Liberty University Club Sports Health Insurance Information/Authorization Page 1 of 5

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1 LIBERTY UNIVERSITY CLUB SPORTS Health Insurance Information / Authorization s Name Classification: Date of Birth Sport Returning Athlete? Yes/No Social Security No. LU Permanent Home Address City/State/Zip Permanent Home Phone # Cell Phone # In case of emergency contact: Name: Relationship: Phone # Medical History Medications currently taking: Allergies/Asthma? Previous Surgeries (please describe): History of Concussions (how many): Health Insurance Information: Provider: Policy Number Provider's Address and Phone Number: Policy Holder: Relationship to Student Date of Birth and Social Security Number of Policy Holder: Parent/Guardian Information: Father Name: Mother Name: Primary Phone: Primary Phone: Is father employed? Y/N If yes, fill out section A Is mother employed? Y/N If yes, fill out Section B Section A (Father) Section B (Mother) Employer: Employer: Phone: Phone: Insurance Company: Insurance Company: PLEASE READ THE NEXT PAGE CAREFULLY! Health Insurance Information/Authorization Page 1 of 5

2 The accident policy provides insurance for student-athletes with injuries occurring only when participating in the play or practice of club athletics. This accident policy is considered EXCESS or SECONDARY to any other collectible group insurance benefits. Therefore, any claims for benefits must first be filed with the group insurance company providing coverage. Only after all available benefits have been exhausted will the Liberty University Club Athletics insurance carrier consider payment for any remaining balances. I understand that Liberty University s club insurance policy does not cover expenses for pre-existing conditions or for medical services received outside of Liberty s medical providers without permission from the designated Club Sports Official. This includes second opinions. I hereby authorize, hospitals, & physicians connected with or provided, to furnish information to insurance carriers concerning any illness, injury, & treatments & I hereby assign to the party all payments for medical services rendered to the student-athlete. I agree to supply any & all information requested by my primary insurance, & their excess insurance company in a timely manner. I hereby authorize and their excess insurance company to secure & inspect copies of case history records, lab reports, diagnoses, x-rays, & any other data pertaining to the injury/illness I am receiving care for or previous confinements of disabilities relevant to the care of the injury/illness. I hereby authorize and/or my coach to hospitalize & secure treatment for me for any athletic injury/illness. A photocopy of this authorization shall be deemed as effective & valid as the original. I agree to notify immediately upon any change in the above health insurance information. If I fail to do so, I fully understand that I may be responsible for any & all charges incurred. I hereby certify that I have read & understand the above statements, that any & all questions have been answered to my satisfaction, & that the answers provided are true, complete, & correct to the best of my knowledge. SIGNATURE OF ATHLETE:

3 WARNING, AGREEMENT TO OBEY INSTRUCTIONS, AND ASSUMPTION OF RISK Information Name (Last, First, M.I.): SSN: - - M F DOB: Academic Classification (for upcoming year): Fresh. Soph. Jr. Sr. 5 th Year Primary Sport: I am aware that playing or practicing to play/participate in any sport can be a dangerous activity involving many risks of injury. I understand that the dangers and risks of playing or practicing to play/participate in the above sport include, but are not limited to: death, serious neck and spinal injuries which may result in complete or partial paralysis and/or brain damage; serious injury to virtually all internal organs; and/or serious injury to virtually all bones, joints, ligaments, muscles, tendons, and other aspects of the musculoskeletal system, and serious injury or impairment to other aspects of my body, general health, and well-being. I understand that the dangers and risks of playing or practicing to play/participate in the above sport may result in not only serious injury but also in serious impairment to my future abilities to earn a living, engage in other business, social and recreational activities, and generally to enjoy life. Because of the dangers of participating in the above sport, I recognize the importance of following coaches instructions regarding playing techniques, training and other team rules, etc., and agree to obey such instructions. I also recognize the importance of following the advice of the athletic training staff and team physicians concerning the treatment and rehabilitation of any injury that may be sustained while playing or practicing to play/participate in the above sport. I desire to participate in club sports at Liberty University. In order to participate in club sports, I agree to the terms of this agreement and assume all risks associated with my participation in club sports, including those specifically outlined below. Risks: PARTICIPATION IN CLUB SPORTS INCLUDES CERTAIN ACTIVITIES THAT HAVE INHERENT RISKS WHICH MAY AFFECT ME, INCLUDING, BUT NOT LIMITED TO, PROPERTY DAMAGE OR LOSS, TEMPORARY OR PERMANENT BODILY INJURY, SICKNESS, DISEASE, AND EVEN DEATH. Specific risks that may be involved in participating in club sports include, but are not limited to: unwanted contact with other participants and their playing equipment, equipment failure, fastmoving playing equipment (including things like balls), contact with the playing surface and surrounding elements, environmental conditions (including weather), slipping, tripping, falling, and my individual susceptibility to harm or injury (whether known or unknown to me). The results of these and other inherent risks may include, but are not limited to, serious neck and spinal injuries, complete or partial paralysis and/or brain damage, serious injury to internal organs, bones, joints, ligaments, muscles, tendons, and other aspects of my musculoskeletal system, concussions, sprains, and other serious injury or impairment to other aspects of my body, and my general health and well-being. The following is to be completed if your sports participation is with one of the following contact/collision sport teams: Hockey Lacrosse Wrestling I am aware that the nature of the sport noted above enhances the possibility of severe injury, complete or partial paralysis, serious brain injury, and/or death due to the contact nature of the sport with other players or objects/equipment of the game. I specifically acknowledge that is a VIOLENT CONTACT/COLLISION SPORT (Indicate sport) involving even greater risk of injury than other sports. Health Insurance Information/Authorization Page 3 of 5

