Albright College Sports Medicine Medical Insurance Information

Transcription

1 Albright College Sports Medicine Medical Insurance Information Please complete the following information about the student athlete. Name: Year in college: Fr So Jr Sr 5th Social Security: Age: Date of Birth: Home Phone #: Albright Campus Cell Phone #: Emergency Contact: Phone #: Sport/s Participating In: Please complete the following information about the cardholder (i.e. father/ mother) of your Medical Insurance. If one of your parents is not insured please write, NOT INSURED when asked for insurance company name. PRIMARY INSURANCE: Card Holder Name: Card Holder SS#: Card Holder DOB: Insurance Company Name: Insurance Company Insurance Company Phone #: Group #: Identification #: Is student insured under this policy? SECONDARY INSURANCE: Card Holder Name: Card Holder SS#: Card Holder DOB: Insurance Company Name: Insurance Company Insurance Company Phone #: Group #: Identification #: Is student Insured under this policy? Is this Policy an HMO / PPO? YES NO Is this Policy an HMO / PPO? YES NO ALL INFORMATION ON THIS FORM MUST BE COMPLETED AND RETURNED TO THE ATHLETIC TRAINING STAFF PRIOR TO FIRST AHLETIC PRACTICE SESSION. PLEASE INCLUDE A COPY OF THE FRONT AND BACK OF ALL INSURANCE CARDS. 1

2 ALBRIGHT COLLEGE MEDICAL HISTORY UPDATE FOR RETURNING ATHLETES DATE: / / Athlete s Month Day Year Name: Sports(s): (Last) (First) (Middle) (Nickname) Social Security No: / / Date of Birth: / / / / Month Day Year Age Sex Race Classification: Fr. So. Jr. Sr. 5 th Year Sr. Address(es): Local Apartment, Address, Dormitory, etc. Cell Phone: I. Person to notify in case of an Emergency: Relationship: Home Phone: ( ) Business Phone: ( ) Cell Phone ( ) II. Father s Name: III. Mother s Name: Home Phone: ( ) Business Phone: ( ) Cell Phone ( ) Home Phone: ( ) Business Phone: ( ) Cell Phone ( ) IIV. Name of family physicians: Business Phone ( ) V. Name of Orthopedic Physician: BusinessPhone( ) Adress: 2

3 Medical History for Returning Athletes In the Past 12 Months Have You Experienced the Following: SYMPTOMS Yes NO EXPLAIN Chest pain or tightness Palpitations (Skipped Beats) Swollen legs/feet High blood pressure Blood clots Fainting/Dizzy spells Numbness in limbs Muscle weakness Impaired memory/confusion Difficulty concentrating Panic attacks Weight loss or gain of 10 or more pounds Intolerance to exercise In the Past 12 Months Were You Diagnosed with: CONDITION Yes No EXPLAIN Staph infection/ Has this since resolved? MRSA Concussion Date sustained? Have you received clearance? Date? Symptoms: ADD/ADHD Learning Disability Serious Disease/Illness Mental Illness Drug and dosage information: Drug and dosage information: Still receiving treatment? Drug and dosage information: In the Past 12 Months Have you: Required Hospitalization Had an Accident Required Blood Tests Required Xrays, MRI s, other Imaging Had a Surgical Operation Had an examination by someone other than Albright College s Physician/Team physician Traveled Outside of the United States Suddenly lost an immediate family member Yes No Explain Where? Cause of death? 3

4 Complete the Orthopedic Chart below Include details to the right if you have sustained injuries during the past 12 months. Body Part HEAD YES NO Side NECK YES NO R L SHOULDER YES NO R L ARM YES NO R L ELBOW YES NO R L FOREARM YES NO R L WRIST YES NO R L HAND YES NO R L FINGERS YES NO R L CHEST YES NO R L SPINE YES NO R L ABDOMEN YES NO PELVIS YES NO R L HIP YES NO R L THIGH YES NO R L KNEE YES NO R L LEG YES NO R L ANKLE YES NO R L FOOT YES NO R L TOES YES NO R L OTHER Details If you have any additional conditions, problems, or comments that have not been addressed thoroughly in the above questionnaire, please use the space below to inform us so that we may be able to better serve you with our best medical care. All statements and answers in the above medical history questionnaire are true and complete to the best of my knowledge. I have no abnormality, limitation, or restriction not mentioned in this record. I understand that this information is to help determine my fitness to participate in athletics, and to aid in the treatment and diagnosis of future injuries/illnesses that I may incur. DATE PRINTED NAME OF ATHLETE (First) (Middle) (Last) DATE SIGNATURE OF ATHLETE 4

