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1 Oklahoma Baptist University Sports Medicine Injury and Illness Procedures The Sports Medicine Department is primarily responsible for the delivery of health care to all student athletes participating in Oklahoma Baptists University Intercollegiate Athletic Programs. This health care includes prevention, evaluation, referral, treatment, and rehabilitation of athletic injuries and illness sustained during practices or games. Unfortunately, injuries and illnesses occur and we strive to coordinate and provide our student athletes with the best care available. PRE PARTICIPATION CLEARANCE Every Athlete is required to receive physical clearance from a physician (MD or DO) prior to participation in intercollegiate athletics at OBU. A pre participation physical exam will be offered, free of charge on a date just prior to the onset of practice. Every athlete is required to be there. You may opt to have your own personal physician perform the pre participation exam. OBU will not accept clearance from a chiropractor, only a MD or Osteopathic Physician. You must use the OBU Medical History Form, Medical History Summary Form and the Physical Exam form included in this e mail (No other form will be allowed). Any financial charges for your physical are your responsibility and not OBU s. Decisions concerning the medical eligibility of a student athlete for athletic participation shall be the sole responsibility of the Director of Athlete Medical Services and/or Team Physician(s). The Head Team Physician is the final authority regarding all medical eligibility. You must be present at the OBU physical to turn in your forms and so our team physicians can also review your forms and clear you for participation. The following forms must be reviewed and understood by you and a parent/guardian. You are required to sign an affirmation by you and a parent/guardian (if you are a minor) on the Sports Medicine Policies Signature/Affirmation page for each of the following: Incoming Athletes Medical/Dental/Vision Insurance Information/emergency contacts Immunization Record Assumption of Risk Consent for Treatment Policy Signature Page Release and Indemnification form (adult or minor) Combo Release of Medical Information Form Sickle Cell Test Results Concussion Policy Acknowledgement Drug Testing Consent Privacy Practices HIPAA Release Form Dental Waiver Supplement Disclosure Form Letter from your physician if taking prescription medications: requires diagnosis, medication, dose and frequency. ADHD medication physician letter if applicable. We also require a copy of your Medical Insurance Card and a Copy of your Dental and Vision Insurance Cards. Physicals: Medical History Form, Medical Summary/Emergency Contact form, Physical Form. Returning Athletes Medical/Dental/Vision Insurance Information/emergency contacts Policy Signature Page Supplement Disclosure Form Letter from your physician if taking prescription medications: requires diagnosis, medication, dose and frequency. ADHD medication physician letter if applicable. We also require a copy of your Medical Insurance Card and a Copy of your Dental and Vision Insurance Cards.

2 Physical: Annual Health Review Form FINANCIAL RESPONSIBILITY The possibility of incurring a sports related injury is a reality for any athlete. The OBU Athletic department has a program that will assist parents if a student athlete is injured by providing secondary or excess medical coverage for student athletes participating in varsity sports. This means the family s insurance is primary and will be billed in every circumstance. If an injury to a student athlete occurs, the student athlete/family is responsible for satisfying their annual deductible on their primary insurance and file a claim with their primary insurance before OBU s secondary insurance will begin coverage. INSURANCE COVERAGE OF STUDENT ATHLETES OBU recommends that All student athletes who participate in varsity and/or junior varsity sports at OBU must have primary medical insurance which would cover them in the case of an injury sustained while participating in athletic practice or competition. 1. All student athletes must provide a copy of a current insurance card to the Department of Athletics prior to participation in athletics. This has to be done each academic year or anytime your primary insurance changes. (If you do not provide verification of insurance coverage you will be assessed a $500 annual fee ($250 per semester). 2. All International students must have medical insurance, which will cover them in case of illness as well as an athletic injury. These policies must originate in the United States of America. Policies from countries outside the USA will not be considered valid and will require purchase of the student health insurance with intercollegiate athletic coverage. OBU s secondary athletic accident insurance will ONLY cover those injuries that are a direct result of intercollegiate athletic practice or play while a student athlete at OBU. This means that injuries that are not related to athletics (car accidents, serious illnesses such as appendicitis, etc) are not covered. Please be aware that before THE SECONDARY INSURANCE CARRIER can pay any bills, they must be submitted to your insurance plan that covers your student athlete and your deductible must be paid by you. OBU s secondary athletic insurance is only responsible for covering athletic injuries that occur during the competitive season, offseason team training during the fall and spring semester and championships that extend beyond the academic semester. OBU s secondary athletic insurance coverage does not cover injuries that occur during the summer. If OBU s secondary athletic insurance denies your claim for any reason, OBU is not financially responsible to cover the expenses. The most common reasons for this are: The condition is not directly related to an athletic injury. The condition is an illness. The condition is deemed pre existing by OBU s insurance carrier. If your student athlete is on a HMO and must see their PCP (primary care physician) for insurance coverage, please communicate this to the Sports Medicine Staff prior to them setting up any appointments. Also, if there are Hospital or Facility restrictions on your primary insurance plan, please communicate this to the Sports Medicine Staff prior to any scheduled tests or procedures. The student athlete is financially responsible for all medical expenses incurred during any lapses in primary insurance coverage, regardless of whether the injury is caused through participation in athletics or otherwise. We strongly recommend that studentathletes maintain insurance coverage when participating in any sport related activity or training, even when the student may not be enrolled in classes. Due to the Health Care Affordability Act (Obama care) there are minor changes in our Policies for the upcoming year. We anticipate our secondary athletic injury policies will continue to change over the next one two years. We are working very hard to minimize any negative impact of these changes. STUDENT ATHLETE RESPONSIBILITY All student athletes have the following responsibilities: Meeting your deductible on your primary insurance coverage. Providing EOBs, bills, statements to the secondary insurance carrier. Monitor claim status via secondary insurance carrier. Expenses related to non athletic related injury or illness which is inclusive of any condition(s) that occurs outside an

