Please use this space to list other medical conditions or explain any Yes answers

Transcription

1 Previous Medical History Form Name: (first) (last) (middle) Sport(s): Athlete Medical History Conditions/History Yes No Conditions/History Yes No Hospitalization Reason and Date(s): Osgood Schlatter/Spina Bifida Diabetes (family member and type) Heart Murmur Date Diagnosed: Heart Disease Date Diagnosed: Family Member with Heart Attack under age 50 Relation: High Blood Pressure Medications: Asthma Type of Controller Medication: Allergies Medications (Prescription and OTC) Dosage: Do you take medication for ADHD/ADD? If yes, print out Medical Exception Form Online And have your physician fill it out Concussion Date(s): Mono/Pneumonia/Hepatitis Date(s): Vision Problems (glasses/contacts/color blindness/astigmatism) Hernia Date Diagnosed/Surgery: Triggers: Fractures/Dislocations/ Ligament Damage/Surgeries Area(s) of Body and Date(s): Women Only: Irregular Menstrual Cycle Please use this space to list other medical conditions or explain any Yes answers

2 University of Pittsburgh at Greensburg Physical Examination Form I-TO BE COMPLETED BY PHYSICIAN FLOW Check in Vitals MD/DO Body Comp Check out Ligamentous UQS LQS Flexibility Cardiac Name: Date of Birth: Sports: Age: Height: Weight: B/P: Pulse: Visual Acuity CV: Pulses Lungs Heart HEENT Abdominal Skin Genitalia Musculoskeletal Neck Shoulder Elbow Wrist Hand Back Knee Ankle Foot Assessment: Recommendation:

3 Clearance (circle if appropriate clearance): 1. No restrictions A. Contact/collision B. Limited contact/impact C. Non-contact 1). Strenuous 2). Moderately strenuous 3). Non-strenuous 2. Cleared after notification of coach, athletic trainer, physician 3. Clearance deferred until evaluation by a physician Comments/explanations: Exam Date,MD/DO/PA/CSNP Signed

4 Secondary Medical Insurance Information/Authorization Primary coverage for any intercollegiate athletic related injuries is the responsibility of the student athlete s personal or family insurance policy. Prior to participation in any intercollegiate activity, a student athlete MUST provide proof of insurance to the Head Athletic Trainer per NCAA regulations. University of Pittsburgh at Greensburg provides secondary or excess coverage for student athletes for injuries sustained while participating or competing in intercollegiate. This secondary policy has a $500 deductible per injury which has to be met by either the athlete and/or family. Below is a brief summary of the University of Pittsburgh at Greensburg secondary insurance: 1. All claims must be first submitted and processed with your personal insurance company prior to forwarding them to the University of Pittsburgh at Greensburg Athletic Department. 2. The student athlete must report the injury to the University of Pittsburgh at Greensburg athletic training staff within two weeks so a record can be made in order to file a claim. 3. Injuries subject to coverage include: participation during a scheduled varsity event, practice or conditioning workout supervised by a coach. This DOES NOT include non supervised workouts or injuries/illnesses that prevent participation in athletics, not directly caused by participation in athletics. 4. In the event that NAHGA Claim Services., the University of Pittsburgh at Greensburg s insurance carrier, denies the claim for whatever reason, the remaining balance is considered your responsibility. The procedure for filing a claim with the University of Pittsburgh at Greensburg secondary insurance policy is: 1. All claims will be first submitted to your personal insurance to be processed. 2. After your insurance has paid its portion, you will receive a bill from the provider with the remaining balance. Send this bill along with the Explanation of Benefits (EOB) for each service, along with an itemized bill (either form UB04 or HCFA 1500)to: NAHGA Claim Services P.O. Box 189 Bridgton, ME The UB04 or HCFA 1500 needs to come from the provider (Dr s office, PT clinic, etc). This is the itemized medical bill required by NAHGA Claim Services. For PT services the following needs to be submitted for reimbursement: - Script from MD or DO - Treatment Plan from the PT - All progress notes from the PT 3. Once the bill has been received by the insurance company, processing a claim can take up to six (6) weeks. This necessitates bills being submitted in a timely manner as we do not have the ability to negotiate with collections agencies. If a claim is approved after you have paid a bill, the insurance company may authorize reimbursement. University of Pittsburgh at Greensburg will submit the initial Intercollegiate Sports Accident Claim Form only. The athlete/family is responsible for submitting all needed documentation to NAHGA Claim Services. For more information please contact NAHGA Claim Services at or go to I have read and understand the University of Pittsburgh at Greensburg summary of its secondary athletic insurance policy and the procedures for filing a claim that may affect me as a parent/guardian and/or studentathlete.

