Authorization of Release of Medical Information Clause Samples

Authorization of Release of Medical Information. I authorize New York Institute of Technology and any of its health or physical care providers or practitioners to release to coaches, athletic trainers, or other individuals employed by or associated or assisting with New York Institute of Technology athletic programs or student-­‐ athletes, any and all records, documents, or information they may have regarding my medical, physical or psychological condition, for the purpose of informing such individual(s) regarding such condition(s), such as records, documents or information may become available or be developed over the course of the year including and following the date of this Release Authorization, except for records, documents or information created or maintained in connection with an alcohol or drug abuse treatment or prevention program. I further authorize the release of records, documents or information regarding my medical, physical, or psychological condition to other entities or individuals, including but not limited to the New York Institute of Technology Sports Information department, media outlets and personnel, and professional team personnel for the purpose of informing such entities or individuals of such conditions. The Release Authorization should not be construed, however, to require such release. This Release Authorization is effective for the year including and following the date of execution, and I may revoke it by means of a written statement to that effect, except to the extent that action has been taken based upon this Release Authorization.