Returner Student-Athlete Medical Packet Checklist:

Transcription

1 Returner Student-Athlete Medical Packet Checklist: o Parent s Letter o Emergency Contact Form o Sports Nutrition Questionnaire o Medical Insurance Questionnaire o Copy front and back health insurance card o Copy front and back dental insurance card o Copy front and back vision insurance card o Authorization for Release of Medical Information Please fill out all forms in this packet and send completed packet back to the athletic training room no later than July 1, Mail your packet to: Tulane University Athletics Department Attn: Andy Massey, Head Athletic Trainer James Wilson, Jr. Center Ben Weiner Drive New Orleans, LA

2 Dear Parents/Guardian, We are extremely pleased to have your son/daughter as a student-athlete at Tulane University for the upcoming year. Enclosed is important information regarding the healthcare of our student-athletes. Please read this information carefully, fill out the enclosed form and return them to the athletic training room. You may find it beneficial to retain this letter throughout the year as it explains our policies regarding healthcare and insurance of student-athletes. Accidents do occur and we strive to provide our student-athletes with the best care possible. Please note that our secondary accident insurance policy covers only injuries/illnesses sustained that are the direct result of participation in Tulane intercollegiate athletics. Coverage does not include pre-existing conditions. ALL medical services must be coordinated through the athletic training room. Unapproved consultations or treatments are not covered and will be the responsibility of the student-athlete. Therefore, review your hospitalization coverage under your own policy in order to provide coverage for any non-athletic injuries and illnesses that might be sustained while your son/daughter is at Tulane. Tulane University Athletics carries a secondary accident insurance policy. Only athletic injury expenses will be covered under this policy while your child is a student-athlete at Tulane University. All other injuries or accidents will be the responsibility of the student-athlete. Tulane University Athletics is not responsible for the following: 1. Medical treatment for injuries or illnesses that existed prior to initial enrollment at Tulane University. 2. Medical treatment for injuries or illnesses not reported to the Athletic Training Staff within a reasonable amount of time. 3. Medical treatment for which a referral is not obtained. 4. Medical treatment in violation of Athletic Training Policies. Please completely fill out the enclosed Medical Insurance Questionnaire Form. This information will be provided to the medical providers in the event medical charges do occur. Please include a clear copy of the front and back of your current insurance card, including dental and vision care coverage cards if applicable. These are required prior to participation. Please view the claim procedures below in order to become familiar with the process: 1. Once an athletic injury has occurred and the student-athlete has been referred for medical services, the provider will file with your primary insurance first. 2. Once your primary insurance has taken action on the claim, an Explanation of Benefits (EOB) will be sent to you and the provider. Please mail the EOB to Andy Massey, Head Athletic Trainer. 3. Tulane Athletics will then file a claim with our secondary insurance company, subject to its limitations and conditions, for payment of the remainder of the bill. 4. Whether or not the student-athlete s insurance pays on a bill or denies it and applies it towards the deductible, and EOB and the itemized bill is needed for Tulane to be able to pay the remaining balance. 5. The EOB and the itemized bill should be submitted by the parents and/or provider to Tulane University to ensure timely payment of all bills. ***Parents Please verify your son/daughter s full-time student status with your primary insurance company per their requirements. This is typically done yearly, but may be required each semester.

3 The Tulane University Department of Athletics does not assume financial responsibility for any bills. The student-athlete and/or the student athlete s family are ultimately responsible for payment pending the insurance company s decision. However, if the proper referral and insurance procedures mentioned above are followed, the department s secondary insurance program will be made available to file claims against for bills generated from the care of an athletic injury and thus outof-pocket expenses should not be incurred. Any payment made to the student-athlete or studentathletes family by the primary insurance company for a claim filed for injury must be forwarded with the EOB to the provider or the Department of Athletics so that the remaining balance can be filed with the secondary insurance. If a bill becomes delinquent as a result of failure to submit itemized bills, EOB s and/or payments received from insurance companies in a timely manner, the Department of Athletics will not assume financial responsibility. We strongly encourage parents to review their child s current health insurance status to make sure that they will still be covered throughout their years at Tulane. If your insurance is through a Health Maintenance Organization (HMO) or other contractual agreements with your health insurance plan please note this on the Health Insurance Information form. Furthermore, we would like to request an Out of Area Endorsement Letter from your primary care physician. In the event of an injury, this will aid us in the prompt treatment of your son/daughter and will help insure prompt payment of any incurred medical expenses. If surgery is indicated, it is your responsibility to notify the primary care physician if prior approval is required by your insurance. If your health insurance plan does not cover your child while they are away at college or you do not have health insurance for your son/daughter, then we strongly encourage you to consider purchasing coverage for your son/daughter. If you have questions regarding purchasing your son/daughter primary health insurance, please contact the athletic training department at (504) If you are unable to provide primary health insurance for your son or daughter, a letter must be sent to the athletic training department stating the lack of coverage. Please note that this does not relate to the Proof of Insurance Waiver required by Tulane University that all students must complete. Please notify us immediately if there are ANY changes to the status of coverage in regards to your son/daughter. If additional information is needed to process a claim, we ask for your cooperation in obtaining this information in a reasonable amount of time. It is in your best interest to have the claim settled promptly since all bills incurred are in your name. Sincerely, Andy Massey, MAT, ATC Head Athletic Trainer

