UNIVERSITY OF THE INCARNATE WORD SPORTS MEDICINE DEPARTMENT

Transcription

1 UNIVERSITY OF THE INCARNATE WORD SPORTS MEDICINE DEPARTMENT Release and Waiver of Liability, Assumption of Risk, Indemnity and Hold Harmless Agreements The signed student-athlete is enrolled at the University of the Incarnate Word (UIW) and will be participating in Intercollegiate Athletics. The student-athlete who is of eighteen 18 years of age or the parent/guardian of the student-athlete who is under the age of 18 represents and acknowledges by their electronic signature that they are fully competent to sign this Release and Waiver of Liability, Assumption of Risk, Indemnity and Hold Harmless Agreement. In consideration for participating in UIW Intercollegiate Athletics and other valuable considerations, the studentathlete/parent/guardian agrees to the following: A. Participation in Intercollegiate Athletics at UIW includes, but is not limited to training, practices, team meetings, tutoring sessions, competitions, playing and travel. B. Understands that there are certain inherent risks involved in participating in intercollegiate athletics and assumes full responsibility for any and all risk of loss, property damage, and permanent physical or mental impairment, personal injury/illness, including death, which may be sustained as a result of participation. C. Acknowledges the fact that these inherent risks exist and are willing to assume responsibility for any and all such risks while participating and realizes that UIW is not responsible for any injuries or conditions that may be caused by their own actions or actions of other athletes or teams. D. Accepts that UIW and its personnel are not responsible for any pre-existing medical conditions(s), and that having passed the physical examination does not necessarily mean that the student-athlete is physically qualified to participate in intercollegiate athletics at UIW, but only that the evaluator did not find a medical reason to disqualify the student-athlete at the time of the physical examination. E. Will refrain from practice while injured or ill, whether or not receiving medical care. While under medical care they may not return to participation until they have been given permission, based on independent exercise of professional judgment, by the attending Team Physician(s) or his/her designate after review of their condition and fitness for the rigors of their sport. F. If experiences an injury/illness (including concussions) or change in their health status it is the student-athlete s responsibility to inform the Head Coach and a Sports Medicine Department staff member and to adhere to the established injury management guidelines which includes total rehabilitation and reassessments before they are released to return to full participation. G. Wears the proper equipment as dictated by the rules of the sport and the NCAA and UIW staff. The student-athlete may also have to wear padding or braces as directed by the coaching staff, sports medicine staff or other medical personnel. Failure to do so may put them at risk for further injury/death and if they fail to wear the proper equipment they agree that they will not hold UIW, its Board of Trustees, officers, employees and agents financially or otherwise responsible. H. Understands that UIW is not responsible for any medical expenses associated with any personal injury that they may sustain. I. RELEASES UIW, ITS BOARD OF TRUSTEES, OFFICERS, EMPLOYEES, AND REPRESENTATIVES FROM ALL LIABILITY FOR CLAIMS AND CAUSES OF ACTION FOR LOSS OF PROPERTY OR PERSONAL INJURY TO THE STUDENT-ATHLETE, INCLUDING DEATH, OCCURRING DURING OR CONNECTED WITH PARTICIPATION IN INTERCOLLEGIATE ATHLETICS, WHEN CAUSED BY THE NEGLIGENCE OF UIW, ITS BOARD OF TRUSTEES, OFFICERS, EMPLOYEES, AND REPRESENTATIVES, OR ANY OTHER PERSON, THAT MAY BE SUSTAINED BY THE STUDENT-ATHLETE WHILE PARTICIPATING IN UIW INTERCOLLEGIATE ATHLETICS. J. AGREES TO INDEMNIFY AND HOLD HARMLESS, WAIVE AND COVENANT NOT TO SUE UIW, ITS BOARD OF TRUSTEES, OFFICERS, EMPLOYEES, AND REPRESENTATIVES FROM LIABILITY FOR LOSS TO PROPERTY OR PERSONAL INJURY, INCLUDING DEATH, TO THE STUDENT-ATHLETE OR OTHER PERSON(S) THAT MAY RESULT FROM ANY NEGLIGENT OR INTENTIONAL ACT OR OMISSION WHILE PARTICIPATING IN UIW INTERCOLLEGIATE ATHLETICS, WHETHER CAUSED BY THE NEGLIGENCE OF UIW OR OTHERWISE. THE STUDENT-ATHLETE AND/OR PARENT/GUARDIAN AGREES TO HAVE CAREFULLY READ AND UNDERSTANDS THIS RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, INDEMNITY AND HOLD HARMLESS AGREEMENT AND VOLUNTARILY EXECUTE IT INTENDING TO BE BOUND BY IT.

