ADHD Physician Reporting Requirements for the Athletic Trainer

Transcription

1 ADHD Physician Reporting Requirements for the Athletic Trainer The following is the recommended minimum requirements for a letter from the prescribing physician to provide documentation to the Athletics Department/Athletic Training Staff regarding assessment of student-athletes taking prescribed stimulants for Attention Deficit Hyperactivity Disorder (ADHD), in support of an NCAA Medical Exception request for the use of a banned substance. For more information on this NCAA policy, please visit: The following MUST be included in supporting documentation: Student-athlete name Student-athlete date of birth Date of clinical evaluation Clinical evaluation components MUST include: Summary of comprehensive clinical evaluation (referencing DSM-IV criteria) attach supporting documentation ADHD Rating Scale(s) (e.g., Connors, ASRS, CAARS) scores and report summary attach supporting documentation Blood pressure and pulse reading and comments Note that alternative non-banned medications have been considered, and comments Diagnosis Original medication(s) and dosage Current medication(s) and dosage Copy of Current Prescription Follow-up orders. Additional ADHD evaluation components, if available: Report ADHD symptoms by other significant individuals(s) Psychological testing results Physical exam date and results Laboratory/testing results Summary of previous ADHD diagnosis Other comments Documentation from prescribing physician MUST also include the following: Physician name (Printed) Office address and contact information Specialty Physician signature and date Please note, that follow up documentation of treatment must be submitted and placed in the student-athlete s file each year of eligibility. Please refer any questions regarding this form to the Villanova Sports Medicine Staff. Effective 8/1/2009 Created 10/7/2009

2 Villanova Sports Medicine Medical Insurance Policy Dear Parent/Guardian of Student-Athlete, On behalf of Villanova Sports Medicine I would like to inform you of our medical insurance policies. As you know, risks are associated with playing sports and it is crucial that we communicate these policies and procedures in order to appropriately handle these injuries when they occur. The Athletic Department maintains a secondary insurance policy to supplement costs not covered by a studentathlete s required primary insurance. The secondary policy provides medical expense benefits for accidents or injuries only related to a student-athlete s participation in a scheduled and sponsored practice or competition while representing Villanova University Athletics. If or when an athletic related injury has occurred, the student athlete s primary health insurance will be billed first, followed by the university s secondary policy. In the case that billing statements are sent to the student-athlete and/or their primary residence, these charges must be sent to the Sports Medicine Department so that the school may process the payment immediately. PLEASE DO NOT IGNORE MEDICAL BILLS AS THIS MAY RESULT IN INVOLVEMENT WITH COLLECTION AGENCIES AND NEGATIVE CREDIT Not all medical expenses incurred by the athlete are payable by this policy, so please check with the Sports Medicine Staff should you have any questions about your coverage. All medical treatment for an injury or illness must begin with a Villanova University Athletic Trainer and/or Team Physician. Any medical treatment engaged, and the expenses associated with treatment, without the explicit knowledge or approval from the Sports Medicine Department or a referral from a physician, will be the financial responsibility of the student-athlete and/or their family. I,, as parent, guardian or legal representative, attest that (parent, please print) DOES/DOES NOT (circle one) have insurance coverage (student-athlete name) under a current, in force insurance policy for injuries that occur while he/she is participating in intercollegiate athletics. This coverage has limits of at least $75,000 and is valid in the state of Pennsylvania. If there is a material change in coverage or expiration of coverage, I agree to notify Villanova University of this development and update the insurance information I have on file. I understand and agree that, if I do not do so, Villanova University will assume no responsibility whatsoever for the payment of, or authorization to pay, medical expenses resulting in injuries that occur while participating in intercollegiate athletics at Villanova University. (parent signature) (date) PLEASE INCLUDE A COPY (FRONT & BACK) OF YOUR CURRENT INSURANCE CARD

