Pre-Participation Physical Evaluation

Transcription

1 1 Dear Returning YHC Student-Athlete and Parents/Guardians, As a Young Harris College student-athlete, we certainly hope that medical treatment for a serious injury is not necessary, but in the event that it is, we want to be fully prepared. In preparing for such an event, we need to have current and updated information before the student-athlete can begin official team practices or workouts. All student-athletes are required to have a Pre-Participation Physical Evaluation through our Sports Medicine Physician, John G. Vachtsevanos, and his staff upon coming to campus in the fall. Each team will have a scheduled date and time for their physicals which will be announced at a later date. Attached are all the necessary forms that need to be completely filled out and returned to the athletic training staff as soon as possible. Please be sure to read all documents enclosed and sign and date the appropriate areas. In addition, please provide a front and back copy of the student-athlete s insurance card and fill out the policy holder information completely. It is required for the student-athlete to have and maintain primary health insurance that covers sports injures while participating in athletics here at Young Harris College. These forms must be on file in the athletic training room before the student-athlete can participate in YHC intercollegiate athletics. If you have any questions related to your son/daughter s health, or regarding health insurance coverage please feel free to contact Head Athletic Trainer Jared Sandler ATC at Mailing Address: Young Harris College Sports Medicine PO Box 37 Young Harris, GA Sincerely, Jared Sandler M.Ed., ATC, LAT Head Athletic Trainer

2 2 YOUNG HARRIS COLLEGE SPORTS MEDICINE STUDENT-ATHLETE DEMOGRAPHIC INFORMATION STUDENT-ATHLETE INFORMATION- Sport: NAME: Last First Middle SSN: - - DATE OF BIRTH: / / HOME ADDRESS: CITY: STATE: ZIP CODE HOME PHONE: ( ) - CELL PHONE: ( ) - STUDENT-ATHLETE INSURANCE INFORMATION- PLAN NAME: ID#: POLICY HOLDER NAME: GROUP#: CLAIMS ADDRESS & PHONE NUMBER: POLICY HOLDER INFORMATION- NAME: Last First Middle DATE OF BIRTH: / / SOCIAL SECURITY NUMBER: - - HOME ADDRESS: CITY: STATE: ZIP CODE HOME PHONE: ( ) - CELL PHONE: ( ) - RELATIONSHIP (CHECK ONE): MOTHER FATHER OTHER EMERGENCY CONTACT INFORMATION- NAME: Last First Middle DATE OF BIRTH: / / HOME ADDRESS: CITY: STATE: ZIP CODE HOME PHONE: ( ) - CELL PHONE: ( ) - RELATIONSHIP (CHECK ONE): MOTHER FATHER OTHER

3 3 YOUNG HARRIS COLLEGE SPORTS MEDICINE STUDENT-ATHLETE HEALTH INSURANCE INFORMATION NAME: SPORT: SOCIAL SECURITY #: BIRTHDATE: PHONE # Please PRINT this form, attach a LEGIBLE front and back copy of the student-athlete s health insurance card to this form and return to YHC Sports Medicine by mail along with this packet. Young Harris College Sports Medicine PO Box 37 Young Harris, GA ATTACH FRONT OF INSURANCE CARD HERE ATTACH BACK OF INSURANCE CARD HERE

4 4 YOUNG HARRIS COLLEGE SPORTS MEDICINE CONSENT FOR TREATMENT I,, do hereby grant permission to the Young Harris College Athletics Department, Sports Medicine Staff, and any other medical professional deemed necessary, to treat any athletic injury I might incur during my athletic career, according to the policies and procedures of the NCAA and the Young Harris College Athletics Department. Student-Athlete Signature Parent s Signature (if student-athlete is under 18) YOUNG HARRIS COLLEGE SPORTS MEDICINE AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION I,, hereby authorize release of all medical information to all team physicians and members of the athletic training staff of Young Harris College. These medical records may be used to help file claims with insurance companies and aid to enhance my care as a student-athlete of Young Harris College. Medical information is confidential and, except as provided in this release, will not be otherwise released by the parties in charge of the information. I understand that any injury/illness information is protected by federal regulations under either the Health Information Portability and Accountability Act (HIPAA) or the Family Educational Rights and Privacy Act of 1974 (the Buckley Amendment) and may not be disclosed without my authorization. This release remains valid until one calendar year after the signed date, or if otherwise revoked by me in writing. Printed Name of Student Athlete Signature

