TARLETON SPORTS MEDICINE. Student-Athlete Medical Information

Transcription

1 TARLETON SPORTS MEDICINE Student-Athlete Medical Information

2 TARLETON STATE UNIVERSITY ATHLETICS DEPARTMENT Box T-0080 Stephenville, TX FAX Dear Parent / Guardian: Enclosed you will find important information from the Tarleton State University Athletics Department. You and the student-athlete must read and complete all of the attached forms and sign the signature sheet. It would be advisable for you to make a copy of these forms for your records before returning them to your head coach. It is imperative that you return these forms as soon as possible. No student-athlete will be allowed to participate in practice or competition until these forms have been received and approved. Make sure you provide a legible front and back copy of your current insurance card as required by university policy. The following documents are enclosed in this packet: Contact Information Insurance Policy Information Waiver of Liability and Hold Harmless Agreement Tarleton Sports Medicine Policies If you have any questions, please do not hesitate to contact me. Sincerely, Lonn Reisman Lonn Reisman Athletics Director Tarleton State University

3 TARLETON SPORTS MEDICINE Contact Information - - LAST NAME FIRST NAME SSN Transfer Student-Athlete? Y / N SPORT PREVIOUS SCHOOL PERMANENT ADDRESS SECONDARY (SCHOOL) ADDRESS CELL CELL EMERGENCY CONTACT SECONDARY EMERGENCY CONTACT _ LAST FIRST _ LAST FIRST HOME WORK HOME WORK CELL CELL _ RELATIONSHIP _ RELATIONSHIP

4 TARLETON STATE UNIVERSITY Insurance Policy Information Tarleton State University provides Sports Medicine care for all student-athletes injured while participating for TSU. Catastrophic insurance is provided by the NCAA for all Tarleton student-athletes. Tarleton State University will provide secondary coverage for all athletic injuries. Any insurance that a student-athlete or family has will be filed first. It is the responsibility of the student-athlete and his/her family to see that claims are filed with their personal insurance carrier in a timely manner. Tarleton State University will only be financially responsible for amounts that are not covered by a personal medical insurance policy. Pre-existing injuries will not be covered by Tarleton State University. In addition, all walk-on student-athletes MUST provide their own personal primary medical insurance. A walk-on student-athlete is defined as receiving NO athletics aid. Personal items will not be covered by TSU. Claims for medical expenses will not be processed for payment with Tarleton State University until TSU is furnished a copy of the explanation of benefits (EOB) and itemized statement. Until then, the responsibility of medical expense lies with the student-athlete. Failure to provide the necessary and current insurance information to TSU and the medical provider will result in loss of services and collection proceedings from the provider of services. If the athlete or parent chooses to use the Tarleton State University team physicians for their treatment, TSU will pay all expenses that the private insurance does not cover. The advantages of using TSU physicians include immediate care, daily follow-up care, timely evaluations by the physicians, sports medicine rehabilitation, etc. If the student-athlete or parent chooses to use their own physician, Tarleton State University will not be responsible for payment. If the student-athlete does not have medical insurance, expenses will be covered by TSU only if TSU team physicians are utilized. A copy of the current personal insurance card must be provided with the attached forms. Please provide a legible front / back copy of the card. Proof of the lack of medical insurance must be provided to the Athletics Director at Tarleton State University. All medical and physician appointments must be made through the Tarleton Sports Medicine Department. Please provide a legible front and back copy of your current insurance card.

5 TARLETON STATE UNIVERSITY Insurance Policy Information / / LAST NAME FIRST NAME DOB Please provide the information requested below so that it will be readily available if an injury should occur. PRINT CLEARLY PRIMARY INSURANCE INSURANCE COMPANY PO Box PLAN/GROUP # POLICY/MEMBER # NAME OF POLICY HOLDER / / ID DOB HMO PPO HSA Other TYPE OF INSURANCE Is a referral required by a primary care physician? Yes No PHYSICIAN NAME SECONDARY INSURANCE INSURANCE COMPANY PO Box PLAN/GROUP # POLICY/MEMBER # NAME OF POLICY HOLDER / / ID DOB HMO PPO HSA Other TYPE OF INSURANCE Is a referral required by a primary care physician? Yes No PHYSICIAN NAME Does insurance policy cover the student-athlete during participation in intercollegiate athletic events? Yes No (INITIAL) The student-athlete is not covered under any group or personal medical insurance. I will provide any information requested by the Athletics Director. I agree and consent that any amounts payable under the above policy be paid to the medical provider or to the Tarleton State University Athletics Department. I hereby grant permission to Tarleton State University to release medical records to medical providers (hospitals, doctors, etc.), sports agents, scouts and other universities to which the student-athlete might transfer. The signatures below give authorization that is necessary for Tarleton State University, its athletic trainers, coaches, and physicians to share information concerning medical diagnosis and treatment for the student-athlete.

