AUTHORIZATION FOR USE AND DISCLOSURE OF HEALTH INFORMATION

By completing this Authorization for Use and Disclosure of Health Information (“Authorization”), you authorize the use and disclosure of the health information about yourself that you self-report through this website to KO Bros, LLC, federal and state public health agencies and, unless you opt-out, with coaches staffing our Registration Services and the Members of our NCAA Subscription Services - in each case consistent with Federal and California state law concerning the privacy of such information.  Failure to provide all information requested may invalidate this Authorization and make you unable to use this website to report your health information.

USE OF HEALTH INFORMATION

By accepting this Authorization, you are agreeing that KO Bros, LLC (“KO”) may use the health information about yourself that you self-report through this website (“Injury Report/ History” to prepare such information for submission to federal and state public health agencies, to aggregate Your Health Information with other health information, to operate this website and, unless you opt-out, with the coaches on our staff.  

DISCLOSURE OF HEALTH INFORMATION

By accepting this Authorization, you further authorize KO to disclose Your Health Information to federal and state public health agencies and authorize those agencies to use Your Health Information for all public health purposes, including but not limited to all efforts to improve and further the sport of football at all levels.  You further authorize KO to disclose Your Health Information to those KO employees, contractors, and subcontractors who require it to assist KO in operating the website, collecting Your Health Information and aggregating it with other health information. Finally, unless you opt-out, you further authorize KO to disclose Your Health Information to coaches, trainers, and other support staff and authorize those them to use Your Health Information to contact you regarding any your recruiting journey.

EXPIRATION

This Authorization expires January 1, 2050.

YOUR RIGHTS

You may refuse to sign this Authorization and neither health care treatment, payment, enrollment or eligibility for benefits will be conditioned on your providing or refusing to provide this Authorization.  

You may revoke this Authorization at any time.  Your revocation must be in writing, signed by you or on your behalf, and delivered to KO at the following address: 16155 Sierra Lake Pkwy #160, Fontana, CA 92336.  Your revocation will be effective upon receipt, but will not be effective to the extent that KO or others have acted in reliance upon this Authorization.

You have a right to receive a copy of this Authorization.  You may inspect or obtain a copy of the health information received, used, or disclosed subject to this Authorization.

ACCEPTANCE

Date  __________________________                      Time  __________________ AM/PM

Signature:                                                                    Name: __________________________

If you have authorized the disclosure of your health information to someone who is not legally required to keep it confidential, it may be redisclosed and may no longer be protected.