5 5 YOUNG HARRIS COLLEGE SPORTS MEDICINE ASSUMPTION OF RISK WAIVER I understand that participation in intercollegiate athletics requires an acceptance of risk of injury. Young Harris College has taken reasonable precautions to minimize the risk of significant injury by providing competent coaching, well maintained equipment and facilities, and good medical care. The chances of an athlete sustaining a catastrophic sports injury are extremely remote, yet I understand that serious injuries can happen to anyone. Participation in sports can result in death, serious head, neck, and spinal injuries which may result in complete or partial paralysis, brain damage, serious injury to virtually all bones, joints, ligaments, muscles, tendons, and other aspects of the musculoskeletal system or impairment to other aspects of my body, general health, and well-being. By signing this Assumption of Risk Waiver, I do assume the risks of becoming tragically injured while participating in intercollegiate athletics at Young Harris College, as well as understand the consequences of such injury. Printed Name of Student Athlete Signature Printed Name of Guardian (if under 18) Signature

6 6 YOUNG HARRIS COLLEGE SPORTS MEDICINE DRUG EDUCATION & TESTING PROGRAM STUDENT-ATHLETE CONSENT FORM I,, hereby acknowledge that I have received a copy of, read, and been given the opportunity to ask questions regarding the Drug Education & Testing Program implemented for the Department of Athletics at Young Harris College. I understand the policies, procedures and my responsibilities as described in such policy. As a condition to my participation in intercollegiate athletics at Young Harris College, I consent to participate in the Drug Education & Testing Program. I understand that my participation in this program includes the collection and testing of my urine at various times during the academic year for drugs, alcohol, and/or other banned substances. I further consent to the release of the results of any drug test to the Director of Athletics or his/her designee, Senior Women s Administrator, my head coach, Head Athletic Trainer, College President, Campus Police, office of Counseling and Psychological Services, Office of Student Development, and/or parent/guardian if I am a minor. I acknowledge and understand that a copy of this consent form may be sent to my parent(s) or guardian(s) along with a copy of the Drug Education & Testing Program. To the extent set forth in this document, I waive my privilege I may have in connection with such information. I fully understand the Young Harris College Drug Education & Testing Program is separate and distinct from the NCAA drug-testing program and its sanctions, however, I also understand that sanctions may be imposed by Young Harris College under its Drug Education & Testing Program upon a positive result under the NCAA drug-testing program. Young Harris College, its officers, employees, and agents are hereby released from legal responsibility and/or liability for the release of any information and/or record as authorized by this consent form. I fully and forever release and discharge the aforementioned parties from any claims, demands, rights of action, or causes of action, present or future, whether the same be known or unknown, anticipated or unanticipated, resulting from my participation in Young Harris College s Drug Education & Testing Program including those claims, demands, rights of action, or causes of action arising out of any positive result under such Drug Education & Testing Program. Signature of Student-Athlete Printed Name of Student-Athlete of Birth Social Security Number Sport(s) Signature of Parent/Guardian (if a minor)

7 7 YOUNG HARRIS COLLEGE SPORTS MEDICINE STUDENT-ATHLETE DIETARY SUPPLEMENT DISCLOSURE & REVIEW FORM I,, am taking or intend to take the following dietary supplements. I acknowledge the risk of losing my eligibility to participate in intercollegiate athletics if I test positive for an NCAA or Young Harris College banned substance that may be found in any substance that I take, regardless of the reason or purpose for taking such supplements. I acknowledge and understand the labeling on these products can be misleading and inaccurate, and that sales personnel are neither motivated nor qualified to accurately certify that these products contain no banned substances. Healthy or naturally occurring are terms often used to market sales of dietary supplements, but do not necessarily mean they are safe. Before taking or using any dietary supplement, I am responsible for ensuring the product does not contain any banned substance. By making this disclosure, I am requesting that these products and their ingredients be reviewed by Young Harris College s sports medicine staff for the purposes of determining whether they are medically safe to use and do not contain banned substances. I understand that I should not take or use these products until their usage has been reviewed by Young Harris College s sports medicine staff. BRAND NAME: LISTED ACTIVE INGREDIENTS: Signature of Student-Athlete Signature of Athletic Trainer

