Southern Arkansas University Athletic Medical Insurance Information June 2017

Transcription

1 Athletic Medical Insurance Information June 2017 Dear Parent/Guardian: I would like to take this opportunity to share with you s (SAU) Athletic Department policies regarding medical insurance and payment of medical services. The purpose of which is to explain areas that may affect you as parent s/guardians with the intent of decreasing the level of confusion or questions you have pertaining to insurance and medical expenses incurred by your daughter/son. At the beginning of each fall semester, each student-athlete is advised of these policies during a meeting held for all student-athletes. Student Athlete Responsibilities/Requirements 1. All student-athletes who participate in intercollegiate athletics at SAU are required to carry their own Primary Medical Insurance policy. SAU requests that the individual deductible of no more than $1500 and a Stop-Loss of no more $10,000 and must cover intercollegiate athletics including football, and must maintain this insurance throughout their athletic career. 2. The athlete s primary insurance must be acceptable for use in the state of Arkansas. Arkansas providers (Doctors, Hospitals, etc.) do not except Out of State Medicaid. Also SAU will not accept any Medicare or Medicaid from any state as primary insurance for our athletes. 3. Any athlete who is covered by a Medicare/Medicaid from any state, or is not covered by any primary insurance is required to purchase their own medical insurance. If the student-athlete is on an athletic scholarship, SAU will purchase the insurance policy for them and the cost will be deducted from their athletic scholarship. Any non-scholarship athlete will be responsible for the cost of the insurance. 4. The student-athlete must report any changes in the student s-athlete s insurance to the athletic training department at the time of the change, or the athlete will be responsible for all medical expenses that may be incurred. 5. Any athlete, or the parent(s), who is found to have dropped their insurance, for any reason, will be fully responsible for any and all medical expenses. 6. Each student-athlete is required to submit to the athletic training department their Medical Insurance Information form by July 15 th each year prior to arriving on campus. Any student-athlete who does not submit complete and accurate information will not be allowed to participate in athletics. Any student-athlete who is injured or becomes ill due to athletic participation and is then found to have provided false or incorrect insurance information; will be responsible for any and all medical expenses. 7. The SAU Athletic Training Staff is must be notified prior to all medical visits, either on or off campus, excluding emergency room visits. We will provide the Student- Athlete with documentation to bring to the medical visit. If a student-athlete goes to a doctor without prior notification to the athletic training staff, SAU will not be responsible for the expenses. The medical information is placed in the student-

2 athletes file as record of each medical visit they have had. This documentation is needed for medical records, medical participation, medical release, and to compare dates to medical billing and insurance documentation. 8. The SAU Athletic Training Department must receive all documentation, including all medical bills from all providers and facilities utilized and all explanation of benefit forms (EOB) from the primary insurance company before payment by the SAU Athletic Department insurance will be forwarded. All medical bills and EOBs must be received by the SAU Athletic Training Department within 90 days of the date of service or the SAU Athletic Department will not be responsible for these expenses. Southern Arkansas Responsibilities/Requirements The SAU Athletic Department provides supplemental financial coverage that requires all medical charges to be filed with a primary insurance company prior to consideration of acceptable charges that may assume. Therefore, all medical expenses must be filed with the student-athlete s primary insurance first 1. SAU will be financially responsible for allowable medical charges such as: a. The deductible and the stop loss provisions that meet the limit requirements as required in the Student Responsibility (# 1). b. The remainder of acceptable and approved medical expenses accrued after your primary insurance has paid in full, its portion up to $ This means that SAU will cover medical charges up to $4, and the athlete or her/his parents will be responsible for any amount over the $4, limit. c. These medical expenses are those that occur from and injury/illness sustained during official NCAA playing and practice season, sanctioned competition or university sponsored travel to or from competition under SAU s athletic department auspices. University sanctioned athletic activity includes all practices on university or shared community facilities authorized by the athletic director, and any events to which a student-athlete travels with university support or financial assistance. 2. SAU will not be responsible for any pre-existing injury that: a. Occurred prior to participation with an SAU athletic team. or b. An illness, or any injury or illness that occurs outside of athletic participation or any general medical condition which include but not limited to; Colds, Flu, Asthma, Heart condition, Eye problems, Dental problem or Staph infections. (NCAA Rule ) 3. SAU will not be responsible for any out of network expenses. These are any expenses that may be incurred by an athlete who chooses to go to their own doctor and/or outside of our network of doctors. As a member institution of the NCAA, catastrophic injury coverage is dictated by the policy provided by the NCAA. 4. SAU will not be financially responsible for any injury/illness incurred that does not fit into any of the acceptable parameters of competition listed in #1(c) above. At all times, the SAU athletic training staff will be involved in making all appointments even though the injury/illness is not athletic related. We are very aware that insurance companies pay different percentages at different medical facilities. We try at all times to get the student-athlete to the provider that is most compatible with your primary insurance company. Even if we make the appointment in this

