***COPY OF FRONT AND BACK OF INSURANCE CARD***

Transcription

1 We would like to take a moment to welcome you back for school year at the University of San Francisco. This packet is intended to introduce you to the Sports Medicine staff and to provide information on the medical policies of the Sports Medicine department and USF Athletics. Enclosed are several important forms. Please read each of these thoroughly and complete and return all pertinent forms to USF. The USF Sports Medicine Department must have this information prior to your participation in any team activities. This checklist is for you to assure that all necessary forms are ready to mail back to USF Athletics by May 4, It is required to update all forms once a year in order to determine your participation in team activities at the University of San Francisco. It is encouraged that you fill out all forms with your parent/guardian. The Parent Handbook is attached to the end of this document. Your parent/guardian is also required to sign the acknowledgment form. 1. Insurance Information Form (Please open an attachment and type in your information before printing) Complete student athlete information, parent/guardian information, and insurance information ***COPY OF FRONT AND BACK OF INSURANCE CARD*** *You are encouraged to keep the original or copy of your insurance card in case of emergency Read the brief insurance policy and sign at the student-athletes line 2. Treatment Consent Form Read each section and sign each line with date If you are under 18 years old, parents/guardian must sign along your signature 3. Authorization to Release Health Information Form Fill out appropriate lines and sign at the bottom 4. Returning Student- Athlete Medical History Questionnaire Form Fill out thoroughly and initial each page at the bottom 5. Parent/Guardian Handbook Your parent/guardian must complete the 1 st page of Parent/Guardian Handbook 6. Return Envelope Prepare an envelope with a stamp and address to (Due date is May 4, 2015): Ben Metzler Associate Athletic Trainer USF Athletics 2130 Fulton Street San Francisco, CA 94117

2 INSURANCE INFORMATION FORM ATHLETE S NAME: SPORT: USF ID Number: BIRTHDATE (MM/DD/YYYY): LAST 4 OF SSN: ADDRESS: LOCAL/CELL PH#: NAME OF FATHER/GUARDIAN: PHONE # (H) (W) (C) HOME ADDRESS: street city state zip ADDRESS: EMPLOYER: ADDRESS: NAME OF MOTHER/GUARDIAN: PHONE # (H) (W) (C) HOME ADDRESS street city state zip ADDRESS: EMPLOYER: ADDRESS: INSURANCE COMPANY: PHONE# CLAIMS PAYING OFFICE: street city state zip POLICY # GROUP # SUSCRIBER S NAME: LAST 4 OF SUSCRIBER S SSN: SUSCRIBER S DATE OF BIRTH: PRIMARY CARE PHYSICIAN: PHONE # MEDICAL GROUP NAME: HMO PPO OTHER (circle one) *PLEASE ALSO INCLUDE COPY OF FRONT AND BACK OF INSURANCE CARD* I understand that any cost for medical expenses incurred as a result of accidental injury while participating in any scheduled college activity will not be paid under the insurance policy carried by the University of San Francisco until all payments under any existing policies are made. I understand the limits of insurance coverage under the University of San Francisco s insurance policy will be for 2 years from the date of injury or $90,000 per injury, whichever comes first. I further understand that failure to report injuries to USF Athletic Trainers, failure to meet scheduled physician appointments, falsifying injury information, or incorrect or invalid primary insurance information may void University responsibility. ATHLETE S SIGNATURE: DATE:

