Dear Parents/Student-Athletes:

Transcription

1 Dear Parents/Student-Athletes: Indiana University and the Athletic Department provides excellent health care for our student-athletes. Superior facilities with certified athletic trainers in attendance are available in the athletic complex for assessment, treatment and rehabilitation of athletic injuries. All of the medical facilities are under the supervision of the team physician. Should it be necessary to utilize specialists, excellent consultants are available in all areas. Enclosed with this letter are several pieces of information that we would like you to become familiar with so that you will know what your son or daughter can expect as a student-athlete at Indiana University. The pages entitled "Sports Medicine Program" are very important. They explain our policies and procedures regarding medical, dental, optometric services, insurance and participation eligibility. Please keep these pages to refer to from time to time. Also enclosed is a health history questionnaire, physical exam, and insurance form to be filled out in conjunction with your family doctor and return to us for processing as soon as possible. All new student-athletes must pass a physical examination before being allowed to compete. Any student-athlete who wishes to compete and is not on a scholarship from the Athletic Department must provide proof of health insurance and get their own physical examination utilizing I.U. Sports Medicine forms. If your son or daughter becomes a rostered squad member, all subsequent physical exams are provided by the Athletic Department. If an injury does occur during participation in an intercollegiate sport, the Athletic Department would utilize any medical insurance coverage your son or daughter may have to assist in defraying medical expenses and have enclosed an insurance form to be filled out and returned to us. Any costs not covered by your insurance will be paid by the Athletic Department so that no out-of-pocket expenses will be incurred by you. The Athletic Department cannot be responsible for the costs of any medically related accident, injury or illness that may occur outside of the intercollegiate sport that the student-athlete may compete in. Therefore, we greatly encourage you to evaluate your personal medical insurance to be sure you have the appropriate coverage. Thank you for your cooperation. If you have any questions please feel free to contact me at (812) Sincerely, Kip Smith, MEd, LAT, ATC Head Athletic Trainer Enclosures

2 ATTENTION BEFORE MAILING, PLEASE USE THE CHECKLIST BELOW TO MAKE SURE YOU HAVE ALL THE INFORMATION NEEDED. _ Medical History questionnaire is completed (front and back) _ Immunization dates are completed _ Physical is completed INCLUDING blood work. _ Insurance form is completed [front and back] and signed by parents and athlete _ Clear readable copies of both front and back of all Insurance and Pharmacy cards are enclosed (This information must be received BEFORE you come to campus) If you have checked all these boxes then mail the completed packet to the below address. PLEASE NOTE: Indiana University Sports Medicine Department Assembly Hall 1001 E. 17 th Street Bloomington, IN You will also receive, in separate mailings, a yellow Health History Form from the Indiana University Health Center and a brown Student Immunization Record Form from the Office of the Registrar. These should NOT be confused with our forms as they are two separate forms and go to different locations. Please return the yellow and brown forms to their respective locations and the attached white forms to the Sports Medicine Department.

3 SPORTS MEDICINE PROGRAM A. MEDICAL SERVICES The sports medicine program at Indiana University works under the direct supervision of the team physician who is located in Assembly Hall. If a student-athlete should be injured while participating in an intercollegiate sports program, he/she will be evaluated by a competent athletic trainer, provided immediate care, and referred to whatever medical personnel necessary. The role and function of the athletic trainers are to implement prevention of injury programs, provide immediate care and treatment, and follow rehabilitation procedures for the injured student-athlete as directed by the team physician. Certified athletic trainers will provide the student-athlete with the basic health care needs and direct him/her to the team physician, adult nurse practitioner, etc., when it is necessary. Today's athletic trainer is a well-trained professional who is an integral part of a complete athletic program. The team physician has at his disposal medical consultants in every field of the medical profession. If a student-athlete is sent to one of the medical consultants, he/she will be given a referral form or a phone call will be made on their behalf to arrange for an appointment. If, for any reason, other than a life threatening situation, a student-athlete goes to a doctor or hospital without prior approval of the team physician or athletic trainer, the student-athlete will be responsible for those fees incurred. The sports medicine program will provide direct medical coverage, with its staff and/or athletic training students, only if the sport activity is an approved Athletic Department scheduled event, or coach supervised practice. Every effort will be made to provide coverage for the non-traditional or out-ofseason practices or workout during the academic school year. Summer conditioning workouts will only receive coverage if there is strength/conditioning supervision as mandated by NCAA. B. MEDICAL FACILITIES The Athletic Training Rooms located at Assembly Hall, Memorial Stadium and University Gym are the main source of medical care for student-athletes during their competitive season. The Indiana University Health Center is an ancillary facility which is used for physician referral, pharmacy, lab tests and x-rays. Bloomington Hospital should be accessed when one is unable to locate their respective staff athletic trainer and/or team physician. The hospital is also used for physician referral, surgeries, diagnostic tests, emergencies, etc. C. IN-SEASON AND OUT-OF-SEASON INJURIES OR ILLNESS All injuries, cuts, abrasions, etc. must be reported after practice or competition during the athletes' traditional as well as non-traditional seasons. The athletic trainer responsible for the sport will make an evaluation and take the appropriate action of treatment or referral. If an illness occurs, the student-athletes must check with their respective athletic trainer and let him/her evaluate the problem and refer to the appropriate physician, adult nurse practitioner, or medical facility.