3 organized, supervised athletic workout or intercollegiate competition for which the student athlete is not representing the Oklahoma Baptist University. Expenses related to athletic injury when an athlete decides to obtain a second opinion or chooses a physician not associated with OBU Athletics. Expense related to condition(s) not arising from practice or competition (such as, but not limited to: domestic accidents, motor vehicle accidents, sexually transmitted disease, or dental conditions not related to injury). Expense related to denial from OBU s secondary athletic insurance. Unresolved athletically related injury or illness upon termination of athletic participation, withdrawal, or graduation from the University, unless arrangements for provision of medical care for the unresolved athletically related injury or illness is made prior to withdrawal, graduation, or termination of athletic participation. Student athletes are no longer eligible for medical coverage through the Athletics Department if: The student athlete quits the sport. The student athlete is dismissed from the sport. An injured student athlete discontinues rehabilitation as prescribed by the Team Physician. The Team Physician certifies that an injured student athlete has recovered sufficiently to reasonably permit him or her to compete, and that student athlete nonetheless chooses to quit athletic participation. DENTAL INJURIES OBU recommends that you wear a protective mouth guard at all times during participation in intercollegiate athletics. Any dental injury incurred while not wearing a mouth guard will not be covered by OBU secondary Athletic Injury Insurance. Injuries that occur as a result of athletic participation while the athlete is wearing a protective mouth guard will be handled as any other athletic injury. Your primary medical and/or dental insurance will be billed first before OBU s secondary insurance will be billed. If you refuse to wear a mouth guard you will be required to sign a Dental Waiver Form. Pre existing conditions (example: cavities requiring fillings) will be not be covered as per OBU s pre existing injury policy. PRE EXISTING INJURIES OR ILLNESSES The student athlete is financially responsible for medical expenses related to pre existing injuries and illnesses. Every incoming athlete will have a complete history and physical examination. Pre existing illnesses or injuries will be identified at this time. While the Sports Medicine Department may provide treatment for such conditions, the Department of Athletics assumes no financial responsibility for their management. Pre existing injuries or illnesses not disclosed during the pre participation evaluation, which are later exacerbated by intercollegiate sport participation, are the financial responsibility of the student athlete. SECONDARY EXPENSES FOR ATHLETIC RELATES INJURIES AND ILLNESSES OBU s secondary insurance will cover most excess costs (those your insurance won t pay) for athletic related conditions while the student is at Oklahoma Baptist University. Any residual balance after the secondary insurance has paid is the responsibility of the student athlete. If the student athlete graduates, medical care must still be provided by OBU Sports Medicine team physicians or approved physicians to be covered. It is your responsibility to provide an EOB to our secondary insurance carrier for payment. If they do not have this information our secondary coverage is unable to pay the remaining balance. OBU secondary insurance is only financially responsible for medical referrals made by the Sports Medicine Staff. ATHLETIC VS NON ATHLETIC INJURIES An athletic injury is defined as an injury or illness that occurs as a direct result of participation in intercollegiate sanctioned conditioning, practice or competition. When an athletic injury occurs, your primary insurance will be billed. Any costs your primary insurance does not pay will be absorbed by OBU s secondary insurance and you will not be financially responsible for the balance. You may receive an Explanation of Benefits from your insurance. Please forward copies of these immediately to the Sports Medicine Department so the secondary billing process can go into effect. REPORTING INJURIES/ILLNESSES including CONCUSSIONS All injuries and illnesses must be reported to an Athletic Trainer of the Sports Medicine Staff immediately and prior to initiating care. Whether during the season or off season the student athlete is required to communicate with a member of the Sports Medicine Staff prior to initiating care. OBU s secondary insurance requires that the athlete initiate care with an OBU physician within 90 days of the date of injury. Delays greater than 90 days may not be covered by OBU s secondary insurance. In an emergency or in the

4 absence of an athletic trainer the athlete must report the injury and any care provided as soon as possible. All injuries will be evaluated, documented and kept on file in the athletic training room. Failure to do so may result in loss of benefits through the university s athletic insurance policy. Please notify an athletic trainer immediately if you have suffered a head injury, you need to be evaluated for a concussion. Signs and symptoms of a concussion include headache, dizziness, confusion, amnesia, nausea, double or fuzzy vision, feeling unusually irritable, concentration or memory problems. TREATMENT REFERRALS If the athletic trainer determines the student athlete needs to be referred for further evaluation or diagnostic testing, the athletic trainer will coordinate care and arrange appointments with one of the Physician Providers to OBU Athletics. The athletic trainer will make sure you see one of the Physicians in a timely manner in the Training Room or at their office. OBU secondary insurance is only financially responsible for medical referrals made by the Sports Medicine Staff. Any restrictions of providers/facilities/hospitals by your primary insurance are your responsibility to communicate to the Sports Medicine Staff prior to referral. SECOND OPINION Parents and student athletes have the right to choose other medical professionals other than those associated with Oklahoma Baptist University. If you choose to have a second opinion, or seek a physician on your own, Oklahoma Baptist University is not financially responsible for ANY expenses incurred. It is the student athlete s responsibility to turn in all medical records including a written release for participation in association with the second opinion. If you have received treatment from an outside physician, Oklahoma Baptist University Department of Athletics may not: Render any follow up care; or, allow the student athlete to participate until the following conditions are met: The Director of Athlete Medical Services has received written clearance from the attending health care provider. The student athlete has received medical clearance from the Head Team Physician to resume athletic participation. REHABILITATION SERVICES Most of the injuries that occur will need some type of rehabilitation. Rehabilitation after an injury is available on site in the Oklahoma Baptist University facilities by the Sports Medicine Staff and supervised by a Physical Therapist. Physical Therapy services will be billed to your primary insurance as Functional Performance Training and Physical Therapy. OBU s secondary insurance will only cover physical therapy provided by Functional Performance Training and Physical Therapy. DRUG TESTING Random testing for banned substances will occur throughout the year and be performed by an outside agency. Refusal to consent to random drug screening will disallow athletic participation. Some prescription medications contain banned substances. Therefore, please provide a list of medications taken and update with any changes immediately. MEDICATION PRESCRIPTION MEDICATION: you are required to have a doctor s note stating that you are taking a prescription drug for a specific cause, including dosage (does not birth control). This way it is on file and if it comes up positive on a drug test we have the information needed. Otherwise, we wait (which means NO activity) until the letter arrives and have been cleared for participation. OVER THE COUNTER MEDICATION: please ask an athletic trainer before you take any medication. There are ingredients in certain medications that will produce a positive drug test; for example EPHEDRINE in Sudafed. HIPAA COMPLIANCE OBU is required to be compliant with the HIPAA Privacy and Security Regulations. The regulations establish national standards regarding uses and disclosures of protected health information.

