Athletic Training Department * 320 S. Main St. * Olivet, Michigan * Fax (269)

Transcription

1 Athletic Training Department * 320 S. Main St. * Olivet, Michigan * Fax (269) Dear Student-Athlete and Parent(s)/Guardian(s): On behalf of the Olivet College Athletic Training Department, we would like to welcome you to the NCAA Division III Intercollegiate Athletic Program at Olivet College. The Sports Medicine Team at Olivet College consists of team physicians (General Medicine and Orthopedic), three full time Certified Athletic Trainers, and student employees. The Sports Medicine Team s focus is to address the healthcare needs of each student athlete. Each entity of the Sports Medicine Team works collaboratively to address issues such as prevention, evaluation, management, rehabilitation, and referral of athletic injuries and/or illness. Our primary concern is to maintain the health and safety of every student-athlete while participating in Olivet College athletics. Please be aware that Olivet College requires each student to have Primary Health Insurance. Each student will automatically be enrolled in a health plan offered through First Agency, Inc unless a waiver form is completed and forwarded along with a photocopy of the insurance card (front & back), signifying existing coverage to the Olivet College Student Services Department. The waiver form must be submitted to Student Services prior to the start of practice or the first day of school, whichever date occurs first. Complete information of the Primary Health Insurance policy, health history, and physical examination are enclosed in this packet. Student-athletes that do not have a waiver form completed at the time of their physical will either be enrolled in the college health plan OR will not be eligible for participation until proof of existing coverage is provided. All new student-athletes (freshman, transfer or first year collegiate athletes) are required to have a physical preformed by a physician prior to the beginning of practice. A copy of the Olivet College Pre-Participation exam and other required paperwork are enclosed in this packet and are also available online at under the inside athletics tab in Athletic Training. Please fill out the ESSENTIAL documents that the school will need prior to participation: Athlete Fact Sheet Questionnaire Please fill out the form completely and return a copy of your insurance card (front/back). If unable to include a copy of your insurance card, please bring in your card to the Athletic Training room prior to participation and we will make a copy. Please read the enclosed insurance coverage guidelines and policy letter. Athletic Pre-Participation Health History Form Please answer ALL medical history questions honestly and accurately. Please be certain to provide signature(s) on bottom of physical form. A physical examination must be performed prior to reporting to practice. Athletic Pre-Participation Physical Please be sure to have your Physician fill out entire document, and return to the Athletic Trainers prior to participation in practice and games. High School physical forms will not be accepted. Adult ADD/ADHD Form (if applicable) Please be sure to have your Physician complete the entire document, and provide necessary documentation. Please ensure that all forms are fully completed and legible. It is imperative that all information is accurate and that all appropriate signatures are included. Please return the completed forms to the Olivet College Athletic Training Department by August 1 st. If you are unable to make this deadline please bring the completed forms to the athletic training staff at check in. PLEASE NOTE: All student-athletes are required to complete ALL medical paperwork before they will be allowed to participate in any team practice or competition. Sincerely, Ryan Shockey, MBA, AT, ATC Amanda Cox, AT, ATC Lauren Weikel, AT, ATC Head Athletic Trainer Assistant Athletic Trainer Assistant Athletic Trainer rshockey@olivetcollege.edu acox@olivetcollege.edu lweikel@olivetcollege.edu (269) (269) (269)

