Truett-McConnell Athletic Training Forms

Transcription

1 Truett-McConnell Athletic Training Forms

2 Table of contents 1. Welcome letter 2. Assumption of Risk and Consent to Treat 3. Authorization/Consent for Disclosure of Protected Health Information (PHI) 4. Injury Acknowledgment 5. Physician Choice Policy 6. Injury Claim Procedures 7. Confirmation of Primary Insurance 8. Insurance Policy Information 9. Summit America Secondary Insurance Form (sign and return to Athletic Training Office) 10. Drug Testing Consent Form (sign and return to Jenni Shepard, Asst. AD) 11. Statement of Understanding (sign and return to Athletic Training Office)

3 NOTICE 1. Please sign all forms and keep them for future reference. 2. Please sign the drug consent form and return to Jenni Shepard, Asst. AD. Please sign and initial the statement of understanding at the end of this booklet and return to the Truett-McConnell Athletic Training Office with the Summit America Secondary Insurance Form and a copy of your primary insurance card (front and back) prior to participation in any conditioning, practice or competition.

4 Dear Student-Athlete/Parent/ Guardian: The Sports Medicine Department of Truett-McConnell College is pleased to welcome your son/daughter to the athletic year. Athletics at the collegiate level is an exciting adventure, but also brings with it a risk for injury during participation. Our goal is to provide you with the information needed to understand our procedures for injuries sustained at Truett-McConnell. We hope the following information meets that need. Please read and sign each form included in this packet and retain for your records. Please complete the Drug Consent Form and return to Jenni Shepard, Asst. AD. Complete the Summit America Secondary Insurance Form and the Statement of Understanding Form and return to our office as soon as possible along with a copy of the front and back of your primary insurance card that covers your son/daughter. All student-athletes are required to purchase an accidental insurance policy through Summit America that will automatically be billed to their account (approximately $87.50 per semester). All student-athletes are highly encouraged to purchase a primary health insurance policy that covers injuries sustained while participating in intercollegiate athletics. When purchasing said policy, please be certain it covers any athletic injuries sustained during intercollegiate competitions, practices, and travel to and from athletic events. Student-athletes are also required to complete an annual physical prior to any physical activity associated with their athletic team. The physical form can be found at: No student-athlete may participate in any physical activity until all necessary documents are filed and the student-athlete is cleared by the Sports Medicine Department. If you have any questions or concerns about our services, please contact our department at any time. Sincerely, Michelle R. Evans, MS, ATC, CES Head Athletic Trainer Director of Sports Medicine Truett-McConnell 100 Alumni Dr. Cleveland, GA [email protected] office: x174

5 Truett-McConnell Assumption of Risk and Consent to Treat Assumption of Risk I, am aware that my participation in intercollegiate athletics, while attending Truett-McConnell, carries with it the potential risk to sustain serious and possibly debilitating injuries. I understand that the inherent dangers and risks of playing or practicing in athletics at Truett-McConnell include, but are not limited to: death, serious head, neck, and spinal injuries which may result in complete or partial paralysis and/or brain damage, and serious bodily injury. Because of the dangers in participating in athletics, I recognize the importance of following the coach s instruction regarding playing techniques, training, rules of the sport, other team rules, and the importance of obeying such instruction. I rightfully assume that those who are responsible for the conduct of the sport have taken responsible precautions and have participated in annual training exercises to minimize such risk. I also assume that their peers participating in the sport will not intentionally inflict injury upon them. In consideration of Truett-McConnell permitting me to practice, play, or try out for an intercollegiate team, and to engage in all activities related to the team, including practicing, playing, and travel, I hereby voluntarily assume all risks associated with participation. Consent to treat I understand that if I experience an injury/illness then it is my responsibility to inform my Head Coach and the Certified Athletic Trainer immediately. I give consent to the Truett-McConnell Athletic Trainers and/or medical personnel to perform all medical treatment deemed necessary to treat and rehabilitate any injury or illness that I may incur during the intercollegiate athletic seasons. I also understand that should I become injured during my participation in intercollegiate athletics, I will not be allowed to return to my sport until I am cleared by the Truett-McConnell Department of Sports Medicine and/or other associated and approved medical personnel. Signature of Student-Athlete Signature of Parent/Guardian if student-athlete is under 18 years of age