3 Send this claim form, PRIMARY INSURANCE EXPLANATIONS OF BENEFITS, and ITEMIZED BILLS to: P.O. BOX 979, VALLEY FORGE, PA QUESTIONS? Call PA Please Print STUDENT S SOCIAL SECURITY NUMBER TO BE COMPLETED BY THE STUDENT College or University Student s Name Sex Male Female FIRST NAME MIDDLE INITIAL LAST NAME Student s School Address STREET CITY STATE ZIP Student s Home Address STREET CITY STATE ZIP Phone Numbers AT SCHOOL HOME Date of Birth AUTHORIZATION I AUTHORIZE ANY PHYSICIAN AND/OR HOSPITAL TO RELEASE SUCH INFORMATION AS RELATES TO THIS CLAIM TO A-G ADMINISTRATORS, INC. SIGNATURE DATE TO BE COMPLETED BY SCHOOL OFFICIAL WHICH SPORT? DATE & TIME TYPE OF INJURY: INTERCOLLEGIATE CLUB SPORT INTRAMURAL CIRCUMSTANCE: GAME PRACTICE CONDITIONING PLACE OF ACCIDENT: BODY PART INJURED: NATURE OF INJURY DETAILS OF WHAT HAPPENED: Are you aware of any other insurance program covering this athlete? Y N Ins. Co. Name Please attach a copy of Insurance Verification Form. I certify that the above accident resulted from the supervised practice or play or travel to and from an intercollegiate sport. SIGNATURE OF ATHLETIC DEPARTMENT OFFICIAL TITLE DATE MUST BE SIGNED BY SCHOOL ATHLETIC OFFICIAL COL ACC 03/06

4 FRAUD WARNING: Any person who, knowingly and with intent to defraud, or helps commit a fraud against, any insurance company or other person: (1) files an application for insurance or statement of claim containing any materially false information; or (2) conceals for the purpose of misleading, information concerning any material fact thereto, commits or may be committing a fraudulent insurance act, which is a crime and subjects such person to criminal and/or civil penalties. For residents of the following states, please see below: California, Colorado, District of Columbia, Florida, New York, Tennessee, Texas or Virginia. California & Texas Residents: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. Colorado Residents: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies. District of Columbia Residents: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. Florida Residents: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. New York Residents: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. Tennessee Residents: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. Virginia Residents: Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may have violated state law.

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6 Student-Athlete Authorization/Consent For Disclosure of Protected Health Information To the Villanova Sports Medicine Department I, hereby authorize the Villanova Sport Medicine Department, Name of Student Athlete and its physicians, athletic trainers, and other non-affiliated 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 Villanova Sports Medicine and its employees. 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 not condition or withhold 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 Villanova athletics. I understand that while HIPAA regulations do not apply to Villanova Sports Medicine s use or disclosure of my injury/illness information, Villanova is committed to protecting my privacy. 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 Director of Sports Medicine at my institution. I understand that a revocation takes effect on its request date and does not affect any action taken prior to that date. Printed Name Signature Date

7 VILLANOVA SPORTS MEDICINE Health Insurance/ Emergency Contact Information Athlete s Name: Gender: Sport: Soc Sec #: Date of Birth: Cell Phone #: Home Phone #: Academic Year: Athlete s Permanent Address: EMERGENCY CONTACTS Primary Contact Name: Address: Work Phone: Cell Phone: Home Phone: Relation: Secondary Contact Name: Address: Work Phone: Cell Phone: Home Phone: Relation: INSURANCE INFORMATION Company: Address: Phone #: Policy #: Policy Type: HMO PPO Group #: Policy Holder s Name: Policy Holders Soc. Sec. # Policy Holder s Date of Birth Precertification Needed: Yes No Primary Care Physician Physician s Phone # Referral Needed: Yes No

8 Returning Athlete Physical Name: Sport: Date: / / Please list any current conditions: Orthopedic General Med. Do you wish to see a physician for any of the above listed conditions: Yes / No Are you currently taking any medication (including Birth Control)? Yes / No - Are you currently taking Birth Control? Yes / No - Are you currently using supplements/vitamins? Yes / No Do you have any known allergies? Yes / No Do you currently use any prescription eyewear? Yes / No - Have there been any changes to your prescription? Yes / No Have you been hospitalized or had surgery? Yes / No Are you currently in care of a physician? Yes / No Do you have Attention Deficit Hyperactivity Disorder (ADHD)? Yes / No If yes, have you been tested for it? Yes / No Do you have sickle cell anemia or sickle cell trait? Yes / No Have you been tested for it? Yes / No Please explain any yes from above: Are you able to participate at Full Go status? Yes / No BP: Pulse: Height: Weight: Athlete s Signature: Athletic Trainer s Signature: _ Date: / / Date: / /