5 Notice of Privacy Practices OKLAHOMA BAPTIST UNIVERSITY SPORTS MEDICINE DEPT INTERCOLLEGIATE ATHLETICS NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. HIPAA PRIVACY RULES REQUIRE THAT WE FURNISH YOU WITH THIS NOTICE. I. Purpose: The Sports Medicine Department of Intercollegiate Athletics at Oklahoma Baptist University and its professional staff, employees, and volunteers follow the privacy practices described in this Notice. The Sports Medicine Department maintains your medical information in records that will be handled in a confidential manner, as required by law. However, the Sports Medicine Department must use and disclose your medical information to the extent necessary to provide you with quality health care. To do this, the Sports Medicine Department must share your medical information as necessary for treatment, payment, and health care operations. II. What Are Treatment, Payment, and Health Care Operations? Treatment includes sharing information among health care providers involved in your care. For example, your treatment provider may share information about your condition with other treatment providers in the Sports Medicine Department in order to make a diagnosis. The Sports Medicine Department may use your medical information as required by your insurer to obtain payment for your treatment. We also may use and disclose your medical information to improve the quality of care, e.g., for review and training purposes. III. What Are Other Ways the Sports Medicine Department May Use Your Medical Information? Your medical information may be used, unless you ask for restrictions on a specific use of disclosure, for the following purposes: Appointment reminders. To inform you of treatment alternatives or benefits or services related to your health. (You will have an opportunity to refuse to receive this information.) To carry out health care treatment, payment, and operations functions through business associates, e.g., to install a new computer system. Alcohol and drug abuse information has special privacy protections. The Sports Medicine Department will not disclose any information identifying an individual as being a student-athlete or provide any medical information relating to a student-athlete s substance abuse treatment unless: (i) the student-athlete consents in writing; (ii) a court order requires disclosure of the information; (iii) medical personnel need the information to meet a medical emergency; (iv) qualified personnel use this information for the purpose of conducting scientific research, management audits, financial audits, or program evaluation; or (v) it is necessary to report a crime or a threat to commit a crime, or to report abuse or neglect as required by law. Worker s Compensation. (Your medical information regarding benefits for work-related illnesses may be released as appropriate.) Health oversight activities, e.g., audits, inspections, investigations, and licensure. Certain research projects. To prevent a serious threat to health or safety. Law enforcement (e.g., in response to a court order or other legal process; to identify or locate an individual being sought by authorities; about the victim of a crime under restricted circumstances; about a death that may be the result of criminal conduct; circumstances relating to reporting information about a crime). Disaster relief agency if injured in a disaster. National security and intelligence activities. Protection of the President or other authorized persons for foreign heads of state, or to conduct special investigations. Lawsuits and disputes. (We will attempt to provide you advance notice of a subpoena before disclosing the information.) As required by law. IV. Your Authorization Is Required for Other Disclosures. Except as described above, we will not use or disclose your medical information unless you authorize the Sports Medicine Department in writing to disclose your information. You may revoke your permission, which will be effective only after the date of your written revocation. Your medical

6 records may also contain psychotherapy notes from individual, joint, group or family sessions you may have participated in. You will need to sign a separate authorization form for the use and disclosure of this information. You may revoke your permission to use and disclose your psychotherapy records by sending a written revocation to the Sports Medicine Department. V. You Have Rights Regarding Your Medical Information. You have the following rights regarding your medical information, provided that you make a written request to invoke the right. Right to request restrictions. You may request limitations on your medical information that we use or disclose for health care treatment, payment, or operations (e.g., you may ask us not to disclose that you have had a particular treatment), but we are not required to agree to your request. If we agree, we will comply with your request unless the information is needed to provide you with emergency services. Right to confidential communications. You may request communication in a certain way or at a certain location, but you must specify how or where you wish be contacted. Right to inspect and request a copy. You have the right to inspect and request a copy of your medical information regarding decisions about your care. We charge a fee for copying, mailing, and supplies. Under limited circumstances, your request may be denied; in that instance you may request review of the denial by another licensed health care professional chosen by the Sports Medicine Department. The Sports Medicine Department will comply with the outcome of the review. Right to request amendment. If you believe that the medical information we have about you is incorrect or incomplete, you may request an amendment, which requires certain specific information. The Sports Medicine Department is not required to accept the amendment. Right to accounting disclosures. You may request a list of the disclosures of your medical information that have been made to persons or entities other than for health care treatment, payment, or operations in the past six (6) years, but not prior to April 14, After the first request, there will be a charge. Right to a copy of this Notice. You may request a copy of this Notice at any time, even if you have been provided with an electronic copy. VI. Requirements Regarding This Notice. The Sports Medicine Department is required by law to provide you with this Notice. We will be governed by this Notice for as long as it is in effect. The Sports Medicine Department may change this Notice and these changes will be effective for medical information we have about you as well as any information we receive in the future. Each time you register with the Sports Medicine Department for health care services, you may receive a copy of the Notice in effect at the time. VII. Complaints. If you believe your privacy rights have been violated, you may file a complaint with the Sports Medicine Department, with the University s Privacy Officer through the Office of Institutional Compliance, or with the Secretary of the United States Department of Health and Human Services. You will not be penalized or retaliated against in any way for making a complaint to the Sports Medicine Department or the Department of Health and Human Services. Call the Sports Medicine Department at (405) if: You wish to request restrictions on uses and disclosures for health care treatment, payment, or operations. You wish to obtain forms to exercise your individual rights described in paragraph V. FORMS:

7 Insurance Questionnaire EMERGENCY CONTACT Student Athlete Name (please print) Sport Name Relationship Cell Phone # Name Relationship Cell Phone # ALLERGIES (Please list all known allergies) MEDICAL INSURANCE INFORMATION Policy Holder: Employer: Employer s Address: Insurance Company Name: Address: City: State: Zip Code: Phone #: ID#: Group #: HMO/PPO/TRADITIONAL Policy #: Pre Certification Needed: YES or NO Pre Certification Phone #: PARENT/GUARDIAN INFORMATION FOR INSURANCE PURPOSES Father s Name/Address of birth: SSN#: Mother s Name/Address of birth: SSN#: PRIMARY CARE PHYSICIAN /APPROVED HOSPITALS (If restricted by your insurance policy) Physician Name: Phone #: Fax #: HOSPITALS APPROVED BY YOUR INSURANCE Phone #: HOSPITALS NOT APPROVED BY YOUR INSURANCE PLEASE PROVIDE A FRONT AND BACK PHOTOCOPY OF YOUR MEDICAL INSURANCE CARD I DO NOT HAVE ANY MEDICAL SERVICE PLAN UNDER WHICH THE ABOVE NAMED STUDENT ATHLETE IS COVERED. DENTAL INSURANCE INFORMATION Policy Holder: Employer: Employer s Address: Insurance Company Name: Address: City: State: Zip Code: Phone #: ID#: Group #: HMO/PPO/TRADITIONAL Policy #: Pre Certification Needed: YES or NO Pre Certification Phone #: PLEASE PROVIDE A FRONT AND BACK PHOTOCOPY OF YOUR DENTAL INSURANCE CARD I DO NOT HAVE DENTAL INSURANCE COVERAGE OR ANY DENTAL SERVICE PLAN UNDER WHICH THE ABOVE NAMED STUDENT ATHLETE IS COVERED. VISION INSURANCE INFORMATION Policy Holder: Employer: Employer s Address: Insurance Company Name: Address: City: State: Zip Code: Phone #: ID#: Group #: HMO/PPO/TRADITIONAL Policy #: Pre Certification Needed: YES or NO Pre Certification Phone #: PLEASE PROVIDE A FRONT AND BACK PHOTOCOPY OF YOUR VISION INSURANCE CARD I DO NOT HAVE VISION INSURANCE COVERAGE OR ANY VISION SERVICE PLAN UNDER WHICH THE ABOVE NAMED STUDENT ATHLETE IS COVERED. I AGREE THAT, SHOULD IT BE DETERMINED AT A LATER DATE THAT I HAVE COLLECTIBLE COVERAGE, I WILL REIMBURSE THE OBU ATHLETIC DEPARTMENT OR ITS INSURANCE COMPANY TO THE EXTENT OF ANY COLLECTABLE AMOUNT. I hereby certify that the answers provided are true, complete and correct to the best of my knowledge. _ Signature of Student/Athlete (if 18 yo or older) or Parent/Guardian

8 OBU SPORTS MEDICINE SIGNATURE PAGES AFFIRMATION OF SPORTS MEDICINE POLICIES AND PROCEDURES Please affirm by initialing each policy statement If the SA is a minor, both the student athlete and parent/guardian are required to initial each statement. 1. I understand that it is my responsibility to report all injury/illnesses to the Sports Medicine Department. 2. I understand that OBU secondary insurance is only financially responsible for medical referrals made by the Sports Medicine Staff and at any time I may see the Team Physician about an Injury that I have. 3. I understand that I have the right to a second opinion. I understand that Oklahoma Baptist University is NOT financially responsible for any expenses occurred during the visit(s). 4. I understand that if I need medical attention, my personal insurance is primary and will be billed in every circumstance for the medical care received as a result of an Intercollegiate Athletic Injury. 5. I understand that in the case of an athletic injury, I am financially responsible for meeting my deductible on my primary insurance and that OBU s secondary insurance coverage will begin after my deductible is exhausted and primary insurance has paid. 6. I understand that Oklahoma Baptist University is not financially responsible if I arrive at OBU with a pre existing injury or injuries that are not a direct result of participating in intercollegiate athletic activities at OBU. 7. I understand that Oklahoma Baptist University is not financially responsible for going to a Medical Provider who is not pre approved by the OBU Sports Medicine Staff. 8. I understand that my primary insurance will be billed for physical therapy at OBU if deemed necessary by a Team Physician following an intercollegiate athletic injury. 9. I understand that if I am taking a prescription medication I must turn in a letter/note from my physician explaining the needs of the medication as per OBU s policy. 10. I understand that if OBU s secondary athletic insurance coverage denies my claim for any reason, OBU is not financially responsible for any remaining balance after my primary insurance has paid or the entire balance if I am uninsured. 11. I have read and understand the Insurance, Injury and Illness procedures. 12. I have read and understand Oklahoma Baptist University s Secondary Insurance program and I understand that it my responsibility to provide EOBs to OBU s secondary insurance carrier as well as monitor my claim. Please affirm by signing the signature line. If you are a minor please have your parent/guardian also sign. This affirmation will automatically expire six years from the date it is signed. Student Athlete Signature Print Name Sport _ Parent/Guardian Signature if SA is a minor