2 Athletic Training Department * 320 S. Main St. * Olivet, Michigan * Fax (269) The purpose of this letter is to help clarify the current policy regarding insurance coverage at Olivet College. It is REQUIRED that every student carries his/her own PRIMARY HEALTH INSURNACE (or be covered by their parents or guardians policy). Each student choosing to participate in intercollegiate athletics at Olivet College must show proof of insurance prior to receiving his/her pre-participation physical examination. Each student-athlete is required to have a physical examination prior to any participation in Olivet College intercollegiate athletics. Preparticipation physical examinations for new athletes must be performed by a physician prior to arrival at Olivet College. Returning athletes will have a Medical Screening performed by the Certified Athletic Trainers at Olivet College. The final decision regarding physical qualifications or reason for disqualification is the responsibility of the team physician and/or Certified Athletic Trainer. The team physician and/or Certified Athletic Trainer will also make decisions concerning when an athlete may return to participation after all incurred injuries/illness. Student-athletes who fail to show proof of an existing Primary Health Insurance policy prior to their preparticipation examination will be automatically enrolled in the health plan offered through First Agency, Inc at an approximate cost of $1,600 (this amount may be covered by financial aid). Student-athletes with an existing Primary Health Insurance policy that fail to complete the waiver form and provide proof of coverage prior to their scheduled pre-participation physical examination will not be eligible to receive the physical until the waiver form and proof of coverage are completed. Complete information on the Primary Health Insurance Policy and a waiver form has been sent in a separate mailing from the Admissions Office. SECONDARY ATHLETIC INJURY POLICY Accidents do occur and we attempt to provide our student-athletes with the very best possible care. Medical bills may be incurred when the student-athlete is treated for bodily injury due to an accident, whether it is locally, during a road trip, or by a medical vendor in his/her own home area. Olivet College provides a SECONDARY ATHLETIC INJURY POLICY for all student-athletes who participate in Olivet College intercollegiate athletics. This policy is purchased by the athletic department for coverage of its intercollegiate athletic programs and does have certain limitations and exclusions. The Secondary Athletic Injury Policy functions as a secondary/excess policy and will ONLY cover injuries that occur during organized and supervised intercollegiate athletic activity, including sponsored and authorized team travel. This policy has a $ deductible per injury, to be met by the student-athlete or their primary health insurance. In addition, this policy ONLY covers reasonable and/or customary charges and expenses beyond what the student-athlete s primary health insurance will NOT pay. This policy DOES NOT COVER PRE-EXISTING CONDTIONS OR INJURIES. Second Opinions Please note that the Olivet College Secondary insurance does not cover second opinions. Athletes and parents always have the right to seek a second opinion for any injury or illness, but this policy will not endure these costs. In the event of an athletic-related injury to your son/daughter, all medical bills must be SUBMITTED BY YOU TO YOUR PERSONAL MEDICAL INSURANCE COMPANY. Only after you have submitted bills and/or payment to your primary health insurance company will the Secondary Olivet College Athletic Injury Policy come into effect. CLAIM PROCEDURE: All injuries sustained in correlation with intercollegiate sports, MUST be evaluated by a member of the Olivet College Athletic Training staff in order to be considered for submission to the secondary insurance policy. If an athlete chooses to see a physician outside of the Olivet College Team Physicians staff without authorization from the Athletic Training staff, these bills will be the student s responsibility.

3 If a student-athlete chooses to seek a second opinion from another physician, these costs will NOT be covered by the secondary insurance policy. All injuries sustained by a student-athlete MUST be reported to a member of the Athletic Training staff within 24 hours of sustaining the injury. A student-athlete may lose the right to Olivet College s secondary insurance policy if an injury is not reported in a timely matter. CLAIM SUBMISSION All medical bills for your son/daughter incurred as the result of an accident (e.g. strained muscle, sprained ligament etc.) in the intercollegiate athletics program will be sent directly to your son/daughter or to your home address, unless the college or university has instructed the medical vendor otherwise. In some cases the athletic department may get a copy of the bill, but in no case will the athletic department be the primary place for the bill incurred to be sent. A) Submit the bills incurred to your PRIMARY HEALTH INSURANCE POLICY first. The primary health insurance company will do one of two things: 1. Honor the claim and pay all or a portion of the bills incurred. 2. Not honor the claim and send you a letter of denial. B) If a balance remains after your primary health insurance policy has contributed towards the claim, send the claim sheet from the insurance company and a copy of the itemized bills incurred to the Olivet College Athletic Training Department. If you receive a letter of denial from your primary health insurance policy administrator, then send the letter of denial and copy of the bills incurred to the Olivet College Athletic Training Department. If no coverage is available, a letter from your employer with verification will be necessary. C) If the bills incurred are not paid by the primary insurance policy and are larger than the deductible, a claim will then be sent from the Athletic Training Department to our insurance carrier s office for processing. If the insurance carrier needs any additional information please cooperate with them in a timely manner. It is in your best interest to have the claim settled promptly since all the bills incurred are in your name. PLEASE NOTE: All PRIMARY INSURANCE POLICIES must have equitable coverage to that of the coverage provided by First Agency, Inc. If your particular primary insurance policy is NOT equitable, a policy that is equitable must be purchased before a pre-participation physical examination will be administered. If your primary health insurance is through an HMO (Health Maintenance Organization) or PPO (Preferred Provider Organization) you must follow the proper procedures required by your plan in order for the college s secondary athletic insurance to satisfactorily complete its portion of the claim. This is especially important if your plan requires pre-authorization to have your son/daughter treated out of your plan s service area or for diagnostic testing. Should your insurance coverage change during the course of the school year, it is YOUR RESPONSIBILITY to NOTIFY the Olivet College Athletic Training Department so that your son/daughter can be adequately served. If changes are not reported to the Athletic Training Department prior to an injury, all bills will be the student-athlete s responsibility. If you have any questions or would like additional information, please contact the Athletic Training Staff. PLEASE KEEP THIS FOR FURTHER REFERENCE Ryan Shockey, MBA, AT, ATC Amanda Cox, AT, ATC Lauren Weikel, AT, ATC Head Athletic Trainer Assistant Athletic Trainer Assistant Athletic Trainer (269) (O) (269) (O) (269) (O) rshockey@olivetcollege.edu acox@olivetcollege.edu lweikel@olivetcollege.edu

