UALR Sports Medicine PLEASE READ AND FOLLOW ACCORDINGLY Dear Parent or Guardian:

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1 UALR Sports Medicine PLEASE READ AND FOLLOW ACCORDINGLY Dear Parent or Guardian: Enclosed is important information regarding athletic accident insurance that requires your immediate attention and response. The University of Arkansas at Little Rock provides accident insurance which provides coverage for your son or daughter for injuries occurring while participating in play or practice of intercollegiate sports that is "SECONDARY" to any other PRIMARY insurance benefits. This simply means that any claim for benefits must first be filed with your PRIMARY insurance company before it can be submitted UALR s SECONDARY policy. This policy is standard with other NCAA Division I universities. Please Note: The Affordable Care Act allows young adults insurance coverage to be continued until age 26 dependent of university, martial, financial, or employment status. DO NOT drop dependent coverage while your son or daughter is participating in intercollegiate athletics. You must contact your insurance carrier to verify that your young adult will have athletic injury benefits in the State of Arkansas before your young adult may practice or compete at UALR. It is important to understand that the student-athlete or his/her parents must first submit medical expense claims to their personal insurance Claims against your PRIMARY insurance plan DO NOT increase your individual insurance premiums. Non-athletically related medical charges remain the responsibility of the student-athlete. THE ATTACHED INSURANCE INFORMATION, INSURANCE/MEDICAL POLICIES, AND AUTHORIZATION CONSENT FOR DISCLOSURE FORMS MUST BE FULLY COMPLETED, SIGNED AND RETURNED ASAP. IF ALL THREE FORMS ARE NOT RETURNED, YOU RE SON OR DAUGHTER WILL NOT BE ALLOWED TO PRACTICE OR COMPETE UNTIL THEY ARE SUMITTED. If you have any questions or concerns, please feel free to contact me at Please mail fully completed forms to: Michael Switlik, MS, ATC UALR Athletic Department The Jack Stephens Center 2801 S. University Ave. Little Rock, AR

2 UALR Student-Athlete Insurance/Medical Policies 1. UALR shall provide secondary medical insurance coverage to assist in the payment of athletically related injuries that occur during UALR supervised practice or competition. This means that the student athlete will be required to have PRIMARY HEALTH INSURANCE COVERAGE through a parent s/guardian s workplace insurance program or purchase personal health insurance. Please see Healthcare.gov in how to obtain healthcare coverage for your student athlete. 2. Every student-athlete should understand that he/she has a responsibility to have adequate medical insurance coverage. If coverage is not available under a parent, guardian, or spouse, then each student-athlete is advised to purchase his/her own insurance. Again please see Healthcare.gov for how to purchase healthcare coverage for your student athlete. The healthcare coverage on all student athletes will need to be able to work in the State of Arkansas. If your student athlete has insurance from out of state including Medicaid, you will need to contact your insurance company or exchange to make the necessary arrangements to make sure that your student athlete has healthcare coverage in the State of Arkansas. 3. Student-athletes must provide to UALR their current insurance information before the beginning of the school year. Should your insurance information change during the school year; you must provide that information to the Insurance Coordinator within 30 days of enrollment in a new insurance plan. 4. The parent, guardian, or student athlete must file all athletically related accidents or injuries with their primary insurance before claims can be filed to UALR s secondary policy. All bills must be filed to Michael Switlik, MS, ATC, UALR Athletic Insurance Coordinator, within 30 days of seeing any sports medicine provider. There are no exceptions to this policy. Bills turned into the Athletic Insurance Coordinator office 60 days after seeing any sports medicine provider will become the responsibility of the parents and/or student-athlete. 5. An Explanation of Benefits (or EOB) is a form that shows how much your insurance company had paid and what is remaining. This form is always mailed to the holder of the insurance policy. The EOB MUST BE SUBMITTED to the UALR Athletic department s Insurance Coordinator. Once this is done, all remaining balances will be considered by the UALR Athletic Department. Non-athletically related medical charges including general illness or sickness remain the responsibility of the student-athlete. 6. UALR is not responsible to pay for non-athletically related injuries/illnesses. This would include injuries sustained by student-athletes while not participating in UALR supervised practice or competition; surgery/treatment for any type of congenital disorder or illness; preexisting condition/injury, or general illness/sickness. Other examples of conditions not covered by UALR would be: seasonal allergy shots, dental work, exercise induced asthma, eye glasses/contacts, hernias, skin illness, internal diseases (appendicitis, cancer, heart ailments, tonsillectomy, etc.), detection of or treatment for sexually transmitted diseases, diagnostic tests required for medical clearance, protective braces/orthotics needed for previous injuries. 7. UALR will not pay for any medical services obtained without a referral from UALR Sports Medicine staff. According to the NCAA Sports Medicine Handbook Guideline 1B, The Team Physician is ultimately responsible for the clearance to participate and the return-to-play decisions for the institution s student-athletes. In coordination with this policy, UALR s secondary insurance will only pay on claims to our Team Physicians or whom they may refer for further treatment. In most cases, student athletes will be referred to a physician from the University of Arkansas for Medical Sciences (UAMS). UALR s secondary insurance will not be responsible for second opinions or self-referral to a medical provider.