9 CONSENT FOR TREATMENT Consent to Care: I authorize OBU Sports Medicine Staff and Team Physicians to provide preventive, post injury and emergency care. I request and consent to care that the Sports Medicine Staff and team Physicians of OBU determine is necessary. I acknowledge that the care I receive from the Sports Medicine Staff is under the direction of the Team Physician and that the Sports Medicine Staff is not responsible for acts of omission of my care. Disclosure of Information: The undersigned agrees that all records concerning this patient s care shall remain the property of OBU. The undersigned understands that medical records and billing information generated or maintained by OBU are accessible to facility personnel and the Sports Medicine Staff. Facility personnel and the Sports Medicine Staff may use and disclose medical information for treatment, payment and healthcare operations. The Sports Medicine Staff is authorized to disclose all or part of the patient s medical record to any insurance company, third party payor, self insured employer group or other entity (or their authorized representatives) which are necessary for payment of the patient s account. Insurance Precertification: I understand that precertification for my insurance is a patient responsibility. I assume all responsibility for notifying my insurance company and obtaining approval. I acknowledge that no guarantees, either expressed or implied, have been made to me regarding the outcome of any treatments/recommendations and/or procedures. I fully understand that it is impossible to make any guarantees regarding the outcome of any medical treatment procedure. This authorization will automatically expire six years from the date it is signed. Student Athlete Signature Print Name Sport _ Parent/Guardian Signature if SA is a minor

10 CONCUSSION Return to Play Guidelines OKLAHOMA BAPTIST UNIVERSITY Department of Intercollegiate Athletics If the athlete s symptoms do not resolve in less than 15 minutes and they are not returned to play on the day of the concussion the following steps will be taken by the OBU Medical Staff after the student athlete is asymptomatic: hours post-concussion cognitive testing will be done (ImPACT). If the test is normal, proceed to the next step hours post-concussion, light aerobic exercise (less than 70% of maximum heart rate). If no symptoms return, proceed to the next step hours post-concussion, non-contact sports specific drills. If no symptoms return, proceed to the next step. 4. Full contact practice. At this point the athlete has medical clearance, but they must participate in at least one practice before being cleared to return to games. The student athlete progression continues as long as the student athlete is asymptomatic at current level. If the student athlete experiences any post concussive symptoms, he/she must wait 24 hours and then start the progression again at the last step completed asymptomatically. For repeated or severe concussions, the Head Athletic Trainer or team physician partner may require the student athlete to be symptom free for a longer period of time prior to beginning activity based on guidelines from the team physician partner or neurologist (if consulted). This progression is used as a guideline and each student athlete will progress at different rates. Final return to play decision will be made solely by the OBU Medical Staff and the team physician partner (if consulted) based on the return to play protocol. Oklahoma Baptist University Athletic Training Student-Athlete Concussion Statement Please check each box. I understand that it is my responsibility to report all injuries and illnesses to my athletic trainer. I have read and understand the Return to Play Guidelines. I have read and understand the Concussion Fact Sheet. After reading the Concussion Fact Sheet, I am aware of the following information (please initial each one): A concussion is a brain injury, which I am responsible for reporting to my athletic trainer. A concussion can affect my ability to perform everyday activities and affect reaction time, balance, sleep and classroom performance. You cannot see a concussion, but you might notice some of the symptoms right away. Other symptoms can show up hours or days after the injury. If I suspect a teammate has a concussion, I am responsible for reporting the injury to my athletic trainer. I will not return to play in a game or practice if I have received a blow to the head or body that results in concussion-related symptoms. Following a concussion the brain needs time to heal. You are much more likely to have a repeat concussion if you return to play before your symptoms resolve. In rare cases, repeat concussions can cause permanent brain damage and even death. Signature of Student-Athlete Printed Name of Athlete Signature of Parent/Guardian if under 18 yo

11 Oklahoma Baptist University Sports Medicine Sickle Cell Trait Testing About Sickle Cell Trait- Sickle cell trait is an inherited condition of the oxygen-carrying protein, hemoglobin, in the red blood cells. Sickle cell trait is a common condition (> three million Americans) Although Sickle cell trait is most predominant in African-Americans and those of Mediterranean, Middle Eastern, Indian, Caribbean, and South and Central American ancestry, persons of all races and ancestry may test positive for sickle cell trait. Sickle cell trait is usually benign, but during intense, sustained exercise, hypoxia (lack of oxygen) in the muscles may cause sickling of red blood cells (red blood cells changing from a normal disc shape to a crescent or sickle shape), which can accumulate in the bloodstream and logjam blood vessels, leading to collapse from the rapid breakdown of muscles starved of blood. Sickle Cell Trait Testing- The NCAA requires that all OBU student-athletes have knowledge of their sickle cell trait status before the student-athlete participates in any intercollegiate athletics event, including strength and conditioning sessions, practices, competitions, etc. You must provide a copy of your sickle cell test, pay for a test/provide a copy or sign a waiver declining to be tested prior to participating in athletics at OBU. Since 1990, all newborn babies are tested, among other things, for sickle cell. If you do not have proof of this test it may be obtained at the following link. Click on your state and search for a phone number or to contact your state's Genetic Disease Screening Program. It takes awhile to get results, so get started on this today or simply get tested and bring the results to the physical exam. It will save your student/athlete the trouble of getting tested once on campus and possible missing practice or competition. Merely stating test results will not suffice, we must have the actual proof of test results. Contact Information Newborn Screening 1000 N.E. 10th St, RM 709- OKC Phone: (405) Fax: (405) Toll Free SICKLE CELL TRAIT TESTING WAIVER I understand and acknowledge that the Oklahoma Baptist University Athletics Department recommends that all student-athletes have knowledge of their sickle cell trait status. Additionally, I have read and fully understand the aforementioned facts about sickle cell trait and sickle cell trait testing. Recognizing that my true physical condition is dependent upon an accurate medical history and a full disclosure of any symptoms, complaints, prior injuries, ailments, and/or disabilities experienced, I hereby affirm that I have fully disclosed in writing any prior medical history and/or knowledge of sickle cell trait status to Oklahoma Baptist University Athletic Training personnel. I do not wish to undergo sickle cell trait testing as part of my pre-participation physical examination and I voluntarily agree to release, discharge, indemnify and hold harmless the State of Oklahoma, the University, its officers, employees and agents from any and all costs, liabilities, expenses, claims, demands, or causes of action on account of any loss or personal injury that might result from my non-compliance with the recommendation of the Oklahoma Baptist University Athletics Department. I have read and signed this document with full knowledge of its significance. I further state that I am at least 18 years of age and competent to sign this waiver. Student Athlete Signature Printed Name Sport Parent/Guardian Signature if SA is a Minor

