I understand that since I am applying to serve, which is a ministerial position, SAM USA uses outside evaluations to assess my readiness to serve. The mission gathers health information to assess my readiness to serve in locations that may be physically challenging in numerous ways. A third-party psychologist will prepare a Psychological Evaluation Report.

By signing this form, I authorize the SAM Director of Mobilization and/or the International Leadership Members to prepare and review confidential Medical Summary Report of my health information, indicating any medical condition that would affect placement decisions or require ongoing monitoring. This confidential Medical Summary Report will then be released to the SAM Receiving Personnel Leadership or the decision-making authorities of the organizations to which I may be seconded to identify an appropriate placement for missionary service. In addition, a copy of my Medical Summary Report with supporting health information may be released to the SAM receiving Personnel Leadership assigned to the country of placement.

By signing this form, I also authorize the third-party psychologist to send the Psychological Evaluation Report to the SAM USA Coordinator, Director of Mobilization, International Leadership Members to be used in determining my readiness for ministry and appropriate qualifications for specific placement positions. The SAM USA Team will prepare an abbreviated Summary and Recommendations report based on the third-party psychologist’s Psychological Evaluation Report, which will be released to SAM Receiving Personnel Leadership or the decision-making authorities of organizations to which I may be seconded to identity an appropriate placement for missionary service. I also authorize this Summary and Recommendations Report to be referenced by appropriate Receiving Leadership, as well as by SAM USA Personnel and Member Care on a need-to-know basis, to provide ongoing spiritual, emotional and mental health care, while I service with SAM USA.

I understand that once I have released this medical and psychological information, it is no longer protected by HIPAA. This means that information can be further disclosed to others without the protection of HIPAA regulations.

My medical information is maintained by South America Mission in a confidential medical record file with need-to-know access. My third-party Psychological Evaluation Report is maintained by SAM USA in a confidential personnel file with need-to-know access. These reports will not be released to my sending churches, or anyone outside of those indicated above, without express written permission from me.

In exchange for the opportunity to apply to serve as a missionary, I specifically release SAM USA, SAM USA Staff, my health care provider and the psychologist providing the evaluations, from all liability arising out of the use, exchange and discussion of any information covered by this Authorization. This includes but is not limited to all statutory and legal claims of defamation, invasion of privacy, breach of confidentiality and wrongful termination.

This authorization will remain in effort for as long as I am serving with SAM. I agree that I have the right to revoke these authorizations at any time, understanding that this will bring an end to my service with South America Mission. I must revoke these authorizations in writing, and I can only do so to the extent that they have not yet been relied on.