To the Parents of Varsity Athletes:

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1 To the Parents of Varsity Athletes: We are all familiar with rising health care costs. Valparaiso University, in studying its health costs annually, has to struggle with these same issues. Having reviewed the current costs for the University s athletic insurance program, we need to continue our policy that the University s athletic insurance coverage will supplement, and be considered secondary, to the family s coverage and pay those costs not covered by the family s policy. Therefore, the University will need to ask student-athletes and their parents to first submit any claims arising from athletic injuries to their own insurance company. Whatever costs are not covered by the family s policy will be submitted for consideration to the University s insurance carrier. These Accident Benefits apply only when charges are incurred for medical care and treatment needed due to a covered sports injury. No payment will be made for charges incurred in connection with a pre-existing injury or condition or for care and treatment of a sickness. Any claim submitted after 52 weeks from the date of injury will not be considered for benefit coverage. To help explain this policy, we have enclosed an informational sheet. We have also enclosed an insurance questionnaire, which we ask you to complete and return to the Athletic Trainer s office. It is important that this questionnaire be completed as soon as possible. A student athlete must have this form on file before he or she will be eligible to participate in athletics. If you have any questions, please feel free to contact , extension #1. Sincerely, Mark S. LaBarbera Director of Athletics Enclosures

2 Dear Parents incoming Freshman and Transfer Student Athletes, Attached is a checklist and enclosed are forms that need to be completed and returned to their designated addresses no later than July 1 st. If all paper work is not completed and received, your son or daughter may not begin practice with their sport. Thank you for your attention to this information, any questions please call us at or Checklist: Please return the following to: Please Return the Following To: Sports Medicine Valparaiso University Valparaiso Health Center 1009 Union St LaPorte Ave. Valparaiso, IN Valparaiso, IN Insurance Information Form Copy of Insurance Card (Front and Back) Health Center Release of Information Completed Physical (FOUND at Click on Health Form on bottom right) Dear Parents Returning Student Athletes, Attached is a checklist and enclosed are forms that need to be completed and returned to their designated addresses no later than July 1 st. If all paper work is not completed and received, your son or daughter may not begin practice with their sport. Thank you for your attention to this information, any questions please call us at or Checklist: Please return the following to: Please Return the Following To: Sports Medicine Valparaiso University Valparaiso Health Center 1009 Union St LaPorte Ave. Valparaiso, IN Valparaiso, IN Insurance Information Form Copy of Insurance Card (Front and Back) Health Center Release of Information

3 Valparaiso University Sports Medicine Health Insurance & Emergency Contact Information Student-Athlete s Name: Sport(s): Valparaiso University Athletic Department s accident policy only provides insurance coverage for student-athlete injuries that occur while participating in the play or practice of intercollegiate sports. This policy is considered EXCESS or SECONDARY to any other collectible group insurance benefits. This simply means that any claims must FIRST be filed with any other valid and collectible group insurance policy under which the student-athlete is covered. Only after the student-athlete s PRIMARY carrier has exhausted all available benefits will our athletic insurance company consider the payment of remaining balances, PROVIDED THE CLAIMS ARE SUBMITTED WITHIN THE SPECIFIED TIME PERIOD (52 WEEKS) AND THE FOLLOWING CLAIM PROCEDURES ARE FOLLOWED WITH THE REQUIRED DOCUMENTATION PROVIDED. The University s athletic policy covers athletic injuries only and is not a substitute for comprehensive medical coverage. It is important that you send with this form a copy of the front AND back of your health, prescription and /or dental insurance cards. Student-Athlete Information Name: Year in School: Fresh Soph Jr SR 5th Date of Birth: / / Permanent Home Address: City, State, Zip: Cell Phone Number: Social Security #: Emergency Contact Information Primary Contact Name: Relationship: Home Phone: Work Phone: Cell Phone: Secondary Contact Name: Relationship: Home Phone: Work Phone: Cell Phone: Insurance Information Primary Insurance Company: Group # or Name: Policy #: HMO PPO POS Other Insurance Company Phone: Pre-certification required? Yes No Claims Mailing Address: City, State, Zip: Name of Insured: Relationship to Student: Father Mother Self Other: Insured Person s Date of Birth: / / SSN: Phone: Employer: Employer Address: Secondary Insurance Company: Group # or Name: Policy #: HMO PPO POS Other Insurance Company Phone: Pre-certification required? Yes No Claims Mailing Address: City, State, Zip: Name of Insured: Relationship to Student: Father Mother Self Other: Insured Person s Date of Birth: / / Phone: SSN: Employer: Employer Address: ** Please Inform the Sports Medicine office of any insurance changes during the course of the year** Authorization to Obtain Information To all physicians; medical professionals; hospitals; clinics; other health care providers; insures; employers; group policy holders; insurance support organizations; and other persons who have information about the patient. I permit the release of any medical information about me to Valparaiso University and Travelers Mutual Insurance. This applies to all information about the diagnosis, treatment, or prognosis or any illness or injury I now have or had in the past. The company will use this information to find out if any claim is eligible. A Photostat of this authorization shall be deemed as effective and valid as the original. I certify that the above information given by me is true and correct to the best of my knowledge. I authorize Valparaiso University or its insurance agent to pay the medical vendors directly for any bills incurred from the Intercollegiate athletic accidents. Signature of Policy Holder: Date: / /