3 8. UALR shall not assist with payment of medical expenses for any injuries/illnesses sustained to a student-athlete after his/her four (4) years of eligibility are completed. UALR shall assist with secondary payment of medical expenses that would be covered by UALR insurance for injuries sustained to the student-athlete during athletic eligibility for up to one (1) year after the injury, provided the injury was reported to the UALR Sports Medicine staff, within 30 days of the initial injury. 9. All recruited student-athletes shall be given a UALR pre-participation physical before they are eligible to participate in supervised practice or competitions. Insurance information forms must be on file before a physical will be given. 10. Non-scholarship student-athletes walking on or trying out for a sport are required to provide the following before they will be allowed to participate in a tryout activity or practice. Proof of insurance Verification of a physical examination by an MD, DO (Doctor of Osteopathy), PA (Physicians Assistant), or NP (Nurse Practitioner) Confirmation of Sickle Cell trait Verification that paper work has been completed with the UALR Athletics Compliance office Once the prospective student-athlete becomes a team member he/she shall be given a physical examination by a UALR team physician. In the case of non-scholarship student-athlete invited by the head coach to participate in preseason practice, the student-athlete shall be given a physical exam by a UALR team physician along with all recruited student-athletes prior to the onset of practice. 11. The team physicians and athletic trainers shall have authority with regard to all medical disqualifications or medical red shirts, medical treatment, and participation level of an injured/ill student athlete in UALR supervised practice or competition. 12. The team physicians and athletic trainers shall be available to the student-athletes for information or counseling about athletic injuries/illnesses and for the evaluation, treatment and rehabilitation of athletic injuries/illnesses sustained from or related to UALR supervised practice or competition. When expected to travel with a team, they shall be present at practices and competition and available for necessary care. 13. Student-athletes must report all injuries as soon as possible to the sport medicine staff. Acute injuries need to be reported within 48 hours of injury while overuse/chronic injuries need to be reported within a week of onset of symptoms. All medical treatment will be provided by UALR athletic sport medicine staff. Until the team physician and/or athletic training staff releases the student athlete from treatment, the student athlete shall be expected to report daily to the athletic trainer for treatment, rehabilitation, and/or follow-up medical treatment by a team physician. 14. If any of the above procedures are not followed, our secondary insurance will not apply. In this case, it will be the responsibility of the student athlete and/or their parents/guardians for medical bills acquired. I hereby certify that I have read and understand the University of Arkansas at Little Rock Student- Athlete Insurance/Medical Policies Signature of Parent Signature of Athlete

4 University of Arkansas at Little Rock Insurance Information and Authorization Student-Athlete s Name SS# Sport Sex: M or F (circle one) of Birth Parent Information: Father: Home Address (City, State & Zip Code) Home Telephone # Work Telephone # Mother: Home Address (City, State & Zip Code) Home Telephone # Work Telephone # Insurance Information Covering Student/Athlete: Subscriber Social Security # Subscriber s Birth : Relationship to Athlete: Employer's Name Employer's Address (City, State & Zip Code) Name of Group Policy # Insurance Company Group Policy # Mailing Address for Claims Telephone # (City, State, & Zip Code) A. Is your primary insurance an HMO? *YES NO B. Is your primary insurance a PPO? *YES NO C. Does your insurance policy require pre-authorization for services? *YES NO *If yes, PLEASE attach a copy of your policy or a website to access a list of authorized physicians and facilities!

