Completed paperwork can be faxed to , ed, or mailed to Trevecca Sports Medicine 333 Murfreesboro Rd Nashville, TN

Transcription

1 Dear prospective TNU athlete, Welcome to Trevecca! Our sports medicine staff looks forward to working with you and assisting you during your athletic participation at Trevecca. Our goal as a sports medicine department is to provide quality healthcare using a well-balanced approach to the overall wellness of each student-athlete. This interactive journey begins with paperwork, paperwork, paperwork Before you are cleared to participate as a Trevecca athlete, WE REQUIRE you to complete the following: Completely fill out & sign each of the documents that are enclosed in this packet Submit a photo-copy (front& back) of your health insurance card Get a pre-participation physical by a licensed physician prior to arriving on campus Obtain all previous medical history records (those relevant to your sport participation at Trevecca) Completed paperwork can be faxed to , ed, or mailed to Trevecca Sports Medicine 333 Murfreesboro Rd Nashville, TN **REMINDERS** **YOU WILL NOT BE ALLOWED TO PARTICIPATE IN ANY TEAM SANCTIONED ACTIVITIES (i.e. CONDITIONING, PRACTICES, GAMES, etc.) UNTIL YOUR ATHLETIC TRAINER HAS RECEIVED AND APPROVED EACH COMPLETED DOCUMENT.** If you have any questions or concerns, please do not hesitate to call or us. Stephanie Scott - snscott@trevecca.edu Again, we look forward to providing you with any and all necessary assistance during your time here at Trevecca. Check List Athlete Info Page HIPAA Medical Release Signed & Dated Athletic Health Insurance Info Signed & Dated Copy of Front & Back of Insurance Card ACP/PRA form Signed & Dated Pre-Participation physical before arriving on campus Sickle Cell Waiver ADD/ADHD Reporting form (if applicable) Dietary Supplement Disclosure Form First Agency (Secondary Insurance) Information/Consent

2 ATHLETE INFO PAGE (Please Print) FULL LEGAL NAME First Middle Last FIRST NAME YOU GO BY SPORT Mens Womens YOUR CELL NUMBER - 1 -

3 HIPAA Medical Release Form Trevecca Nazarene University Athletic Department HIPAA stands for Health Insurance Portability and Accountability Act and was created to increase the privacy of individuals personal health information. It affects all those who are in contact with medical records or personal health information. Under this law, certified athletic trainers (ATC s) are not able to speak to anyone in regards to an injury or condition unless a release is signed. I (print full legal name) First Middle Last am allowing FULL disclosure of my personal health information in regards to any athletic injury I may sustain while participating in intercollegiate athletics at Trevecca Nazarene University to those listed below who have a need to know in order to provide satisfactory medical treatment and/or claims processes and payment. I understand that by allowing partial or no disclosure of my personal health information I will forfeit my participation in intercollegiate sports at Trevecca Nazarene University. All of the following individuals may be told about my condition: Coaches Parents Athletic Trainer Athletic Director Team Physicians and Doctor s Office Staff Trevecca Nazarene University Insurance Agents and their representatives Trevecca Nazarene University human resources and financial services department employees I understand that if this is not followed, I may lodge a complaint to the US Health and Human Resources Department. X X Student Athlete Signature (parent/guardian if under 18) Date - 2 -

4 ATHLETE HEALTH INSURANCE INFORMATION FOR THE SCHOOL YEAR Athlete s Legal Name (first) (middle) (last) (nickname) Athlete s Gender Male ( ) Female ( ) Sport_ Athlete s Home Address (street) (city) (state) (zip) Athlete s Cell Number ( ) Athlete s Home Phone ( ) Athlete s Social Security # - - Athlete s date of birth / / Complete Name of Insurance Company Subscriber ID Number Policyholder s Group Number (or group name) Does your Primary Insurance require you to use a Network Provider? Yes No (If, Yes.) (physician s name) (phone number) (street address) (city) (zip) Is a referral from your Primary Care Physician required to see another health care provider? Yes No Primary Policyholder s Name (first) (middle initial) (last) Athlete s relationship to Primary Policyholder Self ( ) Spouse ( ) Child ( ) Other ( ) Primary Policyholder s Address (street) (city) (state) (zip) Primary Policyholder s Date of Birth: Phone# In case of emergency, notify: Name_ Relationship Address (street) (city) (state) (zip) Contact Phone # s ( ) ( ) - 3 -