12 HIPPA Authorization Form For Uses and Disclosures of Patient Protected Health Information I hereby authorize Oklahoma Baptist University Department of Intercollegiate Athletics to release my protected health information. Protected health information may include: i. Injury or illness relevant to past, present or future participation in intercollegiate athletics at Oklahoma Baptist University. ii. Information contained in my personal medical record unrelated to my participation in intercollegiate athletics at Oklahoma Baptist University. iii. Information concerning my medical status, medical condition, injuries, prognosis, diagnosis and other related personally identifiable health information, including injury reports, test results, x rays, progress reports and any other documentation regarding my health status. Authorization is granted for release of my protected health information to: the media, including specifically the Oklahoma Baptist University Media Relations Office, to advise the print, radio, television and other media of the nature, diagnosis, prognosis or treatment concerning my medical condition and any injuries or illnesses for the purpose of reporting on it while I am a student athlete. professional athletic teams, their scouts, athletic trainers, physicians, servants, or employees for the purpose of making decisions regarding my prospect as a professional athlete. my parents/guardian and/or spouse for the purpose of assisting me in making Healthcare decisions while I am a student athlete the coaches, assistant coaches and other athletic staff so that they may make decisions regarding my athletic ability and suitability to compete while I am a student athlete my teammates so that they may be aware of limitations that I may be under while I am a student athlete the student athletic trainers and other students who are participating in the provision of sports medicine healthcare to assist and participate in the provision of healthcare to me while I am a student athlete amateur athletic organizations for the purpose of making decisions regarding my prospect as an athletic participant academic departments, including specifically the Oklahoma Baptist University Student Development Office for the purpose of making decisions regarding my ability and suitability to perform academically while I am a student athlete the Sooner Athletic Conference and National Association of Intercollegiate Athletics for the purpose of making determination regarding my eligibility status while I am a student athlete applicable insurance providers for the purpose of processing insurance claims while I am a student athlete Please Note the Following: This authorization will automatically expire six years from the date it is signed You may refuse to sign this authorization. Your refusal will not affect your ability to obtain treatment or payment. 1. If the persons or entities who are authorized to receive the information above are not health care providers or health plans covered by federal health privacy laws, they may re disclose the information and those laws would no longer protect the disclosed health information. 2. Once you sign this authorization, we can rely on it until you revoke it or, if you have not revoked it, until it expires. Any revocation will not be effective as to information already disclosed in reliance on the authorization. You can revoke this authorization by delivering a dated and signed letter to the Director of Athlete Medical Services addressed to: Mark Cranston, MPH, PT,ATC,CSCS.PES,CES Director of Athlete Medical Services Oklahoma Baptist University 500 W. University Shawnee, Oklahoma The information authorized for release may include records which indicate the presence of a communicable or venereal disease including, but not limited to, hepatitis, syphilis, gonorrhea and the human immunodeficiency virus, the virus that leads to Acquired Immuno Deficiency Syndrome ( AIDS ) and/or mental health information. 4. Oklahoma Baptist University will not receive compensation for its use or disclosure of your protected health information. Student Athlete Signature Print Name Sport _ Parent/Guardian Signature if SA is a minor

13 ASSUMPTION OF RISK OBU ATHLETICS Assumption of Risk I verify that I have been informed that I may be injured while participating in intercollegiate athletic practice or competition. I understand that it is possible that I may sustain an injury, which may result in permanent disability, psychological effects, paralysis, or possibly death. I understand that paralysis may include loss of movement, feeling, and use of my arms, legs, and trunk. I further understand that paralysis may involve complete loss of sexual function, and/or bowel and bladder control which would require the use of external aids, attached or inserted in to my body for the collection and removal of body wastes. I understand that paralysis and its effects could last my entire lifetime. In addition, I understand that an injury to any of my body joints (i.e. ankle, knee, hip, spine, shoulder) may result in disfigurement, pain, loss of movement, loss of function, loss of strength, or loss of sensation or feeling which may last my entire lifetime. I understand that it is my responsibility to adhere to all rules and regulations of my chosen sport. I understand that it is my responsibility to be knowledgeable in the proper and safe use of equipment. I understand that infraction of the rules may result in injury to my opponent or myself. I also understand that the student athlete should make no modification of protective equipment or uniform. I understand and agree to properly monitor any protective equipment that I use before application each utilization and to notify the proper authority if I have questions or concerns about safety. I understand that certain risks are present at an athletic venue, in the locker room and in transportation to and from sporting events, including but not limited to, falling and vehicle accidents. I understand that all injuries are to be reported to the athletic trainer and that I am responsible for the follow up care and treatment of my injuries under the athletic trainer s supervision. I accept these risks of participation in intercollegiate athletics during the duration of my attendance at the Oklahoma Baptist University. This affirmation will automatically expire six years from the date it is signed. Student Athlete Signature Print Name Sport _ Parent/Guardian Signature if SA is a minor