3 TREATMENT CONSENT I hereby grant permission to the University of San Francisco Team Physicians and Medical Personnel to treat the stated athlete while engaged in practice or competition conducted under the auspices of the University of San Francisco. SIGNATURE OF ATHLETE DATE OF BIRTH DATE *PARENT/GUARDIAN IF ATHLETE IS UNDER 18 RECOGNITION OF INSURANCE FILING PROCEDURES By my signature, I concede that I have read, understood and agree to cooperate with the procedures outlined in the INSURANCE INFORMATION FORM handout which states that ALL claims must be filed with my PRIMARY Insurance received from a work or family plan before the Athletic Department's SECONDARY policy will consider payment of any portion of the medical bills incurred as a result of participation in U.S.F. sanctioned practices and contests. SIGNATURE OF ATHLETE *PARENT/GUARDIAN IF ATHLETE IS UNDER 18 DATE DATE AUTHORIZATION TO OBTAIN AND DISCLOSE INFORMATION To all physicians, medical professionals, hospitals, clinics, insurers, employers, group policyholders, insurance support organizations, and other persons who have my medical information : I authorize you to give USF Secondary Insurance, A-G Administrators, its reinsurers, or its agents, including the appropriate staff in the Personnel Office at the University of San Francisco: (a) all information you have as to illness, injury, medical history, diagnosis, treatment and prognosis with respect to any physical or mental condition of the patient; (b) all employment information you have; and (c) any other information you have which A-G Administrators or U.S.F. believes it needs pertinent to all injuries. The information obtained will be used to determine if the patient is eligible for benefits in order to coordinate payments. The form is valid for as long as the claim lasts. I understand that I may request a copy of my records and I agree that a photocopy is as valid as the original. SIGNATURE OF ATHLETE DATE *PARENT/GUARDIAN SIGNATURE IF ATHLETE IS UNDER 18 DATE

4 2130 Fulton St. San Francisco, CA Ph. (415) Fax (415) Authorization to Release Health Information STUDENT-ATHLETE: SPORT: DATE OF BIRTH: I hereby authorize the University of San Francisco Athletic Department to release my protected health information. This information may include: injury or illness related to past, present or future participation in intercollegiate athletics at USF information contained in my personal medical record unrelated to my participation in intercollegiate athletics at USF information concerning my medical status, medical condition, injuries, prognosis, diagnosis and other related personally identifiable health information, including injury reports, diagnostic test results, progress reports and any other documentation regarding my health status. Authorization is granted for release of my protected health information to: my parents/guardian and/or spouse for the purpose of assisting me in making healthcare decisions while I am a student-athlete the USF Sports Medicine Staff, team physicians, allied health care professions, and coaching staff so that they may make informed decisions concerning my ability and suitability to compete while I am a student-athlete my teammates so that they may be made aware of limitations that I may be under while I am a student-athlete the media, including specifically the University of San Francisco Sports Information Department, to advise the print, radio, and television and other media of this nature, the prognosis and treatment concerning my medical condition of any injuries or illnesses for the purpose of reporting on it while I am a student-athlete USF athletic support departments, the West Coast Conference, and the National Collegiate Athletic Association for the purpose of making a determination regarding my eligibility status while I am a student-athlete This authorization will automatically expire six years from the date it is signed Please note the following: You may refuse to sign this authorization. Your refusal will not affect your ability to obtain treatment or payment. Once you sign this authorization, we can rely on it until you revoke it or it expires. Any revocation will not apply to information already disclosed in reliance on the authorization. You can revoke this authorization by delivering a dated and signed letter to the University of San Francisco Athletic Training Department. If the persons or entities that are authorized to receive the information above are not covered by federal privacy laws, they may re-disclose the information and those laws would no longer protect the disclosed information. The University of San Francisco will not receive compensation for its use or disclosure of your protected health information. Signature: Date: Student-Athlete or Legal Representative

5 Returning Student-Athlete Medical History Questionnaire Name: DOB: Local/Cell Phone: Emergency Contact Name / Relationship: Emergency Contact Phone #: Active Address: Sport: Last Physical Date (Month/Year): Yes No Allergy or severe reaction to any medication (specify type of reaction) Yes No Any other allergy, or severe reaction to insect, bees, wasps or food (specify type of reaction) Yes No Have you ever experienced any symptoms related to heat or exercising in the heat? If yes, explain. List any medication you are presently taking. (Include prescriptions, over the-counter medication, performance enhancers/supplements, vitamins.) Check whether you or a family member has had any of the following conditions. If yes, provide approximate date(s) and details; if family member, specify relation to you. Heart murmur Irregular heart beat or extra beats Chest pains Fatigue or shortness of breath (e.g. asthma) Fainting or passing out Sudden death before age 50 High blood pressure Other history of heart problems Check whether you have ever had any of the following conditions. If YES, provide approximate date(s) and details. Anemia Eating disorder Asthma, allergy, hay fever Gynecologic disorder Any Heart or Cardiac conditions Fainting Drug or alcohol dependency Headaches Depression or anxiety Mononucleosis (Mono) Diabetes Shortness of Breath or Fatigue with Exercise Epilepsy or seizures Significant illness/injury Head injury, concussion Thyroid disorder Hernia Ulcers, stomach problem, colitis Kidney or bladder problem Other:

6 Yes No Do you have any injury or illness since your last physical examination from which you have not completely rehabilitated or recovered? (i.e. in the last year) If yes, please explain. Yes No Do you know of any reason you should not participate in intercollegiate athletics at USF, or has any health care provider cautioned you about your participation in intercollegiate athletics at USF? If yes, please explain. Yes No Have you had ANY surgical procedure in the last 12 months? If yes, please explain. Yes No Have you had a weight change (loss or gain) greater than 10 pounds in the past year? Yes No Do you control your caloric intake carefully? If yes, please explain. Yes No Have you ever tried to control your weight with fasting, vomiting, laxatives, diuretics, diet pills, or excessive exercise? If yes, please explain. Yes No Do you have reason that you would like to speak to a physician? If yes please note reason below. Check whether YOU have any of the following since your last Physical Examination (i.e. in the last year) Hospitalizations Current/Ongoing Illness Major Injuries including Concussions Operations/Surgeries Physician Visits Special Testing (X-Ray, MRI, EKG, CT Missing any paired organs Scan, etc.) If yes on any of the above please explain: Part II: AEDICAL EVALUATION BY A HEALTH CARE PROVIDER IS REQUIRED I hereby state, that to the best of my knowledge, my answers to the above questions are complete and correct to the best of my abilities. I understand that falsification of information may alter the medical attention I receive, alter my playing status and or void University responsibility. Signature: Date:

7 Acknowledgment Form Dear Parent/Guardian: The following information will acquaint you with the secondary insurance policy furnished by the University of San Francisco Department of Athletics for its student-athletes, as well as the proper protocol for completing the pre-participation medical forms, referral policy, and return to play guidelines. If you have any questions, please feel free to contact us at the numbers found at the end of this handbook. PLEASE PRINT AND SIGN THIS PAGE TO ACKNOWLEDGE RECEIPT OF THE PARENT HANDBOOK. PLEASE RETURN THIS PAGE TO: Benjamin Metzler Department of Athletics University of San Francisco 2130 Fulton Street San Francisco, CA Fax: (415) I understand that any cost for medical expenses incurred by a student-athlete as a result of accidental injury while participating in any scheduled college activity will not be paid under the insurance policy carried by the University of San Francisco until all payments under any existing policies are made. I understand the limits of insurance coverage under the University of San Francisco s insurance policy will be for 2 years from the date of injury or $90,000 per injury, whichever comes first. I further understand that failure to report injuries to USF Sports Medicine Staff, failure to meet scheduled physician appointments, falsifying injury information, or incorrect or invalid primary insurance information may void University responsibility. I have received the parent handbook and understand the policies and procedures of the University of San Francisco Sports Medicine Department. STUDENT-ATHLETE S NAME (Please Print) SPORT PARENT/GUARDIAN SIGNATURE DATE