4 MEDICAL AUTHORIZATION Permission is hereby granted to the Liberty University Club Athletic Training staff to proceed with any needed medical or minor surgical treatment, X-ray, examination, and/or immunizations for the above named student-athlete. In the event that I am unconscious or mentally unable to make a sound reasonable decision due to a serious injury or illness, I understand that the decision for needed major surgery or emergency medical treatment will be made by the attending physician and/or athletic training staff member. School year: STUDENT-ATHLETE AUTHORIZATION/CONSENT FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION I hereby authorize the physicians, athletic trainers, athletic training staff and other health care personnel representing Liberty University and to release information regarding my protected health information and any related information regarding any injury or illness during my training for and participation in club athletics at Liberty University. I also authorize the release of medical information to NFL, NHL, NBA, WNBA, MLB and USATF scouts. This protected health information may concern my medical status, medical condition, injuries, prognosis, diagnosis, athletic participation status and related personally identifiable health information. This protected health information may be released to other health care providers, parents/guardians, hospitals and/or medical clinics and laboratories, athletic coaches, strength and conditioning coaches, medical insurance coordinators, insurance carriers, medical supply vendors and/or service companies, academic counselors, athletic and/or university administrators, chaplains and/or clergy members, sports information staff and members of the media I understand that my authorization/consent for the disclosure of my protected health information is a condition for participation as a club athlete at Liberty University. I understand that my protected health information is protected by federal regulations under either the Health Information Portability and Accountability Act (HIPAA) or the Family Education Rights and Privacy Act of 1974 (Buckley Amendment) and may not be disclosed without either my authorization under HIPAA or my consent under the Buckley Amendment. I understand that once information is disclosed per my authorization/consent, the information is subject to re-disclosure and may no longer be protected by HIPAA or the Buckley Amendment. I understand that I may revoke this authorization/consent at any time by notifying the Club Head Athletic Trainer in writing, but if I do, it will have not have any effect on the actions the took in reliance on this authorization/consent prior to receiving the revocation. I also understand that revoking this authorization/consent is a condition for participation in club athletics at Liberty University. This authorization/consent expires six years from the date it is signed. A complete copy of the Notice of Privacy Practices can be viewed on-line at Signature of : Printed Name of : SS# of : Sport: Date of Birth: Signature of Parent/Legal Guardian (if student athlete is under 18)

5 Authorization to Disclose HIPPA Information to Third Parties By law, if you are over 18 we, the Coaching and Athletic Training Staff, cannot discuss your health or financial/billing information with anyone without your written permission. Please either list anyone who you give permission for us to speak with concerning your health or financial billing information other than yourself or write "NONE" and initial your choices. Please note that in order to discuss any information either in written form or by telephone, the person must be listed below. Athlete's Name Date of Birth I give permission for you to discuss my health and/or financial information with: Relationship to Patient Initial Relationship to Patient Initial Relationship to Patient Initial Relationship to Patient Initial Relationship to Patient Initial Relationship to Patient Initial Athlete's Signature Date Health Insurance Information/Authorization Page 5 of 5