6 Truett-McConnell Intercollegiate Athletics Student-Athlete Authorization/Consent for Disclosure of Protected Health Information (PHI) I hereby authorize the physicians, athletic trainers (AT), and other health care personnel representing Truett-McConnell to release and/or obtain information regarding my protected health information and any related information regarding any injury or illness during my training for and participation in intercollegiate athletics. This PHI may concern my medical status, medical condition, injuries, prognosis, diagnosis, athletic participation status, and related personally identifiable health information. This PHI may be released to other health care providers, the student-athlete s parents/guardians, hospitals, and/or medical clinics, laboratories, athletic coaches, medical insurance coordinators, insurance carriers, medical supply vendors and/or service companies, athletic and/or college administrators, and academic counselors/instructors. I understand that my PHI is protected by federal regulations under either the Health Information Portability and Accountability Act (HIPPA) or the Family Educational Rights and Privacy Act of 1974 (the Buckley Amendment) and may not be disclosed without either my authorization under HIPPA or my consent under the Buckley Amendment. I understand that once information is disclosed per my authorization/consent, the information is subject to re-disclosure and may no longer be protected by HIPPA and/or the Buckley Amendment. I understand that I may revoke this authorization/consent at any time by notifying in writing to the Department of Sports Medicine, but if I do, it will not have any effect on actions Truett-McConnell took in reliance on this authorization/consent prior to receiving the revocation. Name of Student-Athlete (print) Signature of Student-Athlete Signature of Parent/Guardian (if athlete is under 18 years of age)

7 Truett-McConnell Intercollegiate Athletics Injury Acknowledgement Form I, hereby understand that in the occurrence I become injured or my medical condition changes, it is my responsibility to notify a member of the Sports Medicine Staff and temporarily remove myself from all practices, conditioning, and competitions until gaining examination from a TMC Certified Athletic Trainer (ATC). Upon evaluation, if the ATC deems medical clearance is necessary, I will work with the Sports Medicine Staff to obtain official written clearance from the physician best suited to meet my medical needs. TMC must receive official written documentation from the physician (MD or DO only) giving you the clearance to participate. Student-Athlete Signature Witness Signature

8 Physician Choice Policy The Truett-McConnell Departments of Athletics and Sports Medicine believe our student-athletes deserve the best medical care available. The TMC Department of Sports Medicine 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 TMC 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 a TMC athletics injury must be coordinated through the TMC Department of Sports Medicine. TMC will not be financially responsible for services unless a staff athletic trainer at TMC has evaluated and pre-approved a physician visit (with the exception of emergency medical care). The physician used may be affiliated with TMC Sports Medicine or of your own choosing. If the physician used is not affiliated with TMC Sports Medicine, written documentation of the visit and treatment parameters must be provided to the Sports Medicine staff as soon as possible in order to ensure the continuation of consistent care. The names of the TMC Sports Medicine staff must be included on all medical information release forms for injuries or conditions that are related to or can affect athletic participation. All athletes MUST report conditions not relating to athletic injuries, but have the potential to adversely affect the ability to actively participate in athletic conditioning, practice or competition, i.e., asthma, diabetes, POTS, epilepsy or other conditions that require physicians care. 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. If a second opinion is obtained, it is the responsibility of the student athlete to notify the TMC Sports Medicine 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