3 circumstance, we are in no way financially responsible for any medical expenses not covered by your primary insurance company. 5. will not be responsible for any eligible medical expenses three months (90 days) past the date a student-athlete has exhausted eligibility in his or her sport. The intent of this document is to explain and clarify some areas of confusion regarding medical insurance and payments of medical bills incurred by the student-athlete while participating in athletics at. Please feel free at any time to call if you have any questions regarding medical care and treatment of your daughter/son while at SAU. Please sign and return this document to me at the address below. Your daughter/son will not be allowed to participate in athletics until their medical file is complete. Thank you, Ken Cole MS, LAT, ATC Head Athletic Trainer P.O. Box 8800 Magnolia, AR (O)

4 Athletic Medical Insurance Information Acknowledgement Form Please sign and return this page to the Athletic Training Department and keep the above information for your records. Each athlete and his/her parent(s) or guardian must sign and return this page before the athlete will be allowed to participate. I/WE,, have read and understand the above policies and do agree to abide by them. I/WE understand that if I/we do not follow these policies I/we will be responsible for any/all medical expenses that I may incur while participating in athletics at. Parent/Guardians Name (Print) Signature of Parent/Guardian Student-Athlete Name (Print) Signature of Student-Athlete Sport Date

5 SOUTHERN ARKANSAS UNIVERSITY STATEMENT OF RISK AND MEDICAL CONSENT FORM Athlete: Sport: STATEMENT OF RISK: While benefits derived from intercollegiate athletic participation are great, there are also calculated risks involved in such competition. Intercollegiate athletes need well-conditioned bodies to perform in a successful manner. No matter how well conditioned the human body is, injuries may and will occur. These injuries range from very minor injuries to major injuries that may require minor or major surgery. Some injuries could possibly cause permanent damage (paralysis) or even be life threatening (death). The coaches working in our program are well-qualified, professional people. Fundamentals related to their specific sport will be emphasized repeatedly on and off the field. These fundamentals are designed to help prevent injury. But, even with the best of fundamentals, the risk of injury still exists. Both participants and parents are hereby advised that an element of risk is still present in all intercollegiate athletic participation. MEDICAL CARE CONSENT: Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examinations and immunizations for the above named student. In the event of serious illness, the need for major surgery, or significant accidental injury, I understand that an attempt will be made by the attending physician to contact me in the most expeditious way possible. If said physician is not able to communicate with me, the treatment necessary for the best interest of the above named student may be given. Major emergency surgery will not be performed unless the medical opinion of another licensed physician concurring if necessity for such surgery is obtained prior to the performance of such surgery. In the event that an emergency arises during a practice session or game, an effort will be made to contact the parents or guardians as soon as possible. Permission is also granted to the athletic trainer and/or Team Physician to provide the needed emergency treatment and first aid to the athlete prior to his referral to the attending physician or admission to the medical facilities. I hereby affirm that I have read the above information and understand that the risk of injury exists in all Intercollegiate Athletic Participation. Signature of Parent or Guardian Signature of Student Athlete Date Date