2 Primary Insurance Statements Student-athletes and/or parents/guardians agree to the following: All student-athletes are required and agree to have some type of primary medical insurance coverage prior to and during participation in intercollegiate athletics; moreover, failure to do so may result in delays to care, delays in payments to medical providers, and/or may lead to financial collection procedures against the student-athlete and/or their parents, guardians, etc. It is the student-athlete s responsibility to update their online profile or to notify the sports medicine department of any changes to their primary insurance coverage. That having personal, private medical insurance (Blue Cross Blue Shield, Aetna, Humana, etc.) has been recommended. That the university s student health insurance plan currently meets the minimum standards required by the Affordable Health Care Act, including covering athletic injuries. That the university s international student health insurance plan currently meets the minimum standards required by the Affordable Health Care Act. If the student-athlete s primary medical insurance plan requires a claim form, it is the student-athlete s responsibility for filling out each claim form and submitting it to their primary medical insurance company. Secondary Insurance Statements Student-athletes and/or parents/guardians agree to the following: All injuries and/or illnesses must be reported to the sports medicine department prior to seeking medical attention; otherwise, the student-athlete assumes all financial responsibility for any expenses incurred. Exceptions include emergencies in which 911, campus police or EMS is notified. All outside medical referrals and second opinions must be approved by the sports medicine department. The student-athlete is responsible for providing proof of primary and secondary insurance to all medical providers. Proof of secondary insurance can be obtained from the sports medicine department. The student-athlete is ultimately financially responsible for any and all medical bills that may incur because of an injury and/or illness while participating in intercollegiate athletics for UIW. The student-athlete s/parent s/guardian s credit report may be negatively affected if they fail to recognize/pay the incurred medical bills. All medical bills are sent directly to the student-athlete s home address, campus address and/or primary insurance company; the bills will not be sent to the university s athletic department. It is the responsibility of the student-athlete to bring all medical bills to the sports medicine department for questions, interpretation, explanation, and settlement. The University of the Incarnate Word will supply a secondary medical insurance policy to help cover injuries and/or illnesses that are sustained while participating in NCAA intercollegiate athletics. This policy is SECONDARY to, or in excess of, the student-athlete s primary health insurance. It is the student-athlete s responsibility to sign any and all PRIMARY and/or SECONDARY insurance claim forms in order for each claim to be processed and paid according to procedures. The university s secondary insurance company has a $ disappearing deductible for EACH injury sustained. This $ is paid by the university s secondary insurance company directly to the medical providers but may be reimbursed to the financially responsible party with proper documentation/receipts. Charges may incur which are NOT covered by the university or its secondary insurance company because they are above and beyond usual and customary insurance pricing. The student-athlete WILL BE financially responsible for these possible costs. The secondary insurance policy will cover injuries sustained in practices, games or competitions, and/or related travel that is supervised by an UIW coaching staff member and approved by the Director of Athletics as outlined by NCAA regulations. Volunteer and open forum participation is NOT covered by this policy including, but not limited to, open field, open gym, 7 on 7, captain s practices, personal workouts, or any other such gatherings/participation. The secondary policy will cover aggravation or re-injury to a preexisting injury ONLY if the preexisting injury is revealed on the Health History Form AND made known to the team physicians at the time of the physical examination. Self-inflicted or intentional injuries are not covered by the secondary policy or the university. The sports medicine department will assist in settling disputed claims and bills from medical providers as long as the studentathlete presents the issues in a timely manner.