4 The Athletic Department can only provide expenses for medical treatment incurred by a studentathlete as a result of an athletically related injury (coach supervised practice or competition) or while participating in voluntary physical activities that will prepare the student-athlete for competition during the academic year (as per department policy). When out-of-season and the team physician or nurse practitioner is not available, the Indiana University Health Center or Bloomington Hospital is the source of medical service. Any costs or fees incurred at this time are the responsibility of the student-athlete. The athletic trainers, however, will always be available for consultation about personal problems and provide any treatment and rehabilitation for injuries caused during the in-season. D. MEDICAL CARE AFTER ELIGIBILITY When a student-athlete's playing eligibility is completed, he/she must receive an exit physical review from a sports medicine staff member to identify any existing medical injury or problem. It is a Department policy that a student-athlete be allowed one year to take care of any medical problem, i.e., surgery, rehabilitation, etc., as a result of direct and eligible athletic participation. This should be coordinated through the team physician and staff athletic trainer. Otherwise, the Athletic Department cannot be responsible for the charges. E. EMERGENCY TREATMENT When the training room happens to be closed and you find yourself in need of medical treatment, call either the head athletic trainer or the staff athletic trainer responsible to your sport. In extreme emergencies, and only after failing to reach either the head athletic trainer or staff trainer at home, notify the team physician as soon as possible and report directly to Bloomington Hospital. F. THE ATHLETIC TRAINING ROOM As stated previously, the Assembly Hall, University Gym and the John Miller (Stadium) athletic training rooms are the main facilities for the sports medicine program. During the Fall and Spring semesters, the Athletic Training Rooms will generally be open Monday to Friday, 8:00 a.m. to 6:00 p.m. for injury evaluation, treatment and rehabilitation. Other athletic training room hours will be set up between the athletic trainer and their respective athletes. G. GENERAL TRAINING ROOM RULES 1. Student-athletes should park their vehicle only in those areas so designated. Do not block the driveway to the loading area. 2. All Athletic Training Room facilities are coeducational; therefore, be sure to be dressed properly. 3. Do not wear cleats or dirty uniforms into the Athletic Training Room. Shower first before entering. 4. The Athletic Training Room is not a self-serve facility. All taping, first aid, and treatment will be administered by the athletic trainers in charge. Be patient and wait your turn. 5. The telephones in the Athletic Training Room are for business only. Student-athletes are not to use their cell phones in the Athletic Training Room. 6. Return all loaned items to the Athletic Training Room. Each student-athlete will be charged for those items not returned and placed on a checklist until returned. 7. Remember, all the athletic trainers are dedicated to each student-athlete's health and safety. We will attempt to give each the best possible care but we expect courtesy, cooperation, and respect in return.