6 *PARENTS/GUARDIANS MUST COMPLETE AND RETURN:* FAILURE TO COMPLETE ALL BLANKS WILL RESULT IN CLAIMS PROCESSING DELAYS AND/OR FAILURE TO DISCLOSE INSURANCE INFORMATION WILL CAUSE YOU TO BE RESPONSIBLE FOR ANY AND ALL MEDICAL BILLS. NOTE: Complete all blanks. If information is not applicable, indicate the reason it is not, i.e., deceased, divorced, unknown. Name of Athlete SS# Student ID #: Birth date: Sport: Home Address: Phone#: City: State: Zip: Father/Guardian: SS #: DOB: Address: Mother/Guardian: SS #: DOB: Address: Employer: Employer: Address: Address: Phone: Phone: Medical Ins. Co. Medical Ins. Co. Address: Policy #: Address: Policy #: Deductible: Stop Loss Limit: Deductible: Stop Loss Limit: Phone: Phone #: HMO: Yes No PPO: Yes No Does your Insurance require a second opinion before surgery? Yes No I hereby authorize (SAU) and/or its representatives to inspect or secure copies of case history records, laboratory reports, diagnoses, x-rays, and any other data covering this and/or previous confinements and/or disabilities. A photo static copy of this authorization shall be deemed as effective and valid as the original and valid up to two years from the date of signature. We authorize or its insurance agent to pay the medical providers directly for any bills incurred from intercollegiate injuries/illnesses. We also authorize our insurance company to release needed information to SAU for the purpose of processing medical cost coverage. Students Signature: Date: Parent s Signature: Date:

7 PLEASE PRINT ALL INFORMATION Athletic General Information Full Name: SS#: DOB: / / Home Address: City: St: Zip: Home Phone #: Year in College: Year in Sport: Father Name: (Guardian) DOB: Home Address: City: St: Zip: Home Phone #: Work Phone #: Cell Phone #: Mother Name: (Guardian) DOB: Home Address: City: St: Zip: Home Phone #: Work Phone #: Cell Phone #: Emergency Contact: Other than those listed above. Name: Relation: Home Phone #: Work Phone #: Cell Phone #: Name of Family Physician: Phone #: Address: City: St: Zip:

8 Athletic Physical Examination Report Name: Social Security #: Sport: DOB: Age: Height: Weight: Heart Rate: BP: / Vision: RT 20 / Uncorrected Corrected Wears: Contacts LT 20 / Uncorrected Corrected Glasses Sickle Cell Test: (The NCAA requires that ALL athletes be tested for the Sickle Cell trait and provide test results. July 2012) 1. Eyes 2. Ears, Nose, Throat 3. Mouth, Teeth 4. Neck 5. Heart/Cardiovascular 6. Chest, Lungs 7. Abdomen 8. Skin 9. Reproductive Organs: Hernia 10. Musculoskeletal Orthopedics a. Neck b. Spine c. Shoulder d. Elbow e. Arms, Hands f. Hips g. Thighs h. Knees i. Ankles j. Feet 11. Neuromuscular Normal Abnormal Findings Initials Comments on abnormal findings: Unrestricted Activity: Restricted Activity: Exclusions: Further Evaluation: Comments on restrictions or further evaluation: Physician Signature: Physicians Name: Address: Phone # Date:

9 NCAA Sickle Cell Testing Position Statement The NCAA believes that the knowledge of sickle cell trait status provides the best environment for student-athlete safety through intervention and education as one more layer of protection. If sickle cell trait status is not known, NCAA legislation requires testing to be a component of a student-athletes medical examination in Division I and Division II and recommends in Division III that this status be confirmed during the mandatory medical examination. NCAA legislation also offers an opt out for those student-athletes who have personal reasons why they would not want to be tested. Everyone should know their own sickle cell trait status. In addition, the athlete should be encouraged to share this information with medical professionals and coaching staff, as they would any other piece of medical information. Coaches should conduct appropriate sportspecific conditioning based on sound scientific principles and be ready to intervene when athletes show signs of distress. requests that ALL student-athletes be tested for the sickle cell trait and a copy of this result be sent to the Athletic Training Department along with their Physical Exam. Athletes will not be allowed to participate in any athletic activity without this report on file. If you have questions, please call Ken Cole MS, LAT, ATC; Head Athletic Trainer at