Therapeutic Use Exemptions Form

Therapeutic Use Exemptions (TUE) Application Form

Please complete all sections in capital letters or typing. Athlete to complete sections 1 and 6; physician to complete sections 2, 3, 4 and 5. Illegible or incomplete applications will be returned and will need to be re-submitted in legible and complete form.

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Athlete Information

 

Previous TUE

 

Medical Information

  • Comment: Evidence confirming the diagnosis shall be attached and forwarded with this application. The medical information must include a comprehensive medical history and the results of all relevant examinations, laboratory investigations and imaging studies. Copies of the original reports or letters should be included when possible. Evidence should be as objective as possible in the clinical circumstances. In the case of non-demonstrable conditions, independent supporting medical opinion will assist this application. WADA maintains a series of guidelines to assist physicians in the preparations of complete and thorough TUE applications. These TUE Physician guidelines can be accessed by entering the search term “Medical Information” on the WADA website: https;//www.wada-ama.org The guidelines address the diagnosis and treatment of a number of medical conditions commonly affecting athletes, and requiring treatment with prohibited substances.
 

Prohibited Substance(s):

 
 
 
 
 

Physician’s Declaration (to be completed by your physician)

 

nosing physician (if different from treating physician)

 

Athlete’s Declaration

  • I, certify that the information set out at section 1, is accurate. I authorize the release of personal medical information to the Anti-Doping Organization (ADO) as well as to WADA authorized staff, to the WADA TUEC (Therapeutic Use Exemption Committee) and to other ADO TUECs and authorized staff that may have a right to this information under the World Anti-Doping Code (“Code”) and/or the International Standards for Therapeutic Use Exemptions. I consent to my physician(s) releasing to the above persons any health information that they deem necessary in order to consider and determine my application. I understand that my information will only be used for evaluating my TUE request and in the context of potential antidoping rule violation investigations and procedures. I understand that if I ever wish to (1) obtain more information about the use of my health information; (2) exercise my right of access and correction: or (3) revoke the right of these organizations to obtain my health information, I must notify my medical practitioner and my ADO in writing of that Therapeutic Use Exemptions (TUE) Application Form fact. I understand and agree that it may be retained for the sole purpose of establishing a possible anti-doping rule violation, where this is required by the Code. I consent to the decision on this application being made available to all ADOs, or other organizations, with Testing authority and /or results management authority over me. I understand and accept that the recipients of my information and of the decision on this application may be located outside of the country where I reside. In some of these countries data protection and privacy laws may not be equivalent to those in my country of residence. I understand that if I believe that my Personal Information is not used in conformity with this consent and the International Standard for the Protection of Privacy and Personal Information, I can file a complaint to WADA or CAS.
 

Verification