5 H. MEDICAL EXAMINATION AND CLEARANCE TO OBTAIN EQUIPMENT Any student wishing to participate in athletics must be physically and academically cleared and provide proof of current health insurance prior to try-outs or participation. Each student-athlete must have on file in the Sports Medicine Office an approved physical examination, a medical history and an insurance questionnaire in order to participate in an intercollegiate sport. Approval for participation is based on a thorough review of the student-athlete's health status. Equipment will not be issued until the manager of the equipment room is notified that the student-athlete is eligible to receive equipment. Previous to the receipt of equipment the following steps must be taken by the new (first-time) walk-on student-athlete: 1. Obtain the packet of physical examination materials and insurance form from the Sports Medicine Office or your coach. Follow the instructions outlined in each set of materials. 2. Return the completed materials to the Sports Medicine Office. 3. New walk-on student-athletes must provide the following information for use by the Sports Medicine Department. a. completed medical history questionnaire, b. completed physical examination form; the cost of this physical exam is the responsibility of the individual student-athlete; arrangements for such physical exams can be made through the Indiana University Health Center or a physician of the athlete's choice. c. proof of current health insurance on file with photostatic copies of insurance cards.* The manager of the equipment room cannot issue equipment until the signature of clearance is on file in the Athletic Training Room. "Each student-athlete and cheerleader shall have an initial physical examination when they enter a Conference intercollegiate sports program. The extent of the physical examination including laboratory studies and other diagnostic procedures will be determined by each team physician. Thereafter, an annual review of their health status shall be performed. This may include a physical examination at the discretion of the team physician. A) The final decision on physical qualification or reason for rejection shall be the responsibility of the team physician. B) The team physician shall have final authority regarding participation in practice and competition subsequent to an injury or illness." (Agreement for Men's and Women's Programs Section 16.4, Handbook of the Big Ten Intercollegiate Conference.) *There are no exceptions to this policy unless specifically authorized by the Director of Athletics.

6 I. IMMUNIZATIONS Indiana University is very concerned about providing a safer and healthier environment for all students. The University must comply with an Indiana state law which requires immunization records to be filled out on a form distributed by the Office of the Registrar and returned to their office. The Student Immunization Record form is divided into four sections and asks for important documentation of the following: A. Each student must have been given a Tetanus/Diphtheria (Td) booster within the past 10 years. (If your last booster was given more than 10 years ago, you will need to obtain a current booster). B. The University is required to inform each student about the risk associated with meningococcal diseases and recommends meningitis vaccination. C. Each student is to show dates of immunity for measles, mumps, and rubella (MMR). D. International students are required to be tested for tuberculosis (TB) in the United States. The immunization form must be completed and returned or classes may be canceled. We ask that this immunization information also be printed on the bottom of the enclosed MEDICAL HISTORY QUESTIONNAIRE. Moreover, there is a major concern among health care professionals about the rise of infectious disease in this country and the worry about the risk of transmission of blood pathogens in contact/collision sports. The Hepatitis B Virus (HBV) is 100 times more contagious than the more publicized Human Immunodeficiency Virus (HIV). Thus, the Center for Disease Control (CDC) and now the NCAA are recommending that all adolescents and young adults receive hepatitis B immunization. J. DENTAL CARE While a student-athlete attends Indiana University, the Athletic Department will be responsible for all dental problems caused by injury while participating in an authorized practice or intercollegiate contest. All dental injuries are to be reported to the athletic trainer assigned to that particular sport during that practice or contest, or immediately thereafter. Routine dental care such as routine examinations, dental cavities, wisdom teeth extractions, etc., are the responsibility of each individual athlete. K. EYE GLASSES AND CONTACT LENSES All athletic eye glasses must be safety glasses with shatterproof lenses and frames. Contact lenses will be purchased for only those athletes who, in the opinion of the staff athletic trainer, are in definite need of visual correction in order to participate in intercollegiate athletics. Replacement of lost lenses and glasses will be furnished by the Athletic Department only if they are lost or damaged during practice or a game. The loss or breakage of lenses must be reported immediately. L. INSURANCE 1. The Department of Athletics is responsible for medical services administered to student-athletes who are ill or become injured in a practice or game, which was under the coaches' supervision or while participating in voluntary physical activities that will