8 8 YOUNG HARRIS COLLEGE SPORTS MEDICINE CONCUSSION REPORTING FORM NCAA regulations require all varsity student-athletes to be aware of what a concussion is, as well as signs and symptoms of a concussion. Please read the below information and sign and date the bottom of the form to be in compliance with NCAA regulations. A concussion is a brain injury that may be caused by a blow to the head, face, neck, or elsewhere on the body with an impulsive force transmitted to the head. Concussions can also result from hitting a hard surface such as the ground, ice, or floor, from players colliding with each other, or being hit by a piece of equipment such as a bat, lacrosse stick, or ball. Signs and Symptoms of a Concussion: Headache Nausea Vomiting Balance problems Dizziness Double or Blurry Vision Sensitivity to light Sensitivity to noise Feeling sluggish, hazy, foggy, or groggy Concentration or memory problems Confusion I,, do hereby agree to accept the responsibility for reporting all injuries and illnesses to the Young Harris College Athletic Training Staff, including signs and symptoms of a concussion. Signature of Student-Athlete Signature of Parent/Guardian (If under age of 18)

9 9 YOUNG HARRIS COLLEGE SPORTS MEDICINE ATHLETIC TRAINING ROOM RULES 1. NO CELL PHONES IN THE ATHLETIC TRAINING ROOM 2. The athletic training room is a medical facility and should be treated as such. (It is not a place to hang-out and talk with athletes receiving treatment) 3. Athletes receiving treatment must be appropriately dressed (shorts and t-shirt) at all times while in the athletic training room. 4. No student-athletes or coaches should be in the athletic training room without the supervision of an athletic trainer unless given permission. 5. Report all injuries and conditions as soon as possible to the athletic training staff or the athletic trainer assigned to your team. 6. No student-athletes are to treat themselves. An athletic training staff member must set up the equipment and supervise all treatments. 7. No horseplay, visiting, loitering, swearing, or shouting. 8. Nothing (towels, rehab equipment, etc.) is to be removed from the athletic training room, unless approved by a member of the athletic training staff. 9. No cleats or studded shoes are allowed in the athletic training room. Excessively dirty or muddy tennis shoes should be left outside. (No shoes on the tables) 10. Student-athletes must shower or wash off with soap and water before getting into the whirlpools. 11. Absolutely NO food, drinks, chewing or spit tobacco is ever allowed in the athletic training room. **The athletic training staff reserves the right to withhold treatment in any instance where any member of the athletic training staff is disrespected by a student-athlete.** Printed Name of Student Athlete Signature

10 10 Name: Sport: SSN: Birthdate: Phone: ( ) ** To Be Completed By Physician ** Height: Weight: Pulse: BP: / Eyes: RT: /20 LT: /20 General Medical Normal Abnormal Findings Skin Eyes Ears Nose Mouth/Throat Lymph Nodes Heart / Cardiovascular Pulmonary / Lungs Abdomen / GI Neurological Orthopedic Normal Abnormal Findings Cervical/Thoracic Spine Lumbar Spine Shoulder Elbow Wrist/Hand Knee Hip Ankle/Foot Is the athlete/patient cleared for FULL PARTICIPATION in ATHLETICS? YES NO (circle one) If NO, please explain: Consult Requested: Physicians Signature: Printed name of Physician: Address: Phone: **Section Below To Be Completed By Consulting Physician** Consulting Physicians findings: Is the athlete/patient cleared for FULL PARTICIPATION in ATHLETICS? YES NO (circle one) If NO, please explain: Physicians Signature: Address: Printed name of Physician: Phone:

11 11 THESE NEXT FEW FORMS ARE NEW FOR ALL OF THE FORMS MUST BE SIGNED BY THE INSURED PERSON WHO YOU HAVE INSURANCE THROUGH. FOR INTERNATIONAL STUDENTS: JUST YOUR SIGNATURE WOULD BE FINE.