5 ATHLETIC RELATED MEDICAL BILLS LETTER OF RESPONSIBILITY I,, hereby understand that there may be medical bills resulting from an injury/illness incurred while participating as a member of Albright College Intercollegiate Athletics. I acknowledge that I am responsible for any and all medical bills. I also agree to the following: 1. I understand that in accordance with NCAA guidelines I must provide the Albright College Sports Medicine Staff proof of VALID primary health care insurance in order to participate in intercollegiate athletics.. I also understand that I must be covered under this insurance policy for the ENTIRE academic calendar year. 2. I also understand that it is my responsibility to update the sports medicine staff if and when changes should occur to my health care insurance plans during the academic year. Failure to do so may result in a delay to access medical services and or cause me to become financially responsible for bills related to this injury. 3. I understand that the Albright College Sports Medicine Department will complete an injury claim form and forward it to EIIA, the school s secondary excess insurer but, has no liability for the accuracy or payment of the claims. Completion of an injury claim form must occur within 10 days of injury and can be obtained from the certified athletic trainer. 4. I understand that it is my responsibility to send all outstanding bills and Explanation of benefits to EIIA. Failure to do so will cause me to become financially responsible for bills related to this injury. 5. I understand that if my primary insurance is an HMO/PPO I must secure pre-authorization from the insurance company for all services rendered or benefits provided by Albright College s secondary excess policy will be reduced by 50% 6. I further understand that Albright College, and/or any College employee is in no way liable for payment of any medical bills. 7. I accept the responsibility of ensuring my insurance claims (primary and secondary) are submitted correctly and in a timely manner. I also accept that it is my responsibility to follow up on my medical claims with both the medical providers and insurance companies involved with my bills. 8. I understand that there is a limitation on the time in which medical bills must be submitted to insurance companies and failure to address my medical bills within that time could affect my credit record. For detailed information regarding Albright College s Athletic Accident Excess Insurance Policy please go to: Student Full Name (PRINT) Student Signature Parent s Signature if student is covered under your policy Date Date 5

6 AUTHORIZATION AND CONSENT TO DISCLOSURE OF PROTECTED HEALTH INFORMATION I,, the undersigned ( Participant ) hereby consent to and authorize Albright College and its physicians, athletic trainers, health care personnel, and paramedics, along with my health care providers, to use, disclose and exchange my health information and any related information regarding any injury or illness (referred to as Protected Health Information ) during my training for and participation in intercollegiate athletics to the following: Team physicians; Athletics training staff Other health care providers, including any treating or attending health care provider and any treating hospital or other medical facility; and Representatives of the NCAA. I consent to and authorize Albright College and its physicians, athletic trainers, health care personnel, and paramedics to disclose my health information, as such information pertaining to health and safety, continued medical care, and the health and safety of others participating in or related to intercollegiate athletics, to the following, provided that they will disclose only the minimum amount of health information necessary to accomplish these purposes to: Coaches and athletics staff; Administrators; NCAA representatives; I understand that protected health information will be used by Albright College for the purpose of determining best treatment options for the injury or illness, or for the purpose of releasing only pertinent information to the sources listed above. I further consent to and authorize Albright College and its physicians, athletic trainers, health care personnel, and paramedics to use and disclose my health information in order to make appropriate determinations with regard to eligibility and ability to participate in intercollegiate athletics and to assist in processing intercollegiate secondary insurance policy claims through NAHGA Claims Services. The type of health information authorized to be disclosed includes any or all information regarding my physical or medical condition. I expressly agree to, consent to, and authorize re-disclosure of all such information. I understand that health information may be 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 authorization under HIPPA or consent under the Buckley Amendment. I understand that once information is disclosed per my authorization/consent, the information may be subject to re-disclosure by the recipient and may no longer be protected by HIPAA and/or the Buckley Amendment. I understand that I am not required to sign this consent and authorization. Signing this consent and authorization is not a condition of treatment, payment for any health care services, enrollment in a health plan, 6

7 or eligibility for health care benefits. I have the right to revoke this consent and authorization at any time by providing written notice to Albright College s head athletic trainer. I understand that a revocation is not effective to the extent action has already been taken in reliance on the authorization/consent. Unless earlier revoked, this consent and authorization is valid for and shall expire after the later of the duration of the current academic year for so long as I am receiving any medical treatment occurring as a result of my participation in intercollegiate athletics at Albright College or for any follow-up consultations for injuries or conditions that occur as a result of my participation in intercollegiate athletics during this academic year. Participant s Signature: I hereby acknowledge and agree to the foregoing. I further acknowledge that a copy of this consent form has been provided to me for my records. Date: (Signature) (Printed Name of Participant) Received by: Date: (Signature) (Printed Name of Institution Official) Revised 5/2015 7