7 prepare the student-athlete for competition during the academic year. The word "injury" applies only to those ailments that are caused by the participation in a coach supervised practice or a game. The removal of tonsils or appendix by surgical procedure are examples of the medical problems for which the Department of Athletics cannot be responsible. The participation in sports will not cause conditions such as these and, according to department policy, we cannot be responsible for their remediation. For the above reason, we highly recommend that student-athletes or their parents carry an adequate medical and hospitalization plan on their son/daughter while he/she is in school. 2. The Department of Athletics utilizes a self-insurance program with the Office of Risk Management; however, medical expenses are continually going up. We ask that each athlete review his/her personal hospitalization insurance to help cover the hospitalization and medical fees incurred. The student-athletes' and parents' cooperation will be appreciated to allow the Department of Athletics to utilize your health insurance information. If one belongs to a group policy, such claims probably would not have an affect on the premium. However, if the insurance happens to be an individual policy, discretion should be used. 3. If there is no insurance coverage, we highly recommend that you enroll in the voluntary health coverage plan that is offered by Indiana University called the Aetna- Chickering Health Insurance. This plan would provide coverage of potential nonathletic problems. You may enroll for the Aetna-Chickering Health Insurance plan at Poplar Building, Room 165 or obtain other similar coverage on your own. 4. After completing the enclosed insurance form, please make sure you attach a copy of your insurance and prescription card(s) (front and back). M. HOSPITALIZATION AND SURGERY If a student-athlete requires either hospitalization or surgery, the team physician or the team trainer will call the parents and advise them of the information concerning the case. N. NCAA CHAMPS/Life Skills Indiana University is a participant of the NCAA CHAMPS/Life Skills program, which was created to support the student development initiatives and the quality of the studentathlete's experience while in college. The goal of the IU Student Athlete Development Program is to assist student athletes in utilizing athletic department and campus resources to develop intellectually, physically, professionally, and with an awareness of how to make a difference in society. The IU Student Athlete Development Program works in concert with the Student Athlete Advisory Committee to assist in promotion of their activities for student athletes. The Student Athlete Development Program strives to: Support student athletes in their efforts toward academic excellence and graduation. Help student athletes develop as successful, well rounded individuals. Promote respect, diversity, and collaboration. Evaluate student athlete needs and provide meaningful programs (including

8 nutrition, drug/alcohol education, and career development). Provide orientation programming for new student athletes. Encourage student athletes to contribute to the campus and the community. O. SHARED RESPONSIBILITY FOR SPORTS SAFETY Participation in sports requires an acceptance of risk of injury. Student-athletes rightfully assume that those who are responsible for the conduct of sport have taken reasonable precaution to minimize the risk of significant injury. Periodic analysis of injury patterns continuously leads to refinements in the rules and/or other safety guidelines. Attempting to legislate safety via the rule book and equipment standards alone, while helpful, is seldom effective. Relying on officials to enforce compliance with the rule book is as insufficient as relying on warning labels to produce behavioral compliance with safety guidelines. Compliance means respect on everyone's part (athlete, coach, athletic trainer, physician, athletic director) for the intent and purpose of rules and guidelines. Student-athletes, for their part, should comply with and understand the rules and standards that govern their sports. Coaches should acquaint the student-athlete appropriately with risks of injury and with the rules and practices they are employing to minimize the student-athlete's risk of significant injury while pursuing the many benefits of sport. The athletic trainers and team physician should be responsible for the prevention of injuries (where possible) and the care of those injuries which do occur. The athletics program, via the athletic administrator, is responsible for providing the safest possible environment. The student-athlete and the athletics program have a mutual need for an informed awareness of the risks being accepted and for sharing the responsibility for minimizing those risks." (NCAA "Shared Responsibility for Sports Safety)

9 Dear Health Care Provider: The Indiana University Athletic Department requires all individuals who are not on scholarship funding, and who were not on the previous season's roster, to have a physical examination report and proof of current health insurance on file before being issued equipment or participating in a practice or a tryout. The accompanying IU Athletic Department forms are provided so that the student-athlete may comply by having them completed and returned to us. Lab work is required as noted. If the Health Care Provider performing the physical cannot do this at their office or facility, it can be obtained at the IU Health Center with an order from the Health Care Provider. The charge for this lab work will be approximately $24.00 and will be the athlete's responsibility. We do require that the athlete have had a tetanus toxoid booster (or initial series), when available, within the last ten years and evidence that they have received one Rubella (German measles) and one mumps vaccination on or after the first birthday. They also must have been immunized with live measles vaccine twice, with both doses given on or after the first birthday and separated by at least 30 days. It is also recommended that all incoming student-athletes have received, or begun, the vaccination for Hepatitis B Virus (HBV). Failure to comply with the above may result in some delay in the athlete's being able to practice or tryout. Thank you for your assistance. Andy Hipskind, MD IU Team Physician