12 12 Young Harris College Insurance Memorandum Young Harris College maintains insurance coverage for athletically related injuries of student-athletes. YHC s insurance policy acts as secondary coverage to the student-athlete s health insurance policy. Every student-athlete is required by both the College and YHC Athletics to maintain health insurance coverage. Student athletes are REQUIRED to maintain health insurance and comply with the requirements listed below to receive coverage under the YHC Athletics Secondary Insurance Policy: 1. All student-athletes are required to be covered under a primary major medical insurance policy which guarantees coverage within the United States (i.e. no traveler s policies). 2. Primary insurance deductibles up to $2,000 and coinsurance are covered benefits, but not co-payments per-visit (student athlete and/or parent must pay). Prescriptions will not be a covered expense. 3. The student-athlete s primary insurance policy MUST cover intercollegiate sports injuries. 4. All insurance cards/policies must be submitted to the Head Athletic Trainer for verification of proper coverage no later than August 1 st. If a student-athlete is placed on a roster after August 1 st, the student-athlete must submit the insurance card to the head athletic trainer prior to ANY participation in athletics. 5. All international student-athletes will be required to have a domestic based policy (if your personal international policy has a US claims address it will not meet the requirements). 6. If the student athlete does not have insurance they can purchase one from a U.S carrier or the one that YHC athletics provides, the cost of this policy will be placed on the student-student-athletes account. 7. The student-athlete must carry a proof of health insurance while attending Young Harris College. 8. All injuries must be reported to the head athletic trainer for medical treatment and/or referral for care of the injury. Non-referred treatment is NOT covered. 9. In the event of an emergency referral is not necessary. However, if follow-up treatment is needed, the head athletic trainer must be notified. 10. All injuries requiring medical care in the community must be reported to and approved by athletic training staff immediately. Failure to do so will result in denial of benefits. 11. It is the responsibility of the student-athlete, parent/guardian, and/or policy holder to be familiar with their primary medical plan. Proper procedures must be followed to assure there will be no reduction in benefits. This includes but is not limited to second opinions, pre-certification, and the use of preferred providers. 12. If the student-athlete s primary insurance coverage is provided through an HMO, PPO, POS or any plan using a preferred provider network, a preferred health care provider within the plans network must treat the injured student-athlete, except in the case of an emergency. Claims denied by the primary carrier for failure to follow their procedures and/or failure to seek care from a preferred provider will result in a denial of benefits by Young Harris College. 13. Although the athletic training staff or insurance coordinator may help with accessing health care in the community, it is ultimate of the student-athlete, parent/guardian, and/or policy holder to make sure primary insurance plan(s) rules are being followed (i.e. using preferred providers). 14. Non-athletic related injuries are not covered. Ie.. (cold, flu, other sickness) 15. Expenses related to general illness or routine dental care, are not covered benefits. 16. Pre-existing injuries or aggravation of pre-existing injuries due to athletic participation are not covered. 17. Braces and orthotic devices are not covered expenses unless they are prescribed by the treating physician for rehabilitation following a covered treatment. 18. Medical care payments are limited to usual and customary charges. 19. Physical therapy services not rendered by the Young Harris College athletic training staff will be the responsibility of the student athlete. 20. Young Harris College will not pay for chiropractic visits. 21. Charges not covered by the student-athlete s primary insurance or YHC Athletics Secondary Insurance Policy become the sole responsibility of the student-athlete, parent/guardian, and/or policy holder.

13 All charges must be submitted to Young Harris College within one year of the date of service. 23. The student-athlete must notify the head athletic trainer immediately when there is a change in the primary insurance. 24. If at any time the student-athlete s primary medical insurance coverage lapses the college will not offer any coverage for bills incurred related to participation in the intercollegiate sports program. Please note the NCAA also provides catastrophic athletics injury coverage. The NCAA s Catastrophic Injury Insurance Program covers student-athletes who are catastrophically injured while participating in a covered intercollegiate athletic activity (subject to policy terms and conditions). The policy has a $75,000 deductible and is supplemental coverage in the event of a catastrophic injury. More information can be found on the NCAA s website at I have read the YHC Department of Athletics Insurance Policy. I understand that failure to follow the above listed requirements will result in denial of coverage and the student-athlete will be solely responsible for all expenses associated with any treatment related to athletically related injuries. Student-Athlete Name (please print): Student-Athlete Signature: : Policy Holder Name (please print): If different from student-athlete or parent/guardian Policy Holder Signature: :

