Warrior Sports Medicine

Transcription

1 Warrior Sports Medicine On behalf of Warrior Athletics we would like to welcome Student Athletes and their families to the Academic Year. Please take the time to read this information so that you will understand the objectives of the Warrior Sports Medicine Program. We begin by wishing our student athletes a safe and competitive upcoming season. Sincerely, Dake Walden Head Athletic Trainer Sports Medicine Team: CSU Stanislaus Athletics: Dake Walden, ATC CSU Stanislaus Athletics: Gary Hogan, ATC CSU Stanislaus Health Center: Dr. Sergio Mazon Dr. Scott Hennes Mission: To ensure that all student athletes at CSU Stanislaus and their visiting opponents have their athletic related injuries and illness cared for and managed for maximum potential to continue to play their sport, attend and pass classes and function long beyond the date of graduation. When Injuries and Illness occur: Athletes should report to the athletic training room immediately when injuries occur. A certified athletic trainer will evaluate most injuries first. Injuries within the scope of the staff will be treated in house. Injuries beyond the scope of staff will be referred to an appropriate licensed medical physician and a treatment plan will be developed. Athletes who sustain injuries beyond the scope of the Warrior Sports Medicine Staff will be referred to a physician. Physician referrals are dependent on factors such as severity and primary care insurance. The Student Health Center on Campus provides many services that are paid by students tuition. Students may pay small fees for lab work and prescription medications. When student athletes are referred for services off campus, the Warrior Sports Medicine Staff must make every effort to utilize the Student Athlete s primary care insurance first. Please read and completely fill out the forms that follow this page. These forms must be completed annually. Incomplete forms will be returned. Please mail, FAX, or completed forms to: Dake Walden Head Athletic Trainer California State University Stanislaus Dept. of Athletics One University Circle Turlock, CA Phone: (209) dwalden@csustan.edu FAX: (209) All forms are due by July 15, 2013 ONE UNIVERSITY CIRCLE TURLOCK, CALIFORNIA PHONE (209) FAX (209) THE CALIFORNIA STATE UNIVERSITY Bakersfield Channel Islands Chico Dominguez Hills East Bay Fresno Fullerton Humboldt Long Beach Los Angeles Maritime Academy Monterey Bay Northridge Pomona Sacramento San Bernardino San Diego San Francisco San Jose San Luis Obispo San Marcos Sonoma Stanislaus

2 CSU-STANISLAUS MEDICAL HISTORY /QUESTIONNAIRE NAME: BIRTHDATE: SSN: SPORT CHECK THOSE ILLNESSES/INJURIES YOU HAVE HAD OR HAVE NOW MEDICAL HISTORY: Yes No Diabetes Epilepsy Headaches Asthma Mononucleosis Convulsions Heart Problems Hypertension Kidney Problems Bronchitis/Chronic cough Concussion(s) Heat Illness/Syndromes Currents Illness/Injuries ORTHOPEDIC HISTORY: Yes No Ankle Injuries Any Bone Fractures Any Surgeries Elbow Injuries Foot Injuries Hand Injuries Knee Injuries Rib Injuries Shoulder Injuries Spine/Back IF YOU ANSWERED, YES TO ANY OF THE ABOVE QUESTIONS, PLEASE EXPLAIN IN DETAIL BELOW: PLEASE CHECK BELOW IF YOU HAVE ANY OF THESE ALLERGIES OR LIST ANY THAT MAY NOT APPEAR BLOW: Bee Stings: Please Specify or list any allergies that you have or do not appear at the left: Poison Ivy/Oak: Hay Fever: Adhesive Tape: Foods: Medications: Assumption of Risk Participation in sports/athletics requires an acceptance of risk of injuries. Athletes assume that those who are responsible for the supervision of the sport have taken reasonable precautions to minimize such risks. However, every sport contains inherent risks and the possibility of injury is present, regardless of precautions. I understand that the dangers and risks of playing and/or practicing intercollegiate sports/athletics include but are not limited to: death, serious head and spine injuries which may result in complete or partial paralysis, brain damage, serious injury to virtually all internal organs, and all aspects of musculoskeletal systems, and serious injury or impairments to other aspects of my body and general health and well-being. I understand and assume the risks and dangers associated with participation in intercollegiate athletics at California State University, Stanislaus Athlete Signature

3 Warrior Athletic Insurance Information The following explains the policies and procedures regarding the California State University Risk Management Authority Athletic Injury Medical Expense Program(CSURMA AIME). Please read and understand before signing the bottom line then precede to the next page. CSURMA AIME, California State University, Stanislaus Athletic Injury Secondary Insurance Policy The insurance provided by the AIME is SECONDARY. Student Athletes must file all claims with his/her parent s/spouse s/own primary care insurance BEFORE the AIME policy can be utilized. If an athlete does not have primary care insurance then the athletic departments secondary insurance becomes primary for athletic related injury and illness only. Primary care student insurance is available for purchase through the university s Student Health Center. It is highly recommended that student athletes be in possession of their primary insurance cards. The athletic department s athletic insurance only cover athletic participation related injury and illness. It does not cover the following: Expenses for injuries that occur outside the university s athletic participation (This includes open gym, captain s practice, and other activity not supervised by the coaches). An athlete s pre-existing injury or illness (This includes chronic illness). Injury and illness related to body piercing, tattoos, banned substances and intoxication. Treatments and visits not authorized by the Head Athletic Trainer. Alternative treatment such as Chiropractors and Acupuncture. Expenses for the treatment of sickness or disease in any form. Expenses for lost of damaged eyewear. Other Policy All athletes must report a change in primary care insurance immediately. All athletic related medical services must be pre-approved by the head athletic trainer and the assistant athletic director. This does not include emergencies. Athletes will be held fully responsible for expenses acquired for medical services not approved by the Head Athletic Trainer. All athletes are required to hand carry the University s secondary insurance verification letter to all new providers and to fill out a claim form with the Athletic Trainer. This must be done for each new injury. If an athlete chooses to go to a physician who is not a provider for his/her primary care insurance he/she will be held responsible for all expenses. Athletes are expected to attend all appointments. Athletes are fully responsible for expenses incurred for missed appointments. I hereby acknowledge the above policy and will abide by it. If I/or my dependent(s) do not abide by the policy of the Secondary Insurance provided by California State University, Stanislaus then I will be held for any expenses incurred. Signature of Student Athlete Signature of Parent of Student Athlete