3 Athletic Insurance Claims Procedure Student-athletes and/or parents/guardians agree to the following: The student-athlete is responsible for providing proof of primary and secondary insurance to all medical providers. Proof of secondary insurance can be obtained from the sports medicine department. It is the student-athlete s responsibility to sign any and all PRIMARY and/or SECONDARY insurance claim forms in order for each claim to be processed and paid according to procedures. The secondary insurance claim form will be filled out by the sports medicine department within a timely manner, BUT must be signed by the student-athlete within 90 days from the date of accident. The sports medicine department will notify and send the secondary insurance claim form to the student-athletes UIW address/account for review and signature; moreover, failure to sign the secondary insurance claim form will result in a hold on the student-athlete s overall university business/registration account. The secondary insurance claim form must be turned in to the secondary insurance company within 90 days from the date of the accident. That all medical treatments must take place within 90 days of the initial injury in order to be considered for coverage by the secondary insurance policy. That all medical providers are responsible for providing an itemized bill and the primary insurance company s explanation of benefits forms to the secondary insurance company for consideration of payment and that it is the student-athlete s responsibility to confirm that all medical providers know to provide the itemized bill and primary insurance explanation of benefits forms to the secondary insurance company. The secondary insurance company will provide an explanation of benefits form to both the student-athlete and the university s sports medicine department. Charges may incur which are NOT covered by the university or its secondary insurance company because they are above and beyond usual and customary insurance pricing. The student-athlete WILL BE financially responsible for these possible costs. All secondary medical insurance claims cover medical costs for each injury up to 2 years from the date of injury on the secondary insurance claim form. Each insurance company, primary and secondary, may take up to days to process a claim; therefore, claims may take up to 90 days to be processed in which time the student-athletes and/or their parents/guardians may receive medical bills from the providers. The student-athlete is ultimately financially responsible for any and all medical bills that may incur because of an injury and/or illness while participating in intercollegiate athletics for UIW. The student-athlete s/parent s/guardian s credit report may be negatively affected if they fail to recognize/pay the incurred medical bills. The sports medicine department will assist in settling disputed claims and bills from medical providers as long as the studentathlete presents the issues in a timely manner. Because of the history and possibility of insurance fraud, the university s complete secondary insurance claim forms are NOT available to providers or outside agencies acting on the part of providers. Student-athletes may request a copy of the claim form; however, no copy will be accepted by the secondary insurance company as an original claim form for processing medical bills; moreover, all secondary insurance claims forms must be submitted by the sports medicine department to the secondary insurance company for claims consideration.

