Written authorization from a provider before an athlete removed for a suspected concussion returns to play (KRS 160.445).
- Completed by
- Physician (MD or DO)
- Issued by
- Kentucky High School Athletic Association (KHSAA)
- Format
- Language
- English
Kentucky KHSAA GE04 Consent and PPE01 Physical
Kentucky high school athletes must have the KHSAA GE04 completed before they try out, practice or compete. It combines parent permission, consent and release with a Medical Eligibility Form signed by the examining provider. The combined packet also contains the optional PPE01 history and exam pages, which providers may use or replace with their own exam record.
Who completes it
The examining MD, DO, NP or PA, or a DC within scope of practice, completes and signs the Medical Eligibility Form on page 3 of GE04. The student and parents complete the athlete information, insurance and acknowledgment sections and sign.
Submitting and payment
- How to submit it
- The GE04 goes to the school, which keeps it on file; any PPE01 pages stay with the family and the provider.
- Who pays
- KHSAA sets no fee for the physical and does not say who pays.
Good to know
- If PPE01 is used, its three pages must not be kept with the GE04 or held at the school; KHSAA treats them as confidential between provider and patient.
- Eligibility choices are all sports without restriction, all sports with recommendations, certain sports, not eligible pending evaluation, or not eligible for any sports.
- The eligibility page includes shared emergency information (allergies, medications, other information and emergency contacts), and the GE04 may travel with the team for emergencies.
- High school students use GE04; the middle school equivalent is MS01. KHSAA posts GE04 and PPE01 in English and Spanish.
Get the official form
Download the current version from the source each time; forms change without notice.
GE04 Combined Permission/Consent and Optional PPE01 History and Medical Form (High School)
Fill it with Vero
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
How this list is checked
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Frequently asked questions
Is the KHSAA PPE01 required?
No. The GE04 with the provider's Medical Eligibility Form is required, while the PPE01 history and examination pages are optional. Providers may use their own exam record instead. If PPE01 is used, it stays with the family and provider rather than at the school.
Who can sign the GE04 Medical Eligibility Form?
The signature line lists MD, DO, NP or PA, or DC if within scope of practice. The provider attests that the student was examined, that the athlete has no apparent contraindications as outlined, and that the exam findings are on record in the provider's office.
Is the Kentucky GE04 available in Spanish?
Yes. KHSAA posts the combined GE04 and optional PPE01 packet in Spanish, along with a Spanish PPE01. The English GE04 is revision 7/23, and KHSAA also posts the GE04 and PPE01 as separate files.