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11 Indiana University Athletic Department MEDICAL HISTORY QUESTIONNAIRE Please answer every question below as best you can. This is the only way you can help us serve you better, know more about you and your medical background, as well as give you the best possible medical care and continuation of service. If the space provided to answer questions is not adequate, attach sheet with additional information. Note: PLEASE PRINT AND FILL IN ALL INFORMATION. Name: UID. #: / / (Last or family) (First) (Middle/maiden) Sex: F M Date of Birth: / / Date of Entry to IU I am a candidate for the team (month/year) (SPORT) Home Address: (STREET/PO Box/Rural Route) CITY: STATE: ZIP CODE: Home Phone #: ( ) (area) Bloomington Address, if known: Local Phone #: Cell # IN CASE OF EMERGENCY, PERSON TO NOTIFY: Name: Relationship: Phone:( ) Home Address: ("same" if same as above) (City/State/Zip) HOME PHYSICIAN, HEALTH CLINIC OR FACILITY: Name: Phone:( ) Address: (STREET) (CITY) (STATE) (ZIPCODE) Please check in the appropriate column indicating past and present disease(s) you or members of your family have had. Family Self Family Self Family Self Alcoholism Drug Addiction/abuse Stroke Severe Allergy Epilepsy/Seizures Suicide Attempt/Act Asthma Fainting Spells Ulcer Bleeding Disorder Heart Attack Serious Mental Illness Blind-right eye Heart Disease Measles Blind-left eye Heart Rhythm Problem German Measles-3 days Deaf-left ear Hyperventilation Mumps Deaf-right ear Blood Clot in Lung Chicken Pox Depression-severe Diabetes Comments: Sickle Cell Disease Speech Disability Deaths in immediate family: IMMUNIZATIONS: (Specific measles, rubella, mumps & tetanus dates are required) Required Recommended Measles Hepatitis B Mumps Meningitis Vaccine Rubella TB Test? Yes No List allergies (medicine, foods, insects, etc): Tetanus (booster) Date of most recent Result