4 Medical & Authorization Statements PRESENT PHYSICAL CONDITION The student-athlete warrants and represents to University of the Incarnate Word Athletic Department that he/she is in excellent physical condition. Upon reporting to the University of the Incarnate Word, the student-athlete must complete a health history form and be examined by a University of Incarnate Word and/or consulting physician and/or his/her designee. The studentathlete recognizes that their true physical condition is dependent upon an accurate medical history and a full disclosure of any symptoms, complaints, prior injuries, ailments, and/or disabilities experienced. The student-athlete affirms that he/she has fully disclosed their prior medical history; that the health history form was fully and accurately completed; that all present symptoms, complaints, ailments, disabilities, and/or prior injuries have been disclosed in writing to and discussed with an University of the Incarnate Word Team and/or consulting physician and/or his/her designee; and that the student-athlete is not suffering from any complaints, prior injuries, ailments, disabilities, conditions, or problems not so disclosed and discussed. Furthermore, the studentathlete consents to laboratory analysis, urine screen, blood chemistry, orthopedic, internal, and any other examination deemed necessary to determine his/her physical/mental condition. FUTURE COMPLAINTS The student-athlete acknowledges and agrees that all future injuries, medical, dental, or mental problems, ailments, complaints, concussions, re-injuries, and aggravations of old injuries must be immediately reported to the University s team physicians, athletic trainers, and/or a member of the University of the Incarnate Word Sports Medicine Department, no matter how minor or insignificant they may be. MEDICAL TREATMENT The student-athlete authorizes the University of the Incarnate Word team physicians, athletic trainers, and designated medical staff to examine and treat any injuries, which may occur, while participating in intercollegiate athletics for the University of the Incarnate Word. This includes preventative care, first aid, rehabilitation, and emergency treatment including hospitalization. The student-athlete authorizes the team physicians, athletic trainers, and designated medical staff to communicate with athletic department officials and coaching staff regarding their findings and recommendations; and further understands that the team physician and/or his/her designee have the authority to eliminate the student-athlete from participation as a student-athlete due to an injury/illness, and/or due to undue liability risk of the University of the Incarnate Word. PRESCRIPTION MEDICATION RELEASE AUTHORIZATION The student-athlete authorizes a representative of the University of the Incarnate Word Sports Medicine Department under the supervision and protocol of the team physician, to act as his/her caretaker and agent to receive, procure, store and issue any medication, which are prescribed to the student-athlete. The student-athlete must take the necessary precautions to keep all medication out of the reach of children. The student-athlete authorizes the release of any information regarding prescriptions to University of the Incarnate Word Sports Medicine personnel. SUBSTANCE ABUSE POLICY AND PROCEDURE AUTHORIZATION The student-athlete acknowledges that he/she has had an opportunity to review the complete Substance Abuse Policy and Procedure Program for the academic year. This policy is available through the athletic website, the athletic department, the head coach, and/or the sports medicine department. The student-athlete also consents to follow this policy as it is outlined. The policy will be in effect for the academic year and any changes to the policy may occur or be updated without notice to the student-athlete. Declining this authorization will make the student-athlete ineligible for intercollegiate athletic participation.

5 PRIVACY PRACTICE STATEMENT Privacy Practices & Consent for Disclosure of Personal Information The University of the Incarnate Word s Sports Medicine Department has a legal, ethical and moral obligation to protect the student-athlete s confidentiality. Any information about the student-athlete will be held in strict confidentiality by all staff members and sports medicine students. No discussions about the student-athlete, outside of the medical care framework, will be permitted, and any conversation among staff members that pertains to delivering quality care will be held in a confidential and professional manner. In order to provide quality care to the student-athlete, as well as operate the University of the Incarnate Word Sports Medicine Department in an efficient manner, the Sports Medicine Department will need to access private health care information for purposes of treatment, payment, and operations. In using this information, the Sports Medicine Department will comply with all state and federal laws pertaining to the student-athlete s privacy rights, including the Privacy and Security protections afforded by the Health Insurance Portability and Accountability Act (HIPPA) and/or the Family Educational Rights and Privacy Act (FERPA) of 1974 (the Buckley Amendment). The student-athlete consents use and disclosure of information as described and may revoked said consent in writing at any time. The Associate Athletics Director Sports Medicine must be notified if consent is ever revoked. Specific authorization will be required for the release of any information not included in this document. Authorization will need to be in writing and it will need to be specific to the disclosure requested. The Sports Medicine Department will not release any information on any studentathlete, other than stated in this document, without a signed release from the student-athlete unless required by law. The student-athlete has the right to inspect and copy protected information, amend the medical record, have reasonable requests for confidential communications accommodated and may obtain an accounting of disclosures. All other rights afforded to the student-athlete by state and federal law will be honored. The student-athlete can contact the Associate Athletics Director Sports Medicine if there are any questions about their rights or any other privacy related questions. If the student-athlete wishes to amend their medical record, it is to be done in the Sports Medicine Department office on a separate sheet of paper. In NO CASE will the original record itself be altered or defaced by the student-athlete. The original record will not leave the Sports Medicine Department office premises unless required to do so by law. The Associate Athletics Director Sports Medicine is the person in the department responsible for privacy and the security of student-athlete information. Any complaints in this area should be directed to the Associate Athletics Director Sports Medicine or the Athletics Director. CONSENT FOR DISCLOSURE OF PERSONAL INFORMATION The University of the Incarnate Word Sports Medicine Department will share student-athlete personal medical information a) for purposes of treatment, b) with athletic department staff members, including but not limited to coaches and administrators, c) with athletic training students, d) with academic personnel as necessary and/or when injury/illness requires, e) for payment to medical providers, and f) to persons listed in the online emergency contact profile or in writing to the Sports Medicine Department. The University of the Incarnate Word Sports Medicine Department will use answering machines or voice mail systems, cellular or cordless telephones, fax machines, and/or /internet to discuss or transmit information about the student-athlete and the student-athlete s condition(s) as necessary despite the fact that these transmittals may be intercepted or overheard by other persons, although this is not routinely anticipated.

