those tasks during disaster situations.

3. The following uses and disclosures of your health information require your written authorization:

a. Uses and disclosures for marketing purposes that involve remuneration to us from a third party; and

b. Disclosures that would constitute a sale of your health information.

4. We may use your health information to contact you as part of our efforts to raise funds. You have the right to opt out of receiving such fundraising communications. All fundraising communications will include information about how you may opt out of future fundraising communications.

Except as described in this Notice, uses and disclosures of your health information will be made only with your written authorization. You may revoke your authorization at any time, in writing, unless we have taken action based on your prior authorization, or if you signed the authorization as a condition of obtaining insurance coverage.

Your RightsYour Rights1. To Request Restrictions. You have the right to request restrictions on the use and disclosure of your health information

for treatment, payment or health care operations purposes or notification purposes. We are not required to agree to your request unless your request is to restrict disclosure to a health plan that we would make for payment or healthcare operations purposes, and it is not required by law, and the information pertains to an item or services paid for in full by you or someone on your behalf other than the health plan. If we do agree to a restriction, we will abide by that restriction unless you are in need of emergency treatment and the restricted information is needed to provide that emergency treatment. To request a restriction, submit a written request to the Contact listed on the final page of this Notice.

2. To Limit Communications. You have the right to receive confidential communications about your own health information by alternative means or at alternative locations. This means that you may, for example, designate that we contact you only via e-mail, or at work rather than home. To request communications via alternative means or at alternative locations, you must submit a written request to the Contact listed on the final page of this Notice. All reasonable requests will be granted.

3. To Access and Copy Health Information. You have the right to inspect and copy any health information about you other than information compiled in anticipation of or for use in civil, criminal or administrative proceedings, or certain information that is governed by the Clinical Laboratory Improvement Act. To arrange for access to your records, or to receive a copy of your records, you should submit a written request to the Contact listed on the last page of this Notice. If you request copies, you will be charged our regular fee for copying and mailing the requested information.

Despite your general right to access your Protected Health Information, access may be denied in some limited circumstances. For example, access may be denied if you are an inmate at a correctional institution or if you are a participant in a research program that is still in progress. Access may be denied if the federal Privacy Act applies. Access to information that was obtained from someone other than a health care provider under a promise of confidentiality can be denied if allowing you access would reasonably be likely to reveal the source of the information. The decision to deny access under these circumstances is final and not subject to review.

In addition, access may be denied if (i) access to the information in question is reasonably likely to endanger the life and physical safety of you or anyone else, (ii) the information makes reference to another person and your access would reasonably be likely to cause harm to that person, or (iii) you are the personal representative of another individual and 18

a licensed health care professional determines that your access to the information would cause substantial harm to the patient or another individual. If access is denied for these reasons, you have the right to have the decision reviewed by a health care professional who did not participate in the original decision. If access is ultimately denied, the reasons for that denial will be provided to you in writing.

4. To Request Amendment. You may request that your health information be amended. Your request may be denied if the information in question:(i) was not created by us (unless you show that the original source of the information is no longer available to seek amendment from), (ii) is not part of our records, (iii) is not the type of information that would be available to you for inspection or copying, or (iv) is accurate and complete. If your request to amend your health information is denied, you may submit a written statement disagreeing with the denial, which we will keep on file and distribute with all future disclosures of the information to which it relates. Requests to amend health information must be submitted in writing to the Contact listed on the final page of this Notice.

5. To an Accounting of Disclosures. You have the right to an accounting of any disclosures of your health information made during the six-year period prior to the date of your request. The accounting will include the date of each disclosure, the name of the entity or person who received the information and that person’s address (if known), and a brief description of the information disclosed and the purpose of the disclosure. However, the following disclosures will not be accounted for: (i) disclosures made for the purpose of carrying out treatment, payment or health care operations, (ii) disclosures made to you, (iii) disclosures of information maintained in our patient directory, or disclosures made to persons involved in your care, or for the purpose of notifying your family or friends about your whereabouts, (iv) disclosures for national security or intelligence purposes, (v) disclosures to correctional institutions or law enforcement officials who had you in custody at the time of disclosure, (vi) disclosures that occurred prior to April 14, 2003, (vii) disclosures made pursuant to an authorization signed by you, (viii) disclosures that are part of a limited data set, (ix) disclosures that are incidental to another permissible use or disclosure, or (x) disclosures made to a health oversight agency or law enforcement official, but only if the agency or official asks us not to account to you for such disclosures and only for the limited period of time covered by that request. To request an accounting of disclosures, submit a written request to the Contact listed on the final page of this Notice.

6. To a Paper Copy of this Notice. You have the right to obtain a paper copy of this Notice upon request.

Our DutiesOur Duties1. We are required by law to maintain the privacy of your health information and to provide you with this Notice of our legal

duties and privacy practices.

2. We are required to abide by the terms of this Notice. We reserve the right to change the terms of this Notice and to make those changes applicable to all health information that we maintain. Any changes to this Notice will be posted on our website (if applicable) and at our facility, and will be available from us upon request.

3. We are required by law to notify you if there is a breach of any of your health information which was unsecured.

ComplaintsComplaintsYou can complain to us and to the federal Secretary of the Department of Health and Human Services if you believe your privacy rights have been violated. To lodge a complaint with us, please file a written complaint with the Contact listed below. This Contact person will also provide you with more information about our privacy policies upon request. No action will be taken against you for filing a complaint.

Designated ContactDesignated ContactPrivacy Officer • Corporate Counsel Department • Parkview Health10501 Corporate Drive • PO Box 5600 • Fort Wayne, IN 46895260-373-7021 or toll free 855-773-0012

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