12 Explain "Yes" answers below. 1. Yes No 2. Yes No 3. Yes No 4. Yes No 5. Yes No 6. Yes No 7. Yes No 8. Yes No 9. Yes No 10. Yes No 11. Yes No 12. Yes No 13. Yes No 14. Yes No Has a doctor ever denied or restricted your participation in sports for any reason? 22. Yes No Has a doctor ever told you that you have asthma or allergies? Do you have an ongoing medical condition (like diabetes or asthma)? 23. Yes No Do you cough, wheeze, or have difficulty breathing during or after exercise? Are you currently taking any prescription or nonprescription (over the counter) medicines or pills? 24. Yes No Have you ever used an inhaler or taken asthma medicine? Do you have allergies to medicines, pollens, foods, or stinging insects? 25. Yes No Is there anyone in your family who has asthma? Have you ever passed out or nearly passed out DURING exercise? 26. Yes No Have you had infectious mononucleosis (mono) within the last month? Have you ever passed out or nearly passed out AFTER exercise? 27. Yes No Do you have rashes, pressure sores, or other skin problems? Have you ever had discomfort, pain, or pressure in your chest during exercise? 28. Yes No Have you had a herpes skin infection? Does your heart race or skip beats during exercise? 29. Yes No Have you ever had a head injury or concussion? Has a doctor ever told you that you have (check all that apply) high blood pressure high cholesterol heart murmur 30. Yes No Have you been hit in the head and been confused or lost your memory? Has a doctor ever ordered a test for your heart? (for example, ECG, echo) 31. Yes No Have you ever had a seizure? Has anyone in your family died for no apparent reason? 32. Yes No Do you have headaches with exercise? Does anyone in your family have a heart Have you ever had numbness, tingling, or weakness in your arms or legs after problem? 33. Yes No being hit or falling? Has any family member or relative died of heart problems or of sudden death before age 50? 34. Yes No Does anyone in your family have Marfan syndrome? 35. Yes No Have you ever spent the night in a hospital? 36. Yes No Have you ever been unable to move your arms or legs after being hit or falling? When exercising in the heat, do you have severe muscle cramps or become ill? Has a doctor told you that you or someone in your family has sickle cell trait or sickle cell disease? 15. Yes No 16. Yes No Have you ever had surgery? 37. Yes No Have you had any problems with your eyes or vision? 17. Yes No Have you ever had a stress fracture? 38. Yes No Do you wear glasses or contact lenses? Do you regularly use a brace or assistive 18. Yes No device? 39. Yes No Do you wear protective eyewear, such as goggles or a face shield? Yes No Are you happy with your weight? Have you ever had an injury, like a sprain, muscle or ligament tear, or tendinitis, that caused you to miss a practice or a game? If yes, circle affected area below: 41. Yes No Has anyone recommended you change your weight or eating habits? Have you had a broke or fractured bones for dislocated joints? If yes, circle below: 42. Yes No Were you born with or are you missing a kidney, an eye, a testicle, or any other organ? Have you had a bone or joint injury that required x-rays, MRI, CT, surgery, injections, rehabilitation, physical therapy, a brace, a cast, or crutches? If yes, circle below: 43. Yes No Do you limit or carefully control what you eat? Head Neck Shoulder Upper Arm Elbow Forearm Hand/Finger Chest Upper Back Lower Back Hip Thigh Knee Calf/Shin Ankle Foot/Toes 44. Yes No Do you have any concerns that you would like to discuss with the doctor? Females Only 45. Yes No Do you take nutritional supplements? How old were you when you had your first menstrual period? How many periods have you had in the last 12 months? Area you currently using any form of birth control? Explain "Yes" Answers here: I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct Athlete: Parent/Guardian:

13 Indiana University Athletic Department PHYSICAL EXAMINATION SP0RT NAME D.O.B. SS# BP / PULSE HGT WGT ALLERGIES CURRENT MEDICATIONS MEDICAL EXAM Normal Abnorma l COMMENT Eyes/EOM Ears Nose Throat Skin/Scalp Thyroid Lymphatics Lungs Heart Abdomen Hernia/Genitalia LNMP/Pap Neurologic Signature Date ORTHOPEDIC EXAM Normal Abnorma l COMMENT Neck Shoulder Elbow Hand/Wrist Back Knee Feet Flexibility Other Signature Date 3.

14 LABORATORY: (Required) Hemoglobin Hematocrit White Blood Count Please comment on those Medical History Questionnaire answers you consider significant. I have reviewed the data above, reviewed his/her medical history form and make the following recommendations for his/her participation in athletics. I.U. DIRECTOR OF SPORTS MEDICINE DETERMINES FINAL CLEARANCE. Full Participation No Participation Limited Participation Needs Additional Evaluation If not cleared for full participation, give reasons & recommendations: DATE: EXAMINING PHYSICIAN: (please print) Signature: Address: Telephone: ( ) FOR INDIANA UNIVERSITY USE: RECEIVED: BY: REVIEWED: BY: REVIEWED: BY: ACTION: Approved: Disapproved: Clearance withheld until: Advice:

15 MEDICAL INSURANCE INFORMATION FORM SPORT: THIS FORM MUST BE COMPLETED ANNUALLY (PLEASE COMPLETE BOTH SIDES OF FORM) COORDINATED COVERAGE CANNOT BEGIN UNTIL THIS INFORMATION IS ON FILE PATIENT INFORMATION (STUDENT ATHLETE) NAME: STUDENT ID# E MAIL ADDRESS: DATE OF BIRTH Campus/Local Phone: LAST FIRST MIDDLE CAMPUS ADDRESS: CELL PHONE: STREET CITY STATE ZIP CODE EMERGENCY CONTACT NAME: INFORMATION ADDRESS (Must be in USA) STREET CITY STATE ZIP CODE COUNTY RELATIONSHIP TO STUDENT ATHLETE: DAYTIME PHONE: EVENING PHONE: E MAIL ADDRESS: ALLERGIES IS THE STUDENT ATHLETE ALLERGIC TO ANY DRUGS OR MEDICATIONS? YES NO IF YES, PLEASE SPECIFY: PRIMARY INSURANCE INSURANCE COMPANY NAME INSURANCE COMPANY PHONE: POLICY NUMBER (please provide SS# of Policy holder if this is the ID) GROUP NUMBER: PLAN NUMBER: PRIMARY PHYSICIANS NAME: INSURANCE COMPANY MAILING ADDRESS: PHYSICIAN S PHONE NUMBER: POLICY HOLDER INFORMATION POLICY HOLDER FULL (LEGAL) NAME RELATION TO STUDENT ATHLETE: POLICY HOLDER DATE OF BIRTH: / / POLICY HOLDER EMPLOYER: DOES THIS POLICY REQUIRE PRE AUTHORIZATION FOR OUT OF NETWORK CARE? YES NO PLEASE EXPLAIN: ARE THERE TREATMENTS, CONDITIONS OR ILLNESSES THAT ARE NOT COVERED BY THIS POLICY? YES NO PLEASE EXPLAIN: IS THERE A DEDUCTIBLE AMOUNT PER INDIVIDUAL/PER YEAR/PER FAMILY? YES NO PLEASE EXPLAIN: SECONDARY INSURANCE INSURANCE COMPANY NAME: PHONE NUMBER (IF APPLICABLE) POLICY NUMBER: GROUP NUMBER: PLAN NUMBER: INSURANCE MAILING ADDRESS: POLICY HOLDER NAME: RELATION TO STUDENT ATHLETE: POLICY HOLDER DATE OF BIRTH: POLICY HOLDER S EMPLOYER: (PLEASE COMPLETE BOTH SIDES)

16 We recommend that you keep a copy of this form for your records. If the information you have given us changes, please notify Kutina England, Office of Risk Management, 400 E. 7 th Street, Room 705, Bloomington, Indiana, or at (812) Please copy your health insurance card (front & back) to the space below or attached to a separate sheet of paper. We are now asking medical providers (doctors, hospitals) to file their claims directly with your insurance company. We are requesting that they contact us if any problems with the insurance coverage is encountered and for payment of any noncovered charges or co pay amounts as long as the injury/illness is sports related and/or approved by appropriate personnel within the Athletic Department. We ask you to help us by sending any correspondence you receive about these claims whether from your insurance company or from a medical provider to Kutina England at the address above. If your insurance carrier requires services to be performed in network or requires a referral from the primary care physician, please contact your carrier to see if special arrangements need to be made to insure that charges will be covered. Please make note of these arrangements at the bottom of the form or on a separate sheet of paper. If we file a claim with your insurance company (i.e., a medical provider such as the IU Health Center does not bill private insurance companies), we will send you a letter with an explanation of the bill. Please contact Kutina England at the above telephone number and address or by (kudavis@indiana.edu) if you have questions about payments of bills. Please contact the Athletic Department, Sports Medicine Office, at (812) if you have questions regarding this form or department medical procedures. Please read the following statement and then sign the form before returning it to use. We (or I) have read the reverse side of this document and agree to let Indiana University file insurance claims with my insurance company for costs arising from injuries, illnesses, or other related medical treatment covered by NCAA rules, and on behalf of the above named athlete. Indiana University will notify me when these claims are filed and I will provide IU with copies of any related correspondence, such as explanations of benefits, from the insurance company. In the event my checks are sent to me covering these expenses and provided I have no outstanding expenses on this particular bill, I agree to immediately endorse the check to Indiana University and forwarded it to the address on the reverse side. Indiana University is authorized to release related medical information concerning these covered claims to my insurance company and shall provide us (as parents or guardians and owners of the insurance policy) with information about the illness or injury and treatment received. Please return this form for information purposes regardless of insurance coverage. Policy Holder s Signature (If child is minor) Date Student Athlete Signature Date Other Responsible Party (if any) Date FOR OFFICE USE ONLY