6 TEXAS A&M UNIVERSITY SYSTEM Waiver of Liability and Hold Harmless Agreement In consideration for receiving permission to participate in Tarleton State University athletics, I hereby release, waive, discharge, and covenant not to sue Tarleton State University, The Texas A&M University System, The State of Texas, their officers, agents, servants, or employee (hereinafter referred to as RELEASEES) from any and all liability, claims, demands, actions, and causes of action whatsoever arising out of or related to any loss, damage, or injury, including death, that may be sustained by me, or any of the property belonging to me, whether caused by the negligence of the releasees, or otherwise, while participating in such activity, or while in, on or upon the premises where the activity is being conducted. I am fully aware of the risks involved and hazards connected with athletic participation including but not limited to injury, catastrophic incident or death, and I hereby elect to voluntarily participate in said activity with full knowledge that said activity may be hazardous to me and my property. I voluntarily assume full responsibility for any risks of loss, property damage or personal injury, including death, that may be sustained by me, or any loss or damage to property owned by me, as a result of being engaged in such an activity, whether caused by the negligence of releasees or otherwise. I further hereby agree to indemnify and hold harmless the releasees from any loss, liability, damage or costs, including court costs and attorney fees, that they may incur due to my participation in said activity, whether caused by negligence of releasees or otherwise. I understand that Tarleton State University does not maintain any insurance policy covering any circumstance arising from my participation in this event or any activity associated with or facilitating that participation. As such, I am aware that I should review my personal insurance portfolio. The NCAA does, however, provide catastrophic insurance. It is my express intent that this Waiver of Liability and Hold Harmless Agreement, shall bind the members of my family and spouse, if I am alive, and my heirs, assigns, and personal representative, if I am deceased, and shall be deemed as a release, waiver, discharge and covenant not to sue the above named releasees. I hereby further agree that this Waiver of Liability and Hold Harmless Agreement shall be construed in accordance with the laws of the State of Texas. In signing this release, I acknowledge and represent that I have read the foregoing Waiver of Liability and Hold Harmless Agreement, understand it and sign it voluntarily as my own free act and deed; in oral representations, statements, or inducements, apart from the foregoing written agreement, have been made; I am at least eighteen (18) years of age and fully competent; and I execute this release for full, adequate and complete consideration fully intending to be bound by same. By signing this document, I acknowledge that I have read and understand all documents related to participation in athletics at Tarleton State University.

7 TARLETON SPORTS MEDICINE Medical Policies The purpose of this statement is to inform each student-athlete that it is possible to receive an injury or injuries while participating in intercollegiate athletic competition. The extent of such injuries may be irreversible and in some cases may prove to be fatal. Student-athletes participating in all sports including football, basketball, softball, baseball, track and field, cross-country, volleyball, tennis, golf, and cheer can experience many types of physical trauma. Tarleton State University provides protective equipment and competent instruction for the student-athlete. However, equipment and instruction cannot prevent all serious injuries that may result. Tarleton provides a comprehensive Sports Medicine program designed to assist the student-athlete throughout his / her career. Student-athletes must, however, assume the responsibility and recognize the necessity for following rules and regulations designed to make intercollegiate athletic competition less hazardous. Listed below are the Sports Medicine policies all athletes must follow: 1. All student-athletes must complete a pre-participation physical exam upon first entrance to TSU prior to any participation. 2. All student-athletes must complete a pre-participation physical exam administered by a TSU team physician. 3. All pre-existing conditions must be disclosed on the pre-participation medical history. 4. Pre-existing conditions will not be the financial responsibility of TSU. 5. Student-athletes with a pre-existing condition may be required to complete a waiver prior to participation. 6. The student-athlete must report all athletic injuries immediately to the Tarleton Sports Medicine team. 7. The Sports Medicine Policies, Waiver of Liability and Hold Harmless Agreement, Insurance Policy Information, and Contact Information forms must be completed and returned to the athletics department prior to any participation (annually). 8. All athletic related medical visits, including diagnostic, emergency room, and surgery must be directed in advance by the Head Athletic Trainer and referred to or by Tarleton State University team physicians in writing in order for Tarleton State University to be financially responsible. 9. Insurance policy information must be revised immediately if changes are made in companies or coverage. 10. Failure to comply with orders given by the athletic trainer and/or team physician relating to the care of an injury could result in a loss of benefits, in which case any continued care would be the financial responsibility of the student-athlete. 11. The exit physical exam is to be completed by all Tarleton State University athletes who have completed their athletic eligibility, or who will no longer compete in intercollegiate athletics for TSU within two weeks following completion of the season. Failure to complete the exit physical exam will automatically waive Tarleton State University from any medical or financial responsibility. By signing this document the student-athlete and parent / guardian recognizes that he / she assumes many risks and that they have been warned of the hazards inherent in athletic competition. I have read the above statement and I am aware of the inherent risks involved in athletic related activities. Permission is hereby granted to the team physicians to proceed with any needed medical treatment, surgery, x-ray, examinations, and immunizations for the student-athlete. In the event of serious illness, the need for major surgery, or significant accidental injury, I understand that an attempt will be made by the attending physician to contact me in the most expeditious manner possible. If the physician is unable to communicate with me, the treatment necessary for the best interest of the student-athlete may be given.

8 TARLETON SPORTS MEDICINE Signature Sheet I / we have read and completed all of the forms in this document. By signing this document, I / we acknowledge that I / we have read and understand all these documents related to participation in athletics at Tarleton State University. No student-athlete will be allowed to participate in practice or competition until these forms have been received and approved. / / Printed Name of Student-Athlete Signature of Student-Athlete Date / / Printed Name of Parent / Guardian Signature of Parent / Guardian Date