4 Date: Class: Tulane University Athletic Department Emergency Contact Form Name Last: First: Middle: Nickname: Splash Card#: Tulane MR # SSN: Birthdate: / / Sex: Sport: Local Information: Dorm: Room #: Street: Apt #: City: State: Zip: Primary Phone/Cell #: Secondary Phone/Cell #: Emergency Medical Information: Allergies: Permanent Home Address: Street: Apt # Phone: City: State: Zip: Emergency Contact Persons: Mother/Guardian: Home Phone: Address: Work Phone: Cell Phone: City: State: Zip: Father/Guardian: Home Phone: Address: Work Phone: Cell Phone: City: State: Zip:

5 TULANE Name: 2016/2017 Sport Nutrition Questionnaire Sport: Date: 1. How would you rate your current eating habits on a scale from 1 to 10? Poor Fair Good Very Good Excellent Ranking Scale Poor = eats 1-2 meals per day with no fruit and vegetable intake daily Fair = eats 2-3 meals per day with no to little fruit and vegetable intake daily Good = eats 3-4 meals per day with little to some fruit and vegetable intake Very good = eats 4-5 meals per day with some to regular fruit and vegetable Excellent = eats 5 or more meals/snacks per day with regular fruit and vegetable intake 2. How many times per day to you eat (meals and snacks included)? a. Once per day b. Twice per day c. Three times per day d. Four times per day e. Five or more times per day 3. Are you satisfied with your current weight? Yes No If NO, please specify your specific weight goal: 4. Do you feel your eating habits are limiting your ability to reach your performance potential? Yes No If YES, please list your reasons: 5. How would you rate your overall energy levels on a day-to-day basis? Poor Fair Good Very Good Excellent Have you ever, or do you currently restrict calories (i.e. not eat, skip meals, fast) in order to lose weight? Yes No 7. Have you ever, or do you currently make yourself sick after eating (i.e. vomiting) in order to lose weight? Yes No 8. Would you like to see a Nutritionist for any reason? Yes No

6 Tulane University Athletics Medical Insurance Questionnaire Name: Sport: SS # DOB: Permanent Address: Phone Number: Student Athlete Has Primary Insurance: Yes No Primary Insurance Coverage Name of Policy Holder: DOB: SS#: Home Address: Employer s Name: Employer s Address: Home Telephone#: Work Telephone #: Insurance Company: Group #: Policy #: Claims Address: Claims Telephone #: Pre-Authorization for Services? Yes No Is your insurance a: HMO PPO Dental Insurance Name of Policy Holder: DOB: SS#: Home Address: Employer s Name: Employer s Address: Vision Insurance Name of Policy Holder: DOB: SS#: Home Address: Employer s Name: Employer s Address: Home Telephone#: Work Telephone #: Insurance Company: Group #: Policy #: Claims Address: Claims Telephone #: I acknowledge I have read the letter regarding medical information. I understand and will assist in the filing of accident claims. I understand I will incur no out-of-pocket expenses, provided I follow all procedures outlined by the Tulane University Athletics Department. I hereby authorize Tulane University Athletics Department, its contracted insurance company, and all medical providers to inspect, secure, and release copies of all medical records and other data covering this and/or previous hospitalizations and/or disabilities. A photo static copy of this authorization shall be deemed as effective and valid as the original. I also authorize the Tulane University Athletics Department to provide the best necessary medical care for the above named studentathlete. Home Telephone#: Work Telephone #: Insurance Company: (Signature of Athlete) (Date) Group #: Policy #: Claims Address: Claims Telephone #: (Signature of Parent/Insured) (Date) *If you have secondary insurance please attach on a separate sheet of paper. Please send a photocopy of all insurance cards*

7 AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION You are hereby authorized to release to Gregory Stewart, M.D., Director of Sports Medicine, Tulane University, and the team physicians for Tulane University athletics any and all information regarding my condition when under treatment or observation by you. This may include the history obtained, physical and laboratory findings, your diagnosis and treatment, and if there are any limitations or restrictions regarding participation in intercollegiate athletics. Please include operative reports on any surgical procedure. A photocopy of this release shall be considered as valid as the original. Patient Name (Printed) Patient Signature Date Parent/Guardian Signature (if under age 18) Date