4 Olivet College s Secondary Athletic Insurance Policy Waiver Please sign below showing that you have read and understand all information regarding Olivet College s Athletic Secondary Excess Insurance. (Parent/Guardian Name) (Parent/Guardian Signature) (Date) (Student-Athlete Name) (Sport(s)) *If you have any future questions please feel free to contact the Athletic Training Dpartment.* Ryan Shockey, MBA, AT, ATC Amanda Cox, AT, ATC Lauren Weikel, AT, ATC Head Athletic Trainer Assistant Athletic Trainer Assistant Athletic Trainer (269) (O) (269) (O) (269) (O) rshockey@olivetcollege.edu acox@olivetcollege.edu lweikel@olivetcollege.edu

5 OLIVET COLLEGE ATHLETIC TRAINING PRE-PARTICIPATION PHYSICAL EXAMINATION (AT FORM # ) Name: SS#: Date: Height: Weight: Vision: Pulse: BP: With correction Without correction Orthopedic Examination Body Part/Joint Status Details Cervical Spine Thoracic Spine Lumbar Spine Shoulder Elbow Wrist Hand/Fingers Hip/Pelvis Knee Ankle Foot/Toes General Flexibility General Examination Body Part Status Details Head Eyes Ears Nose Throat Chest Heart Lungs Abdomen Skin Hernia Physician comments and/or recommendations: Athlete cleared to fully participate in athletic activity? YES NO If NO, please explain: Physician Signature Athletic Trainer Signature Date: Date:

6 OLIVET COLLEGE ADULT ADHD/ADD EVALUATION FORM (AT FORM # ) Effective August, 2009 the NCAA has required stricter documentation of the use of prescription medications that contain banned substances. Such medications include those that are used to treat adult ADHD/ADD. As an NCAA institution Olivet College is required to have the following documentation on file for student-athletes that are currently taking medications similar to Adderall and Ritalin, etc. Name: DOB: Sport: Provider: Your patient is a student-athlete participating in intercollegiate athletics at Olivet College. The NCAA bans the use of some stimulant medications and requires that the following documentation be submitted to support a request for a medical exception in the case of a positive drug test for such use. In completing this paper work, you acknowledge that you have reviewed the patient s health history and have informed them at some time of the safety information regarding stimulant use as well as misuse guidelines. Please attach any consult letters or notes that may clarify their diagnosis and the need to use stimulant medication for treatment. Thank you for taking the time to do this. We greatly appreciated your assistance as we are trying to comply with NCAA requirements! Required ADHD evaluation components: Comments: o Comprehensive clinical evaluation (using DSM-IV criteria) _ o Adult ADHD Rating Scale (e.g., Adult ADHD self report scale (ASRS), CONNER s, Adult ADHD reporting scale (CAARS) Score: o Monitored blood pressure and pulse: o Alternative non-banned medications have been considered: *Please submit copies of test results for the student-athlete medical records and NCAA purposes* Reporting of ADHD symptoms by significant individuals: Other Psychological Testing: Physical Examination Date: / / Results: Laboratory/ Testing: Previous Documentation of ADHD Diagnosis: Other/Comments: Diagnosis: Medication and Dosage: The student-athlete will follow up with me in (circle one) 3 months 6 months 12 months Other: Physician Name (printed): Date: Physician Signature: Specialty: (M.D. or D.O.) Office Address: Contact Number: Please feel free to attach any clinical SOAP notes that may help clarify your patient/our athlete s diagnosis of ADHD/ADD and the need for stimulant medications. THANK YOU FOR YOUR TIME! Student Athletes: Please complete the following; I,, give permission to release all information regarding my treatment for ADHD to the Olivet College Athletic Training Department and the National Collegiate Athletic Association. This authorization will be valid for one calendar year and must be resubmitted annually. I may revoke this authorization at any time by submitting a letter in writing to the Athletic Training Department, understanding that all information released prior to my revocation is excluded. My signature below indicates that I have read and understand the above statement. Signature: Date: Parent/Guardian Signature: Date: (if under 18 years)