14 YHC Insurance Information The Young Harris College (YHC) Department of Intercollegiate Athletics carries an EXCESS medical insurance policy for each student-athlete. When a student-athlete is injured, all medical insurance claims will be filed with your personal insurance company. A letter will be mailed to you after an injury to your son/daughter explaining the bills, EOB, etc. that the YHC Athletic Training insurance coordinator may need in order to file the student athlete s claim with our secondary insurance company. Upon receiving the needed information, the claim will be filed with our secondary insurance company. Please be advised that should a balance still exist after both the primary and secondary insurance have paid, this will be the responsibility of the athlete. Please be advised that all injuries must be reported to a staff athletic trainer. We will advise the student-athlete of the proper protocol that must be taken to insure proper payment by all insurance companies involved. Only in the event of a medical emergency should the student-athlete seek medical treatment without the prior approval of an athletic trainer. Medical care that hasn t been approved by the athletic trainer may jeopardize and/or remove responsibility from YHC and its secondary insurance company for payment of medical bills. We strongly recommend that you research and understand your insurance benefits prior to your arrival on campus. If the benefits are insufficient or non-existent (HMO), you may wish to call your carrier to inquire about alternatives. Another option would be for you to purchase the insurance policy offered through the athletic department. Your signature on this letter indicates that you have read, understand and will comply with all that is stated above. Any false information will nullify YHC from responsibility regarding any medical bills. I, have read the above letter and understand that YHC is responsible on a secondary basis only for injuries which occur in an official YHC athletic practice or competition. I also verify that all the insurance information that I have provided is correct and complete. Student-Athlete Signature ** Parent/Guardian Signature ** Must be signed by parent/guardian if student-athlete is on parent s insurance.

15 15 ATHLETIC TRAINING Confirmation of Primary Insurance All student-athletes both domestic and international are required to have private health/accident insurance that covers intercollegiate athletic injuries for a minimum of the academic year. Any student-athlete that does not have or lets their health insurance policy lapse will be ineligible to participate in conditioning, practices, and/or competition with YHC athletic teams until health insurance is reinstated. Also, any student-athlete that lets his/her health insurance lapse or does not inform the athletic training staff of a change in his/her insurance policy will be RESPONSIBLE for all medical bills related to an athletic injury. No student-athlete will be allowed to participate until verification of insurance is on file in the Athletic Training Room. If a student-athlete gets injured and during the billing process it is found out the student-athlete s insurance has been dropped or there is no coverage for any reason, that student-athlete will be responsible for total payment of all medical expenses. If the student-athlete s health insurance is out-of-area (North Georgia Region) or a guest form for coverage cannot be obtained, the student-athlete is responsible for knowing how to obtain medical service when outside of the insured area (i.e. HMO s, Kaiser Permanente, AETNA, Wellcare, Peachcare). It is important that the insured understand that in some instances follow-up medical treatment must be obtained in the coverage area. This may require the student-athlete to travel, at his or her own expense, to the proper coverage area for treatment. In the case of an injury, the student-athlete, the hospital, or physician s office will file the claim with the student-athletes insurance carrier. It is ultimately the student-athlete s/policy holder s responsibility to make sure that all the medical expenses are resolved. I understand that if I drop my primary insurance coverage I will be financially responsible for any and all athletic injury claims and therefore release Young Harris College. I further agree that I may seek other medical consultation ONLY upon consultation with a staff Athletic Trainer or Team Physician. Printed Name Sport M F ** Signature of Student-Athlete Signature of Parent/Guardian ** Must be signed by parent/guardian if student-athlete is on parent s insurance.