5 **If the athlete is covered under the parent/guardian s medical insurance policy, that parent/guardian must also sign below, regardless of athlete s age.** / Student Athlete Printed Name/ Signature Date / Parent/Guardian Printed Name/ Signature

6 University of Pittsburgh-Greensburg Emergency Contact/ Insurance Information Form Section 1: Athlete Contact Information Name: Sport(s): SS Number: - - Level: Fr So Jr Sr Date of Birth: / / Permanent Address: (city) (state) (zip code) Local Address: (city) (state) (zip code) Cell Number: ( ) Home Number: ( ) Campus Extension: Section 2: Parents/Emergency Contact Information Contact One Contact 2 Name: Name: Relationship: Relationship: Address: Address: Home Phone: Home Phone: Cell Phone: Cell Phone: Work Phone: Work Phone:

7 Section 3: Insurance Information Primary Insurance: Policy Holder: (first) (last) (middle) Relationship: Insurance Company: Policy/ID Number: Group Number: Type: HMO PPO Other Insurance Address: Insurance Phone: ( ) Secondary Insurance: Policy Holder: (first) (last) (middle) Relationship: Insurance Company: Policy/ID Number: Group Number: Type: HMO PPO Other Insurance Address: Insurance Phone: ( ) *BY SIGING BELOW, YOU CONFIRM THAT YOU HAVE READ AND UNDERSTAND THE ENCLOSED POLICY, AND GIVE THE UNIVERSITY of PITTSBURGH- GREENSBURG INSURANCE PROVIDER THE RIGHT TO PROCESS ALL ATHLETIC RELATED BILLS AFTER PRIMARY COVEAGE HAS BEEN MET. YOUR SIGNATURE ALSO AUTHORIZES THE RELAEASE OF INFORMATION FROM YOUR PRIMARY AND SECONDARY MEDICAL INSURANCE CARRIER TO THE UNIVERSITY of PITTSBURGH- GREENSBURG ATHLETIC DEPARTMENT. THE INFORMATION WILL BE UTILIZED TO PROPERLY DETERMINE THE COORDINATION OF BENEFITS BETWEEN THE TWO CARRIES AS APPLICABLE. *WE HAVE THE RIGHT TO APPROVE ALL SECOND OPINIONS FOR MEDICAL REFERRAL, AND REQUEST THAT ANY SUCH RECORDS BE SENT TO US AT UNIVERSITY of PITTSBURGH- GREENSBURG (150 Finoli Drive) AS SOON AS POSSIBLE AFTER THE DATE OF SERVICE. PARENT SIGNATURE DATE (if athlete is under 18) ATHLETES SIGNATURE DATE *PLEASE INCUDE A PHOTOCOPY OF FRONT AND BACK OF INSURANCE CARD. The UPMC consent to treat and authorization for release of information forms must be read carefully, and signed. The UPMC documents have been put into place by UPMC due to HIPAA (Health Insurance Portability and Accessibility Act) in order to protect the private health information stored in the athletes files in the training room facility. If the student athlete does not sign the consent to treat form, Athletic training staff will not be able to treat them at all even though they are a student athlete of University of Pittsburgh-Greensburg. Please direct any questions about these forms to Ricky Wheeler II, ATC, LAT at