4 Authorization for Release of Medical Information DATE: ENROLLMENT STATUS: FR SO JR SR NAME: ADDRESS: DOB / / PHONE: SS#. VARSITY SPORT(S): I hearby authorize Valparaiso University Health Center to permit Valparaiso University Sports Medicine Staff to review or receive a copy of my medical record and any information contained therein, whether written or audio taped, saved on computer disk, or any other means of storing and/or exchanging medical information. I understand that I may revoke this authorization to release medical records to Valparaiso University Sports Medicine Staff in writing at any time. This authorization shall remain valid until it is either revoked or the athlete is no longer a member of a Valparaiso University athletic team. I also understand that unless I indicate otherwise, this authorization to release medical records includes permission to release information pertaining to my physical history ONLY. Information pertaining to emotional illness, including treatment for mental illness, drug or alcohol abuse, communicable diseases including HIV/AIDS information may NOT be released without my specific written permission. I understand that my records are protected under federal law and state confidentiality laws and relations and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that I may revoke this consent at any time except to the extent that action has been taken to release therein and that in any event this consent expires automatically as described below. It is understood that this consent can be revoked at any time except to the extent that action has been taken. Student Signature Date I DO NOT authorize the release of a copy of my medical record. Student Signature Date This information has been disclosed to you from records protected by federal confidentiality rules (42C.F.R. part 2). The federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise by 42 C.F.R. Part 2. A general authorization for the release of medical or other information is not sufficient for this purpose. The federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.

5 TO THE PARENTS OF VALPARAISO UNIVERSITY STUDENTS PARTICIPATING IN INTERCOLLEGIATE ATHLETICS * Please Retain This Letter for Future Reference * The program coverage for all intercollegiate athletes is through the Brotherhood Mutual Insurance Company and administered by Special Risk Claims Commercial Travelers Mutual Insurance Company, Utica, NY. The coverage for any injury arising from participation of intercollegiate athletics is for those bills that may be incurred and submitted within ONE YEAR (52 weeks) of the reported injury. The coverage for any injury arising from participation in intercollegiate sports (from date of injury) is up to $50, 000 per claim. Any claim submitted after 52 weeks from the date of injury will not be considered for benefit coverage. No payment will be made for charges incurred in connection with pre-existing injury or condition or for care of treatment of a sickness. The University s coverage, however, is considered secondary to the athlete s or family s own medical benefit plan coverage. Therefore, it is necessary that claims be submitted to the athlete s personal, family or employer group medical benefit plan first so that the insurance company, HMO or PPO may contribute their maximum benefit first. Then, any costs not covered by the personal or family policy, including HMO or PPO plans, will be submitted to the Valparaiso University athletic insurance carrier for consideration PROVIDED THE CLAIMS ARE SUBMITTED WITHIN THE SPECIFIED TIME PERIOD AND THE FOLLOWING CLAIM PROCEDURES ARE FOLLOWED WITH THE REQUIRED DOCUMENTATION PROVIDED. INTERCOLLEGIATE ATHLETIC INJURY INSURANCE CLAIM FILING PROCEDURES. In order to file a VU athletic injury insurance claim for benefit consideration, the following procedures MUST be followed and all required paperwork MUST be supplied and submitted to the VU Athletic Trainer. Failure to do so will result in non-payment of the claim, as the insurance carrier and University will not process or consider benefits unless they receive all the required paperwork from the athlete or parent within ONE YEAR (52 weeks) from the date of injury.

6 1. The athlete must immediately report his/her injury to the Athletic Trainer and personally complete a Notification of Injury claim form. The Athletic Trainers will supply that form. Please Contact: Valparaiso University Sports Medicine Athletics Recreation Center 1009 Union St. Valparaiso, IN PH The athlete or parent is personally responsible for making sure that all of the provider bills as well as prescription bills are initially filed to their own personal, family or employer group medical benefit plan AS QUICKLY AS POSSIBLE - even if claim will be denied. It is necessary for the athlete or parent to supply information to each provider of service. [The University s coverage is considered SECONDARY to the athlete or parents personal, family or employer group medical plan coverage and will not consider benefits until they receive a copy of the private insurance carrier s Explanation of Benefits (EOB) statement indicating how they initially paid or denied the claim.] Note: Before filing claims to their own personal, family or employer group medical benefit plan, the athlete or parent must make copies of all original itemized bills and prescription statements and receipts and submit them to the VU Athletic Trainer immediately. The VU insurance carrier will not consider benefits unless copies of all itemized bills are submitted when the VU claim is filed. The VU insurance carrier will not accept or process subsequent billing statements or ledgers. If the medical provider does not initially send an itemized statement to the athlete it will be necessary for the ATHLETE OR PARENT to contact the medical provider to obtain one. 3. After the athlete s personal, family or employer group carrier, HMO or PPO has been processed and considered the claim, they will send the athlete or parent an Explanation of Benefits (EOB) statement indicating how the plan has paid or denied each claim. 4. The athlete or parent must submit a copy of the EOB statement received to the VU Athletic Trainer for processing. 5. If the athlete has no personal, family or employer group insurance coverage, HMO or PPO, this must be noted on the enclosed parent Insurance Questionnaire. In this case, to file a claim, the athlete should comply with step #1 and submit copies of all medical provider s itemized billing statements and/or prescription statements and receipts to the VU Athletic Trainer for processing.

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