6 Educational Information CONCUSSIONS Per the NCAA, effective August 16, 2010, all active Division I member institutions are to have a concussion management plan for their student-athletes. The University of the Incarnate Word in cooperation with Sports Medicine Associates of San Antonio has developed a concussion management plan to fulfill this requirement. The first part of the legislation requires educational material to be made available to all student-athletes and their parents/guardians. The NCAA has made an educational video available to all student-athletes about concussions. This video can be viewed through the NCAA website at NCAA Concussions: Don't Hide It or in person at the athletic department at the University of the Incarnate Word. All student-athletes will agree that they have had the opportunity to review the NCAA Concussion Fact Sheet available through the NCAA website, the UIW Athletic website, the Athlete s Forms section of the medical database, and/or through their initial team meeting. In summary of this information, the student-athlete must understand that a concussion is a brain injury caused by a blow to the head; it is not an injury that can be seen like a sprained ankle. It changes the way your brain normally works and can be mild, moderate, or severe. The injury is different for each person and can occur any time the athlete hits their head. There are several symptoms of a concussion which may or may not appear, but that the athlete should be aware of. They include amnesia, confusion, headache, dizziness or balance issues, double vision, nausea, light and noise sensitivity, slow reaction time, and concentration and/or memory problems. If a student-athlete thinks they have a concussion they should not hide it but get it checked out by a medical care professional and take time to recover from it. SICKLE CELL TRAIT Per the NCAA, effective August 2010, all Division I student-athletes must be educated and tested for the sickle cell trait, show proof of a prior test, or sign a waiver releasing the university institution from liability should the student-athlete decline to be tested prior to participation in NCAA activities. The NCAA has made an education video available to all student-athletes about sickle cell. This video can be viewed through the NCAA website at NCAA Sickle Cell Resources or in person at the athletic department at the University of the Incarnate Word. All student-athletes will agree that they have had the opportunity to review the NCAA Sickle Cell Trait Fact Sheet available through the NCAA website, the UIW Athletic website, the Athlete s Forms section of the medical database, and/or through their initial team meeting. In summary of this information, the student athlete must understand that sickle cell is not a disease but a genetic condition that will not change over time nor develop into a disease. During intense exercise, red blood cells can change shape from a round cell to a quarter-moon or sickle shaped cell. Heat, dehydration, high altitude, and asthma can increase the risk of this condition even without exercise. The sickle shaped cells accumulate in the bloodstream and can block normal blood flow to tissues and muscles which can cause significant physical distress, physical collapse, and even death. If the student-athlete with sickle cell experiences muscle pain, abnormal weakness, undue fatigue or breathlessness, and/or cramping in the arms and legs, they should seek medical care immediately. Sickle cell is predominately found in student-athletes who have ancestors from Africa, South or Central America, India, Saudi Arabia, the Caribbean, and Mediterranean countries such as Greece and Italy. Most US states test for sickle cell at birth, but many student-athletes and their parents/guardians do not know the results.