16 16 To the Parents/Guardians of all Young Harris College Student-Athletes: Young Harris College Athletic Training staff may provide care for student-athletes for injuries/illnesses that occur during their intercollegiate participation. This letter to inform the athletes of the policy for billing medical care provided by the College to the athlete. All student athletes are responsible for obtaining and maintaining a health insurance policy. Additionally, Young Harris College carries a secondary insurance policy that covers out of pocket costs for student athletes once a the deductible for the athlete has been met. If a student athlete receives medical care approved by our Athletic Training Staff or team physicians for injuries/illnesses that occurred during their intercollegiate participation, the athlete s insurance will be billed for the services they received. Once the athlete has reached the deductible in out of pocket expenses, the college s deductible will have been met, and the student athlete and his or her parents will not be responsible for any additional charges that may be incurred. Typically the student athlete s insurance carrier will provide an explanation of benefits ( EOB ) when a bill is submitted to the insurance company. This document IS NOT A BILL. This is simply a summary of the charges that were filed against the insurance policy for services rendered. Please forward any EOBs for injuries/illnesses that occurred during intercollegiate participation to the attention of Jared Sandler. If for any reason you ever receive a bill from a medical provider for injuries/illnesses that occurred during their intercollegiate participation, we also ask that you send us a copy of this document as well. Some of you may have already received EOBs from your primary insurance carrier. For those documents already received, please send these to us at once. If you feel you have already sent to us, then no need to send again. However, if you have not or are unsure, go ahead and send the document to us to make sure we have what we need to process payment. Here are a few examples of the types of service that may be provided and which would result in an EOB: Surgeries Rehabilitation Services Doctor Visits Anesthesiology Services X-Rays Hospital Charges MRI s Counseling Services CT Scans Nutritional Services Physical Therapy Should you have any questions or concerns regarding any documentation you receive from your insurance carrier, you are welcome to those documents and your questions or concerns to Jared Sandler at jssandler@yhc.edu As always, you are welcome to give me a call directly and I will assist you with your questions and/or issues. I can be reached I understand and acknowledge the policy for billing medical services provided to student athletes for injuries/illnesses that occurred during intercollegiate participation and agree to comply with this policy. Student-Athlete Signature ** Parent/Guardian Signature ** Must be signed by parent/guardian if student-athlete is on parent s insurance.

17 17 ATHLETIC TRAINING Injury Acknowledgement Form I, hereby understand that once I become injured or my medical condition changes it is my responsibility to notify a member of the Athletic Training staff and temporarily remove myself from all practices, conditioning, and competitions until gaining examination from a YHC certified athletic trainer. Upon evaluation, if the ATC deems medical clearance is necessary, I will work with YHC s Athletic Training staff to obtain official written clearance from the physician best suited to meet my medical needs. YHC must receive official written documentation from the physician (MD or DO only) giving you clearance to participate. Student-Athlete Signature Witness Signature

18 18 ATHLETIC TRAINING Physician Choice Policy The Young Harris College Athletic Department and Athletic Training office believes our student athletes deserve the best medical care available. The YHC Athletic Training Program has a network of board certified physicians that can treat any medical issue that may arise from athletic competition or training. The student athlete may choose to use the physicians affiliated with YHC athletics or they may utilize a physician of their own choosing for injury or illness care. Regardless of the decision, the following guidelines have been set in place: All medical care associated with an YHC athletics injury must be coordinated through the YHC Athletic Training department. YHC will not be financially responsible for services unless YHC personnel have seen the student-athlete first. The physician used may be affiliated with YHC athletic training or of your own choosing, but the first opinion is the one that will be followed for care/play by the YHC Athletic Training staff. If the physician used is not affiliated with YHC Athletic Training, written documentation of the visit and treatment parameters must be provided to the Athletic Training staff as soon as possible. Any secondary opinions not deemed necessary by the initial treating physician and any resulting outcomes (i.e. surgeries, diagnostic testing) is the financial responsibility of the athlete. The student athlete also has the right to seek rehabilitation outside of YHC, but at their own expense (rehabilitation bills, transportation). Certain injuries, such as spinal and head trauma may require outside care, but for routine orthopedic injuries (i.e. sprains, strains, fractures of extremities, surgical intervention for such) YHC athletic training staff is well prepared to handle such rehabilitation protocols. If a second opinion is obtained, it is the responsibility of the student athlete to notify the YHC Athletic Training Staff prior to the appointment. I acknowledge and understand the policy related to physician care and agree to the guidelines listed in this policy. Signature of Student-Athlete ** Signature of Parent/Guardian ** Must be signed by parent/guardian if student-athlete is on parent s