14 OKLAHOMA BAPTIST UNIVERSITY ATHLETICS DENTAL WAIVER AND RELEASE I, the below named athlete, have been provided the opportunity to wear a mouth guard, custom fit or generic, for my use during all Oklahoma Baptist University practices and games. I hereby acknowledge that not wearing a mouth guard while participating as a player for Oklahoma Baptist University can potentially cause dental, mouth, jaw and other related injury. I hereby accept full responsibility and all financial liability for any direct or indirect injury, medical and/or dental, any related loss of teeth or mouth function or any condition and/or complication related to not wearing a mouth guard while participating and competing for Oklahoma Baptist University. I hereby forever discharge and release the NAIA, Sooner Athletic Conference, all affiliated and associated teams, Oklahoma Baptist University, administrators, agents, officers, directors, employees, contractors, representatives, coaches, team physicians, team dentist(s), athletic trainers and associated or affiliated medical staff. This waiver will automatically expire six years from the date it is signed. Student Athlete Signature Print Name Sport _ Parent/Guardian Signature if SA is a minor

15 Oklahoma Baptist University Department of Athletics Drug/Alcohol Education & Testing Program Student-Athlete Consent Form I,, hereby acknowledge that I have received a copy of, read and been given the opportunity to ask questions regarding the Drug/Alcohol Education & Testing Program implemented for the Department of Intercollegiate Athletics at Oklahoma Baptist University. I understand the policies, procedures and my responsibilities as described in such policy. As a condition to my participation in intercollegiate athletics at Oklahoma Baptist University, I consent to participate in the Drug/Alcohol Education & Testing Program. I understand that my participation in this program includes the collection and testing of my urine at various times during academic year for drugs, alcohol, and/or other banned substances. I further consent to the release of the results of any drug test to the Director of Athletics or his/her designee, Assistant Director of Athletics, my Head Coach, the Head Athletic Trainer and/or Assistant Athletic Trainers, Team Physician, Appeals Committee and/or my parent(s) or guardian(s). I acknowledge and understand that a copy of this consent form may be sent to my parent(s) or guardian(s) along with a copy of the Drug/Alcohol Education & Testing Program. To the extent set forth in this document, I waive any privilege I may have in connection with such information. I fully understand that the Oklahoma Baptist University Drug/Alcohol Education & Testing Program is separate and distinct from the NCAA drug-testing program and its sanctions, however, I also understand that sanctions may be imposed by Oklahoma Baptist University under its Drug/Alcohol Education & Testing Program upon a positive result under the NCAA drug-testing program. Notwithstanding anything to the contrary in the policy, I fully understand that I may be suspended from competition and/or practice by the team physician if credible evidence suggests that such competition and/or practice poses a health and safety risk to me, my teammates, and/or my competitors. Oklahoma Baptist University, its officers, employees, and agents are hereby released from legal responsibility and/or liability for the release of any information and/or record as authorized by this consent form. I fully and forever release and discharge the aforementioned parties from any claims, demands, rights of action, or causes of action, present or future, whether the same be known or unknown, anticipated or unanticipated, resulting from my participation in Oklahoma Baptist University s Drug/Alcohol Education & Testing Program including those claims, demands, rights of action, or causes of action arising out of any positive result under such Drug/Alcohol Education & Testing Program. Also note that Oklahoma Baptist University may want to test for substances not banned or listed on the NCAA Banned Drug Classes List. Student-Athlete Signature Printed Name of Student-Athlete of Birth Social Security Number Sport(s) Parent/Guardian Signature (if a minor)

16 Release and Indemnification Agreement Adult Oklahoma Baptist University Sports Medicine 500 W University Shawnee, Ok Fax RELEASE AND INDEMNIFICATION AGREEMENT STUDENT-ATHLETE: SPORT: I, the above named student-athlete, am eighteen years of age or older. I acknowledge that participation in intercollegiate athletics may expose me to hazards or risks that may result in my illness, personal injury or death and I understand and appreciate the nature of such hazards and risks. In consideration of my participation as a student-athlete under the auspices of the Department of Intercollegiate Athletics at Oklahoma Baptist University and of my use of the program s facilities and equipment, I hereby accept all risk to my health and of my injury or death that may result from such participation. I hereby release the above named Institution, its governing board, officers, employees, and representatives from any liability to me, my personal representatives, estate, heirs, next of kin, and assigns for any and all claims and causes of action for loss of or damage to my property and for any and all illness or injury to my person, including my death, that may result from or occur during my participation, whether caused by negligence of the Institution, its governing board, officers, employees, or representatives, or otherwise. I further agree to indemnify and hold blameless the Institution and its governing board, officers, employees, and representatives from liability for the injury or death of any person(s) and damage to property that may result from my negligent or intentional act or omission while participating in my sport. I HAVE CAREFULLY READ THIS AGREEMENT AND UNDERSTAND IT TO BE A RELEASE OF ALL CLAIMS AND CAUSES OF ACTION FOR MY INJURY OR DEATH OR DAMAGE TO MY PROPERTY THAT OCCURS WHILE PARTICIPATING IN INTERCOLLEGIATE ATHLETICS AND IT OBLIGATES ME TO INDEMNIFY THE PARTIES NAMED FOR ANY LIABILITY FOR INJURY OR DEATH OF ANY PERSON AND DAMAGE TO PROPERTY CAUSED BY MY NEGLIGENT OR INTENTIONAL ACT OR OMISSION. This release expires six years from the date it is signed. Signature of Student-Athlete Signature of Witness