8 Insurance Handbook for Parents Primary Insurance o All student-athletes are required the University to have primary health insurance on their own or through their parent/guardian that meets University of San Francisco standards. o International student-athletes insurance coverage must meet the University of San Francisco requirements. Please refer to o If the athlete does not furnish proof of a primary insurance policy, no benefits will be paid through the University s secondary athletic insurance policy. o Note: It is advisable for every student-athlete to have a primary care doctor in the Bay Area who meets your specific insurance requirements. USF Insurance Coverage o USF offers a secondary insurance policy to pay for expenses not covered by the athlete s primary insurance. o USF will cover medical expenses for athletic-related injuries that meet specific criteria listed in the student-athlete handbook. o Pre-existing conditions will not be covered by the secondary insurance policy. Getting the Bills Paid When an athlete gets hurt, you may begin to receive bills for the injury. Your insurance policy must process the bill completely before USF s secondary insurance will pay any remaining balance. In order to expedite this process, please forward any and all paperwork regarding the athlete s injury to the USF Sports Medicine Staff. o Explanation of Benefits (EOB) This is very important! The EOB explains what your primary insurance has paid and what it will not pay. Please forward a copy of this paper to the USF Sports Medicine Staff as soon as you receive it. Please note: This process can take a significant period of time because the bill has to be processed by two insurance companies. You can help speed this process by promptly forwarding the insurance paperwork and bills to us. Health History Questionnaire/ Pre-Participation Physical All athletes must complete a Health History Questionnaire prior to the time of their pre-participation physical and mail it to Sports Medicine department. This includes: o All forms legibly filled out with ball-point pen, not with a pencil o A front and back copy of health insurance card enclosed

9 All athletes must have a physical performed by the USF team physicians, as arranged by the Sports Medicine Staff, before you will be allowed to participate in any practice or competition. Athletes are not required to obtain their own physical prior to arriving at USF. Notifying Athletic Training Staff of an Injury/Illness Athletes must report any injury ASAP to the corresponding staff athletic trainer for an initial evaluation. o Student-athletes are responsible for reporting directly to the Certified Athletic Training regarding all medical matters. The ATC will then facilitate communication between the coaching staff and medical staff. Parents and student-athletes should not directly contact physicians. The athletic trainer s evaluation of the injury may result in any or all of the following actions: o Referral to a physician o Treatment of the injury o Rehabilitation of the injury The athletic trainer will then inform coaches of initial evaluation and/or physician referral. The progress of the athlete is monitored by the athletic trainer, who will update coaches of the athlete s progress. All referrals to outside medical personnel must be made by a member of the USF Sports Medicine Staff. Failure to follow this protocol will result in forfeiture of the secondary insurance coverage provided by the USF Athletic Department. Physician Clearance The team physician has the final responsibility to determine whether a student-athlete is removed, withheld, or restricted from participation due to an injury. The University reserves the right to exclude a student-athlete from competition if there is any doubt concerning the student-athlete s physical condition or ability to safely compete in intercollegiate athletics. Return to Play Guidelines Once the team physician has cleared a student-athlete for full athletic activity the corresponding staff athletic trainer will decide the guidelines under which the student-athlete will return to activity, which may include: o o o Limiting Participation Restricting Activity Removing the student-athlete from any or all activity Seeking Outside Medical Advice The athlete should not consult outside medical advice without authorization from the athletic trainer and/or referral from the team physician. If the procedure listed in this handbook and the studentathlete handbook is not followed, the University insurance will not cover any expenses incurred.

10 If a member of the athletic staff in unavailable and the situation is emergent and needs immediate attention, the student-athlete should seek medical attention at the closest facility. Athletes are required to notify the athletic training staff as soon as possible of the emergency room visit. This will help avoid improper billing of services. Sports Medicine Staff Contact Information Jake Aganus, MS, ATC Ben Metzler, MS, ATC Head Athletic Trainer Associate Athletic Trainer Wk Phone: (415) Wk Phone: (415) rshinault@usfca.edu bmetzler@usfca.edu Stephanie Ludwig, MA, ATC Shannon Murphy, M.Ed, ATC Associate Athletic Trainer Assistant Athletic Trainer Wk Phone: (415) Wk Phone: (415) ajaganus@usfca.edu Tyler Arford, MA, ATC Assistant Athletic Trainer Wk Phone: (415) tarford@usfca.edu Megan Mason, ATC Nicole Perez, ATC Graduate Asst. Athletic Trainer Graduate Asst. Athletic Trainer Wk Phone: (415) Wk Phone: (415) mmason@usfca.edu nperez3@usfca.edu