9 About the Department of Sports Medicine Located in the Allen House, the Truett-McConnell Department of Sports Medicine is outfitted with the equipment needed to provide injury treatment and rehabilitation. The Sports Medicine Staff is comprised of Certified Athletic Trainers who are certified by the National Athletic Training Association and licensed by the state of Georgia. Certified Athletic Trainers (ATC s) are leading professionals in the prevention, treatment, and rehabilitation of athletic injuries. The team physicians are board certified and range in expertise from orthopedic surgery and general practice to dentistry and optometry. The Sports Medicine staff has immediate access to these physicians for any needs that may arise. Injury Claim Procedures 1. Should a student-athlete sustain an injury as a result of participation in TMC intercollegiate athletics your personal health insurance policy is considered primary for all medical costs. You are responsible for providing your own health insurance. If your coverage expires or is cancelled during the athletic year you are responsible for notifying the head Athletic Trainer immediately so we may be able to assist you in obtaining affordable health insurance. An accidental insurance policy (Student Accident Shield) is required to be purchased through Truett- McConnell College. Student-Athletes are automatically billed on their account approximately $87.50 per semester. The Department of Athletics covers medical costs in excess of your personal primary coverage and accidental coverage. Balances are paid according to policy limits. Parents or Student- Athletes are responsible for providing all necessary information before our insurance carrier will process a claim. Upon assessment of the athletic injury or illness, an ATC will submit a claim form to our Athletic Department s insurance carrier 2. Most medical providers will file the bills with your insurance company. If not, you should submit all bills to your insurance company first. Your primary insurance company will do one of two things based on your policy: a. Pay all or a portion of the bill(s) b. Deny payment for services In each case you will receive an Explanation of Benefits (EOB) from your insurance company. Please keep these on hand in case it is required by our secondary insurance. 3. Once the secondary insurance company receives the initial claim form and documentation of billing, they will begin correspondence to request any further documentation. **It will be your responsibility to respond to any requests from the TMC Department of Sports Medicine or the secondary insurance claims department. Please provide swift responses to any requests for documentation as this will quicken the payment process.

10 4. Please note that these procedures apply only to TMC athletic injuries. Injuries that occur outside of required practices, training, or game situations and/or general sickness/infections are NOT covered by our secondary insurance policy. TMC s secondary insurer will not consider medical claims from injuries that are deemed to be self-inflicted. HMO/PPO Participants If an HMO or PPO policy covers the student-athlete, it is strongly recommended you consider the following: Change your dependent s primary care provider to a local physician in Cleveland, Dawsonville, or Gainesville (the closest to Truett will be Cleveland). Some policies will allow an out of network medical provider, so please check with your insurance company). Ask your insurance company about a rider for out of network services for your dependent (many insurance companies have special plans for students who attend a school in an out of network region) Taking the above measures will reduce costs and time in providing quality care should the student-athlete sustain an injury while participating in intercollegiate athletics at TMC. It is our experience that many frustrations result when the above measures are not adhered to before participation begins. If you are allowed to make a change in the primary care provider before attendance at TMC, please indicate the physician s name and phone number on the form provided.

11 Truett-McConnell Intercollegiate Athletics Confirmation of Primary Insurance 1. All student-athletes are required to have health/accident insurance that covers intercollegiate athletic injuries for a minimum of the academic school year. Any student-athlete who does not possess health/accident insurance or allows the policy to lapse will be ineligible to participate in conditioning, practices, and/or competition with TMC athletic teams until health/accident insurance coverage is obtained or reinstated. In addition, any student-athlete that allows their health/accident insurance to lapse or does not inform the Department of Sports Medicine of a change in policy will be responsible for all medical bills related to an athletic injury. No studentathlete will be allowed to participate until verification of insurance is on file with the Department of Sports Medicine. 2. If a student-athlete becomes injured, and during the billing process it is discovered that the student-athlete s insurance has been cancelled, dropped, and/or no medical coverage is available, the student-athlete will be responsible for the total payment of all related medical expenses. 3. If the student-athlete s health insurance is out-of-area in Cleveland 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, Kaiser Permanente, AETNA). 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/her own expense to the proper coverage area for treatment. 4. In the instance of an injury, the student-athlete, the hospital, or physician s office will file the claim with the student-athlete s insurance provider. 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 terminate my health/accident insurance coverage I will be financially responsible for any and all athletic injury claims and therefore release Truett-McConnell of liability. I further agree that I may seek other medical consultation ONLY upon consultation with the Department of Sports Medicine or Team Physician. Name Sport (print) M F Signature of Athlete Parent/Guardian Signature

