Appendix BBPlayer Notification Form Club Physician Diagnosis and Prescription Summary
Name of Player:
Email & Mailing Address of Player:
Notice: Player has the right to access his Electronic Medical Records (“EMR”) maintained by the (Insert Team Name) as set forth in Article 40. Questions regarding access toplayer’s EMR may be directed to player’s union representative or [Insert Club Contact].
The charts below have been generated solely based on the data contained in your EMR and includes information concerning Club physician diagnoses and medications prescribed by Club physicians. The Club may elect to include additional medical information in its discretion. The [Insert Team Name] have provided you with this information pursuant to the requirement in Article 40 of the CBA and not for the purpose of acknowledging that any of the conditions listed below constitute compensable, workplace or work-related injury. Information disclosed below may include non-workplace conditions, illnesses and injuries suffered by the players outside the course and scope of employment.
|Initial Date of Diagnosis by Club Physician||Identity of Diagnosis|
|Initial Date of Diagnosis by Club Physician||Prescribed Medication|