17 Release and Indemnification Agreement Minor Oklahoma Baptist University Sports Medicine 500 W University Shawnee, Ok Fax RELEASE AND INDEMNIFICATION AGREEMENT (Applicable only if student-athlete is under 18 years of age) STUDENT-ATHLETE: SPORT: I am the Parent/Guardian of the above-named student-athlete who is under eighteen years of age and am fully competent to sign this Agreement. In consideration of student-athlete being permitted to participate in athletics under the auspices of the Department of Intercollegiate Athletics at Oklahoma Baptist University and to use the program s facilities and equipment, I hereby accept all risk to student-athlete s health and of his/her injury or death that may result from such participation and I hereby release the above named Institution, its governing board, officers, employees, and representatives from any and all liability to student-athlete, student-athlete s personal representatives, estate, heirs, next of kin, and assigns for any and all claims and causes of action for loss of or damage to student-athlete s property and for any and all illness or injury to student-athlete s person, including his/her death, that may result from or occur during athletics participation, whether caused by negligence of the Institution, its governing board, officers, employees, or representatives, or otherwise. I further agree to indemnify and hold blameless the Institution and its governing board, officers, employees, and representatives from liability for the injury or death of any person(s) and damage to property that may result from student-athlete s negligent or intentional act or omission while participating in the sport. I HAVE CAREFULLY READ THIS AGREEMENT AND UNDERSTAND IT TO BE A RELEASE OF ALL CLAIMS AND CAUSES OF ACTION FOR STUDENT-ATHLETE S INJURY OR DEATH OR DAMAGE TO STUDENT-ATHLETE S PROPERTY THAT OCCURS WHILE PARTICIPATING IN INTERCOLLEGIATE ATHLETICS AND IT OBLIGATES ME TO INDEMNIFY THE PARTIES NAMED FOR ANY LIABILITY FOR INJURY OR DEATH OF ANY PERSON AND DAMAGE TO PROPERTY CAUSED BY STUDENT- ATHLETE S NEGLIGENT OR INTENTIONAL ACT OR OMISSION. This release expires six years from the date it is signed. Signature of Parent/Guardian Signed Address(if different than student-athlete s) Signature of Witness Signed

18 Release of Medical Information Composite Oklahoma Baptist University Sports Medicine 500 W University Shawnee, Ok Fax AUTHORIZATION RELEASE OF MEDICAL INFORMATION TO: (PLEASE INITIAL EACH) X MEDIA X PARENTS/GUARDIANS X COACHES/STAFF X TEAMMATES X SPORTS MEDICINE STAFF AND STUDENT ASSISTANTS X PROFESSIONAL TEAMS AND REPRESENTATIVES STUDENT-ATHLETE:_ SPORT: This authorizes the athletic trainers, team physicians and athletics staff including coaches representing OBU to release information concerning my medical status, medical condition, injuries, prognosis, diagnosis and related personally identifiable health information to the media including specifically OBU s Sports Information Department and to the various media outlets. This information includes injuries or illnesses relevant to past, present or future participation in athletics at OBU. The reason for this disclosure is to advise the print, radio, television and other media of the nature, diagnosis, prognosis or treatment concerning my medical condition and any injuries or illnesses so that they may report on it while I am a student athlete. I understand that the entities that receive the information are not health care providers or health plans covered by federal privacy regulations, and that the information described above may be re-disclosed publicly and that the information will no longer be protected by those regulations. I understand that OBU will not receive compensation for its use/disclosure of the information. I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment. I may inspect or copy any information used/disclosed under this authorization. I understand that I may revoke this authorization in writing at any time by notifying in writing the Director of Athlete Medical Services, but if I do, it will not have any effect on actions The University took in reliance on this authorization prior to receiving the revocation. This authorization expires six years from the date it is signed. Signature of Student-Athlete Signature of Parent/Legal Guardian (If student-athlete is under 18 years of age)

19 Oklahoma Baptist University Department of Intercollegiate Athletics Student-Athlete Dietary Supplement Disclosure & Review Form I, Student-Athlete Name am taking or intend to take the following dietary supplements. I acknowledge the risk of losing my eligibility to participate in intercollegiate athletics if I test positive for an NCAA or Oklahoma Baptist University banned substance that may be found in any substance that I take, regardless of the reason or purpose for taking such supplements. I acknowledge and understand that the labeling on these products can be misleading and inaccurate, and that sales personnel are neither motivated nor qualified to accurately certify that these products contain no banned substances. Healthy or naturally occurring are terms often used to market sales of dietary supplements, but do not necessarily mean they are safe. Before taking or using any dietary supplement, I am responsible for ensuring the product does not contain any banned substance. By making this disclosure, I am requesting that these products and their ingredients by reviewed by Oklahoma Baptist University s sports medicine staff for the purposes of determining whether they are medically safe to use and do not contain banned substances. I understand that I should not take or use these products until their usage has been reviewed by Oklahoma Baptist University s sports medicine staff. Brand Name: Listed Ingredients: (Athletic Trainer to review, circle banned substances and notify student-athlete.) Signatures: Student-Athlete Signature Athletic Trainer Signature

20 OKLAHOMA BAPTIST UNIVERSITY Department of Intercollegiate Athletics Student-Athletes with ADHD POLICY: All student-athletes who are taking medications for ADHD are required to provide a letter from their prescribing physician and contain the following information. Some legitimate medications contain banned substances, and their physician to support their general health and academics may prescribe a student-athlete these medications. Adequate medical records must be on file with OBU Sports Medicine in order to request an exception in the event the student-athlete tests positive for a stimulant utilized in the treatment of ADHD. The following documentation must be on file with the OBU Sports Medicine prior to the first practice session. Failure to do so will prohibit the student-athlete from practicing/competing. The treating physician should be contacted to write a letter on behalf of the student-athlete documenting the diagnosis and treatment plan. The letter must contain the following information: Student-athlete name Student-athlete date of birth of clinical evaluation History of ADHD treatment (previous/ongoing) Summary of comprehensive clinical evaluation 9referencing DSM-IV criteria)-attach supporting documentation Blood pressure and pulse readings with comments Statement the alternative non-banned medications have been considered, and comments Diagnosis Medications and dosage Follow-up orders Physician name (printed) Office address and contact information Specialty Physician signature and date Parents and student-athletes need to collect this information ASAP since it will take the treating physician some time to complete this information. Additionally, this information will be required on an annual basis as long as the student-athlete is on ADHD medication that contains a banned substance. Please feel free to contact the Director of Athlete Medical Services at with any questions. Signatue of Athlete Signature of Parent/Guardian

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