7 OLIVET COLLEGE ATHLETIC TRAINING PRE-PARTICPATION HEALTH HISTORY FORM (AT FORM # ) Name Age SS# Gender: M or F Date of Birth Yr./School Sport(s) Local Address _ Cell Phone ( ) MEDICAL HISTORY 1. Yes No Are you currently taking any medication(s)? If yes, please list 2. Yes No Are you currently taking any nutritional, performance, or herbal supplement(s)? If yes, please list. 3. Yes No Do you have any known allergies? If yes please indicate below. Medications, please list Bees, what medication do you take? Food, please list Seasonal, what medication do you take? 4. Yes No Do you have asthma? If yes, please list medication. 5. Yes No Have you ever experienced fainting, dizziness, headaches, or shortness of breath? If yes, please indicate cause(s). Heart Physical Exertion Heat Dehydration Unknown Other, please explain. 6. Yes No Have you ever been diagnosed with a heart related condition? If yes, please explain. 7. Yes No Has anyone in your family ever died suddenly from a heart or lung condition? If yes, please explain. 8. Yes No Have you ever injured (broken/sprained/strained) any part of your body requiring medical attention? If yes, please specify. SIDE BODY PART TYPE OF INJURY YEAR 9. Yes No Did any of these injuries require surgery? If yes, please specify. 10. Yes No Have you ever sustained a head injury or concussion? If yes, please specify how many and the year(s) they occurred. _ 11. Yes No Have you ever lost consciousness or blacked or after sustaining a head injury? If yes, how many times and when? 12. Yes No Have you ever had a stinger/burner/numbness of the neck/shoulder region? If yes, please specify how many and the year(s) they occurred. 13. Yes No Do you utilize any type of assistive devices (braces/orthotics) while participating in athletics? If yes, please specify. 14. Yes No Have you ever experienced removal or loss of function of a paired organ? If yes, please specify organ(s). 15. Yes No Have you ever been advised that you carry the Sickle Cell Trait/I have Sickle Cell Anemia? **I attest that the above medical history questions have been answered honestly and accurately. ** Student-Athlete Signature Parent/Guardian Signature (Required if under 18 years of age) Date Date

8 OLIVET COLLEGE ATHLETIC TRAINING INSURANCE FORM (AT FORM # ) Note: Complete all blanks on this form. Failure to complete all blanks will result in claims processing delays. If information is not applicable, indicate the reason it is not (e.g. deceased, divorced, unknown). Name of Athlete Social Security No. or Passport No. College Address Home Address _ Sport Date of Birth Cell Phone ( ) Home Phone ( ) City State Zip I agree that the following insurance information is correct and current. I am aware it is my responsibility to notify the Athletic Training Department of any changes in this coverage. Signature of student-athlete FATHER/GUARDIAN INFORMATION Father s Name Date of Birth Address MOTHER/GUARDIAN INFORMATION Mother s Name Date of Birth Address Employer Address Telephone ( ) Medical Insurance Company or Plan Address Policy Number Group Number Telephone ( ) Employer Address Telephone ( ) Medical Insurance Company or Plan Address Policy Number Group Number Telephone ( ) STUDENT INSURANCE INFORMATION (ONLY IF YOU HAVE DIFFERENT INSURANCE THEN PARENTS/GUARDIANS) Medical Insurance Company Address City State Zip Telephone Number Policy, Contract, or ID Number Group Number Is Student s Primary Insurance Plan an HMO or PPO? Yes No Is pre-authorization required to obtain treatment? Yes No Is a second opinion required before surgery? Yes No PRIMARY CARE PHSYICIAN PHONE Address **PLEASE ALSO ATTACH A COPY OF THE ATHLETE S INSURANCE CARD (FRONT/BACK)**