12 Insurance Information It is strongly encouraged that each student-athlete is covered by their own personal health insurance policy. 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. Each student-athlete is required to purchase Student Accident Shield a accidental insurance policy provided through Truett-McConnell College and automatically billed to the student-athlete s account. When a student-athlete is injured, all medical insurance claims will be filed with your personal insurance company. It is the responsibility of the student athlete to provide necessary information to the Department of Sports Medicine after an injury in order to submit a claim to our secondary insurance. 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 studentathlete 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 Department of Sports Medicine may jeopardize and/or remove responsibility from TMC and its secondary insurance company for payment of medical bills. If it is discovered that any injury being treated by the TMC sports medicine team existed prior to attending Truett-McConnell, that injury will not be covered by TMC s secondary insurance policy. 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 TMC from responsibility regarding any medical bills. I, have read the above letter and understand that TMC is responsible on a secondary basis only for injuries which occur in an official TMC 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

13 Summit America Secondary Insurance Form STUDENT INFORMATION Personal Information Student Name Student ID # DOB Address Phone Number Fathers Name Mothers Name Address Phone Number Fathers Employer Name Mothers Employer Name Primary Physician Name Phone Number Address Insurance Information Insurance Company Name Address Phone Number Policy Holder Name ID Number I certify that the above information is true and correct. Student Signature Authorization to Release Information I authorize any Health Care Provider, Insurance Company, Employer, Person or Organization to release information regarding medical, dental, mental, alcohol or drug abuse history, treatment or benefits payable, including disability or employment related information, to Summit America Insurance Services, L.C., the Plan Administrator, or their employees and authorized agents for the purpose of validating and determining benefits payable. A photocopy of this authorization shall be as valid as the original. Signature

14 TRUETT-MCCONNELL COLLEGE INTERCOLLEGIATE ATHLETIC PROGRAM DRUG TESTING CONSENT FORM To: Student-Athlete Participation in intercollegiate athletics is one of the privileges afforded as an extracurricular activity to students enrolled at Truett-McConnell College. Truett-McConnell College wishes to ensure that the health and safety of student-athletes are not compromised and that student athletes are discouraged from the use and abuse of illegal drugs. Therefore, it is the policy of Truett-McConnell College that students participating in intercollegiate athletics submit to drug testing and breath alcohol analyzer testing at regular and random intervals, both announced and unannounced. A student-athlete who is found to have tested positive for opiates, PCP, cocaine, marijuana, alcohol, amphetamines, anabolic steroids, diuretics and/or any other illegal drug shall be subject to disciplinary action as stated in the Truett- McConnell College Student-Athlete Code of Conduct. The Code states, A first time positive test will result in notification of the student-athlete, coach, athletic director, and Dean of Students. Parents of students under 21 will be contacted. Counseling and additional testing are required and cancellation of the athletic scholarship and dismissal from the team are possible. A second positive will result in loss of scholarship and dismissal from the team. The student-athlete may appeal as stated in the Code of Conduct Appeal Procedures Failure to sign this form will result in immediate dismissal from the Truett-McConnell College Athletic Program. If you have any questions, please discuss them with the Athletic Director. By signing this form, I have been fully informed of the reasons for the test for drugs and/or alcohol, and do hereby freely give my consent. Return this form to the Truett-McConnell Athletic Training Office. I hereby authorize these test results be released to: Director of Athletics & Head Athletic Trainer Truett-McConnell College 100 Alumni Dr Cleveland, Georgia Signature of Student-Athlete Signature of Parent (if student-athlete is a minor) Name: of Birth Age Home Address

15 Statement of Understanding Please initial by each line signifying that you have read, signed, and understand each policy contained in this booklet. Required documents must be completed in their entirety and returned to the Truett-McConnell Athletic Training Office PRIOR to ANY participation in any athletic activity. Assumption of risk and Consent to Treat form Student-athlete Authorization/Consent for Disclosure of Protected Health Info (PHI) Injury Acknowledgement Physician Choice Policy Injury Claim Procedures Confirmation of Primary Insurance Insurance Information Policy I have read, signed, and understand all documents listed above. I agree to abide by these policies. Failure to do so may result in me assuming all financial responsibility regarding insurance claims due to athletic injury. Failure to complete and turn in these forms, and obtain adequate insurance coverage will result in not being able to participate in conditioning, practices, or competitions with Truett-McConnell athletics teams. Signature Parent Signature