Gender Eligibility Verification

Thank you.

Your information has successfully been submitted. The contents of your application and accompanying documentation will be stored securely, de-identified, and reviewed by a licensed medical professional with the PDGA Medical Committee. If there are any questions, that licensed medical professional will contact the applicant's healthcare provider(s) using information provided by the applicant. That licensed medical professional will provide a recommendation to the PDGA Director of Policy and Compliance concerning the application, and the Director will report the decision to the applicant and make any required changes to the PDGA database. Once those changes have been made, the contents of your application and accompanying documentation will be deleted.

Here is a copy of the authorization notice for your records.

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

The Professional Disc Golf Association (“PDGA”) is dedicated to maintaining the privacy of your Protected Health Information (“PHI”), as may be required by applicable federal or state laws. PHI is information that identifies you and that relates to your physical or mental health condition. Accordingly, the PDGA wants to inform you of how the PDGA will use your PHI and to whom it may disclose your PHI.

The information you are providing pursuant to this notice will solely be used for determination of your eligibility to participate in any restricted gender-based divisions of competition in PDGA sanctioned events. By your signature below you consent to the following uses and handling of your PHI:

1. I consent to share the PHI I am submitting with this form and the personal identifiable information (PII) requested by this form. I understand that this PHI may include psychotherapy notes, and I explicitly authorize the release and uses of such information as part of my PHI.
2. I understand that my PHI will be de-identified, secured, and sent to a physician for the sole purpose of evaluating my eligibility for gender-based divisions (“Evaluating Physician”), and that my PHI will not be retained by the physician or the PDGA after that evaluation has been completed.
3. I authorize the Evaluating Physician to contact my healthcare provider(s) if, in evaluating my eligibility, information is needed beyond what I have provided here. In that event, the PDGA’s Director of Policy and Compliance will transmit the necessary PII to the physician in a manner separate from my PHI and for the sole purpose of communicating with my healthcare provider. That PII will not be retained by the Evaluating Physician after communication with my healthcare provider has been completed.
4. I authorize any of my healthcare provider(s) to discuss the information I am submitting in conjunction with this form with the Evaluating Physician, and I authorize my healthcare provider(s) to provide such other PHI as is requested by the Evaluating Physician.
5. I authorize the Evaluating Physician to provide my eligibility determination to the PDGA’s Director of Policy and Compliance, who will notify me of that determination and make any necessary changes in the PDGA database.
6. I consent to the disclosure of my PHI for law enforcement purposes and as required by state or federal law. For example, the law may require the PDGA or the Evaluating Physician to report instances of abuse, neglect or domestic violence; to report certain injuries such as gunshot wounds; or to disclose PHI to assist law enforcement in locating a suspect, fugitive, material witness or missing person. The PDGA will inform me or my representative if the PDGA discloses my PHI because the PDGA believes I am a victim of abuse, neglect or domestic violence, unless The PDGA determines that informing me or my representative would place me at risk. In addition, the PDGA must provide PHI to comply with an order in a legal or administrative proceeding. Finally, the PDGA may be required to provide PHI in response to a subpoena discovery request or other lawful process, but only if efforts have been made, by the PDGA or the requesting party, to contact me about the request or to obtain an order to protect the requested PHI.
7. I acknowledge that I have received this notice.

You have the right to inspect and copy your PHI for as long as the PDGA maintains these records. You must make a written request for access to the Privacy Officer at the address listed at the end of this Notice. The PDGA may charge you a reasonable fee for the processing of your request and the copying of your records. In certain circumstances the PDGA may deny your request to access your PHI, and you may request that the PDGA reconsider our denial. Depending on the reason for the denial, another licensed health care professional chosen by us may review your request and the denial.

You have the right to request that we communicate with you about your PHI by certain means or at certain locations. For example, you may specify that the PDGA call you only at your home phone number, and not at your work number. You must make a written request, specifying how and where we may contact you, to the Privacy at the address listed at the end of this Notice.

You have the right to request an accounting of disclosures of PHI made by the PDGA (other than those made for treatment, health care operations purposes, or for eligibility determinations) during the 6 years prior to the date of your request. You must make a written request for an accounting, specifying the time period for the accounting, to the Privacy at the address listed at the end of this Notice.

The PDGA reserves the right to change this Notice at any time in accordance with applicable law. Prior to a substantial change to this Notice related to the uses or disclosures of your PHI, your rights or our duties, the PDGA will revise and distribute this Notice.

If you would like more information about the PDGA’s privacy practices or have questions or concerns, please contact the PDGA. If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made regarding the use, disclosure, or access to you PHI, you may complain to us by contacting the PDGA Privacy Officer at [email protected].