4 Warrior Athletics Student Athlete Authorization Form Please read the following statements carefully and initial the line before each statement. Your initials indicate that you fully understand the statement. If you disagree with the statements below you may decline authorization by signing the Signature to Decline line at the bottom. By signing the bottom you are authorizing the athletic trainer to provide services in a prompt and timely manner. I hereby authorize the Sports Medicine Staff at California State University, Stanislaus to release my Protected Health Information for the purpose of further treatment and billing. I hereby authorize the Sports Medicine Staff and Team Physician/Consultant at California State University, Stanislaus permission to render to myself, and/or son/daughter, any treatment or medical care deemed necessary. I also understand that the treatment rendered does not necessarily qualify me for university s secondary insurance benefits. I hereby authorize the Sports Medicine Staff and Treating Physician/consultant at California State University, Stanislaus permission to disclose information in regard to any injuries/illnesses I may sustain to my Head Coach, Athletic Director, Assistant Athletic Director, Parents/Guardians and/or People listed on my Emergency Contact Information. I understand that under the Family Educational Rights and Privacy Act that I may revoke the above authorizations at anytime. To do so I must submit the revocation in writing. Print Name Signature Parent/Guardian (If under 18 years of age) Signature to decline

5 CONSENT TO TESTING OF URINE SAMPLE AND AUTHORIZATION FOR RELEASE OF INFORMATION Drug Education, Testing and Treatment Program Director I hereby consent to have a sample of my urine collected and tested for the presence of certain drugs or substances in accordance with the provisions of the California State University, Stanislaus Department of Intercollegiate Athletics Drug Education, Testing and Treatment Program, and the NCAA, and at such other times as urinalysis testing is required under the program during the academic year. I further authorize you to make a confidential release to the Program Physician, substance abuse counselor, Director of the Department of Intercollegiate Athletics at California State University, Stanislaus of test results you may have relating to the screening or testing of my urine sample(s) in accordance with the provisions of the California State University, Stanislaus Department of Intercollegiate Athletics Drug Education, Testing and Treatment Program. California State University, Stanislaus, its Board of Regent, it officers, employees and agents are hereby released from legal responsibility or liability for the release of such information and records as authorized by this form. Print Name Signature Parent Signature (if under 18)

6 Warrior Athletics Student Athlete Statements of Self Reporting and Medical Compliance Please read the following statements carefully and initial the line before each statement. Your initials indicate that you fully understand the statement. I will promptly report all injuries and illness including signs and symptoms of a concussion to a certified athletic trainer. If an athletic trainer is not immediately available I will report the injury to my coach and make an appointment at the student health center. I will honor and obey all medical advice given to me by all certified athletic trainers and physicians. I will return to activity as directed by a certified athletic trainer and physician. I understand once I see a physician that I may not return to full participation until I have presented the athletic trainer and my coach with written clearance. I acknowledge that I have been presented with educational materials on concussions. Print Name Signature Sport

7 California State Risk Management Authority Intercollegiate Athletic Insurance Questionnaire Accident/Injury benefits for student athletes are provided on an excess basis. This means ATHLETE S OWN GROUP OR THAT OF THE ATHLETE S SPOUSE AND /OR PARENTS MUST BE BILLED FIRST. Benefits are available from our program only when the athlete s coverage is exhausted or does not apply. The following information is essential to assure that expenses are adequately and completely covered by the proper insurance. Inadequate or incomplete answers will delay payment of medical bills and may jeopardize the athlete s credit rating. No medical expenses will be paid out of institutional fund without a signed, accurate questionnaire on file. It is the athlete s sole responsibility to keep the information contained in this document current. Name: Sport: of Birth: SS#: Student ID# Sex: Local School Address: Home Phone # ( Dorm/Street ) Cell # ( ) City State Zip Emergency contact information: Father/ Guardian/Spouse Mother/Guardian Name: Name: Address: Address: Street Street City State Zip City State Zip Home Phone: ( ) Phone: ( ) Cell Phone: ( ) Cell Phone: ( ) Work Phone: ( ) Work Phone: ( ) Do you have primary care health insurance? Yes No If NO, Sign and date the bottom of page! If Yes, Please complete information blow (information is required). Information should be copied from your insurance card. Insurance Company Name: Address: Street City State Zip Insurance Co Phone #: ( ) Plan #: Group #: Plan is under: Father Mother Self Spouse Policy #: ID # : Type of Plan: HMO PPO Family/Private Work Govt Other I hereby certify that the foregoing answers are true, complete, and correct to the best of my knowledge. I also hereby authorize any Insurance company, Organization, employer, Hospital, Physician, Physical Therapist, Pharmacy, or other health care provider to release any information with respect to injury, treatment, or insurance. Athlete s Signature: Please enclose a copy of your insurance card. :

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