5 Prescription Coverage Information: Do you have prescription coverage? *YES NO *If so, please fill out this section! Name of Subscriber ID# RxBin# RxPCN# RxGrp# Insurance Company Mailing Address for Claims Telephone# (City, State, & Zip Code) _ AUTHORIZATION AND ASSIGNMENT OF BENEFITS I, the undersigned authorize any hospital or other medical-care institution, physician or other medical professional, pharmacy, insurance support organization, governmental agency, group policyholder, insurance company, association, employer or benefit plan administrator to furnish to the Insurance Company and/or University of Arkansas at Little Rock athletic department any and all information with respect to any injury or sickness suffered by, the medical history of, or any consultation, prescription or treatment provided to, the person whose death, injury, sickness or loss is the basis of claim and copies of all that person s hospital or medical records, including information relating to mental illness and use of drugs and alcohol, to determine eligibility for benefits. I authorize the group policy policyholder, employer or benefit plan administrator to provide the insurance company and the University of Arkansas at Little Rock Athletic Department s representative with financial and employment-related information. I understand that this authorization is valid up to 1 year from the date of my signature and that a copy of this authorization shall be considered as valid as the original. I understand that I or my authorized representative may request a copy of this authorization. I hereby authorize a claim to be filed on my behalf under the above group medical policy in the event an athletic injury is sustained. Student-Athlete Signature I hereby certify that the answers provided are true, complete and correct to the best of my knowledge. Signature of Parent Signature of Athlete

6 Student-Athlete Authorization Consent For Disclosure of Protected Health Information to the University of Arkansas at Little Rock I,, hereby authorize the University of Arkansas at Little Rock (Name of Student Athlete) (Name of My Institution) and its physicians, athletic trainers and health care personnel to disclose my protected health information and any related information regarding any injury or illness during my training for and participation in intercollegiate athletics to UALR team physicians, athletic trainers, my respective coaches, and its employees or agents. I understand that my 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 either my authorization under HIPAA or my consent under the Buckley Amendment. I understand that my signing of this authorization/consent is voluntary and that my institution will face limitations in any health care treatment or payment, enrollment in a health plan or receipt of any benefits (if applicable) on whether I provide the consent or authorization requested for this disclosure. I also understand that I am not required to sign this authorization/consent in order to be eligible for participation in NCAA or conference athletics. This authorization/consent expires 380 days from the date of my signature below, but I have the right to revoke it in writing at any time by sending written notification to the athletic director at my institution. I understand that a revocation is not effective to the extent action has already been taken in reliance on this authorization/consent. Signature of Student-Athlete I,, of lawful age and being do hereby authorize the head coach, team physician(s) and/or athletic trainer(s) to release, verbally and/or in writing, to sports information and/or journalists, for purposes related to press releases and/or articles, all information pertaining to injuries/illnesses that effect my sports participation. Signature of Student-Athlete

7 NOTICE OF PRIVACY PRACTICES OF The University of Arkansas at Little Rock Athletic Department and other health care providers, which are associated with our department, including the following: University of Arkansas at Little Rock (UALR) Athletic Training Department UALR Sports Information, Sun Belt Conference, and its Media Outlets UALR Team Physicians UALR Health Services Department UALR Counseling Services Department University of Arkansas for Medical Sciences Hospital Orthopedic Rehabilitation & Specialty Centers (OR&SC) Little Rock Family Practice Clinic, West Medical College Physicians Group (MCPG) Medic Pharmacy and Health Services Chenal MRI Other Associated Personnel related to Student-Athlete Healthcare THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW CAREFULLY. EFFECTIVE: UPON SIGNATURE AND RETURN OF THIS DOCUMENT TO UALR If you have any questions or requests, please contact Michael Switlik, MS, ATC Head Athletic Trainer University of Arkansas at Little Rock 2801 South University Little Rock, AR (501) Fax: (501)