9 OLIVET COLLEGE ATHLETIC TRAINING MEDICAL CONSENT & ACCEPTANCE OF RISK FORM (AT FORM # ) THE FOLLOWING POLICY AND CONSENT FORMS WILL REMAIN VALID FOR SIX YEARS FROM THE DATE OF SIGNAUTRE. The following documentation is to be read carefully. If you are under 18 years of age, your parent or guardian must also sign. MEDICAL CONSENT I hereby grant permission to the Olivet College Athletic Training Staff, Team Physician/Consultants, and Student Services to render to my son/daughter, or myself, any medical care deemed reasonably necessary. This includes prevention care, first aid, rehabilitation, and emergency care treatment. Also, if deemed necessary, I grant for hospitalization. PRINT STUDENT-ATHLETE NAME DATE SIGNATURE STUDENT-ATHLETE SIGNATURE PARENT/GUARDIAN (If under 18 years of age) ACCEPTANCE OF RISK AND SHARED RESPONSIBILITY FOR ATHLETIC SAFETY I understand that passing the pre-participation physical examination does not necessarily mean that I am physically qualified to engage in athletics, but only that the examiner did not find a medical reason to disqualify me from participation. I realize that participation in athletics entails risk of injury, permanent disability, and even death. I understand that I share in the responsibility of minimizing the risks to myself and others by keeping in the best possible condition and by following the advice of the Team Physicians/Consultants, Athletic Trainers, Student Services, and Coaches concerning the prevention, treatment, and rehabilitation of athletic injuries or illnesses. I accept the responsibility of promptly reporting all injuries and illnesses. I accept the responsibility of promptly reporting all injuries and illnesses to the Athletic Trainers. I understand that I must provide accurate and honest information regarding my physical condition including all previous history and current medications. I, the undersigned, have read and fully understand the above acceptance of risk and shared responsibility statement. I acknowledge the fact of these risks, and I am willing to assume responsibility while participating in athletics at Olivet College. PRINT STUDENT-ATHLETE NAME DATE SIGNATURE STUDENT-ATHLETE SIGNATURE PARENT/GUARDIAN (If under 18 years old)

10 OLIVET COLLEGE ATHLETIC TRAINING MEDICAL INFORMATION RELEASE FORM (AT FORM # ) I hereby authorize the disclosure of my individual identifiable health information as described below. I understand that this authorization is voluntary and that I may revoke it at any time by submitting my revocation in writing to the entity providing the information. Student-Athlete Name: (Print Name) Persons/organizations authorized to provide the information: Olivet College Athletic Training Staff, Team Physicians/Consultants, and Student Services. Persons/organizations authorized to receive the information: Olivet College Athletic Training Staff, Team Physicians/Consultants, Student Services, Parents or guardians of the student-athlete; Olivet College coaches, sports information department, and administration, and the public media. Specific description of information to be used or disclosed: Any and all information regarding injuries or illnesses received in connection with the student s participation in Olivet College athletics and related medical information. Specific purpose of the disclosure: To communicate pertinent information between the Olivet College Athletic Training Staff, Team Physicians/Consultants, and Student Services regarding a student-athlete s injury or illness. To advise parents/guardians, Olivet College coaches, sports information department, and the public media of the student s physical condition related to the student s participation in Olivet College athletics. This authorization will expire six years after the date of signature. Important Information About Your Rights I have read and understood the following statements about my rights: I may revoke this authorization at any time prior to its expiration date by notifying the providing organization in writing, but revocation will not have any effect on any actions the entity took before it received the revocation. I may see and copy the information described on this form if I ask for it. I am not required to sign this form to receive my health care treatment, but will not be permitted to participate in the Olivet College Athletic Program. The information used or disclosed pursuant to this authorization may be re-disclosed by the receiving entity. Signature of Student-Athlete Signature of Parent/Guardian (if under 18 years of age) Date Date * YOU MAY REFUSE TO SIGN THIS AUTHORIZATION * THIS AUTHORIZATION IS NOT VALID IF IT HAS NOT BEEN FILLED OUT COMPLETELY OR IF THE AUTHORIZATION HAS EXPIRED.