5 Insurance Agreement Policy Read Carefully I authorize payment of medical benefits to all providers for all services and materials they provide during the care of an injury/illness. I agree to supply any and all information requested by my primary insurance, Trevecca Nazarene University and their excess insurance carrier in a timely manner in order to expedite the claims process. I hereby authorize Trevecca Nazarene University and their excess insurance carrier to secure and inspect copies of case history records, lab reports, diagnoses, x-rays, and any other date pertaining to the injury/illness I am receiving care for or previous confinements or disabilities relevant to the care of the injury/illness. I authorize the athletic trainer of Trevecca Nazarene University and/or my coach to hospitalize and secure treatment for me for any athletic injury/illness. If the athlete is under 18 years of age, the undersigned parent grants permission to the Team Physician of Trevecca Nazarene University and/or their coach to hospitalize and secure treatment for their son/daughter for any athletic injury/illness. A photostatic copy of this authorization shall be deemed as effective and valid as the original. I will notify the athletic trainer of Trevecca Nazarene University immediately upon any changes in the above health insurance information. PRINT FULL LEGAL NAME (first) (middle) (last) ATHLETE S SIGNATURE X DATE X (If under 18, parents/guardian MUST sign, otherwise MUST be signed by student-athlete) ***PLEASE PUT A COPY OF YOUR INSURANCE CARD (FRONT/BACK) ON A SEPARATE SHEET OF PAPER*** - 4 -

6 ATHLETIC CARE POLICY In order to ensure proper health care for all student-athletes and to insure proper payments are made for such care, student-athletes, coaches, athletic trainers and parents must adhere to the following policies: 1. All injuries and illnesses must be reported to the athletic trainer immediately. The coaches at TNU are NOT athletic trainers. The athletic trainers are NOT liable for injuries sustained during practices and/or games. 2. The athletic trainer will make any necessary referrals to the proper physician. Parents and athletes SHOULD NOT set up appointments without approval from the Head Athletic Trainer. If an appointment is set by someone other than Trevecca s athletic training staff, all bills will become the responsibility of the athlete and/or their parents. 3. Decisions on treatment will be made with the best interest of the student-athlete in mind. Decisions will be made in consultation with the physician, student-athlete, and with the athletic trainer. In the case of a minor, the parents will be contacted and included in the consultation. In all other cases, the athletic trainer and/or physician will not contact the parent(s) unless requested by the student-athlete. PARENTAL INVOLVEMENT IS ENCOURAGED IN ALL CASES OF ADMISSION TO HOSPITALS, SURGERIES, AND INVASIVE TESTING, AND IT IS HOPED THAT THE ADULT STUDENT- ATHLETE WILL ALLOW THE LINES OF COMMUNICATIONS TO REMAIN OPEN AT ALL TIMES WITH THE PARENTS AND THE ATHLETIC TRAINER AND OR PHYSICIAN. 4. All attempts will be made to utilize Trevecca Nazarene University recommended physicians for treatment. It is understood that some primary insurance carriers (HMO s and PPO s) require certain physicians to treat the patient. In these cases, Trevecca Nazarene University will attempt to cooperate with those carriers. In many cases, it is simply a hardship of the student-athlete to travel home for care. 5. The secondary (excess) insurance coverage provided by Trevecca Nazarene University is for ATHLETIC- RELATED INJURIES OR ILLNESSES ONLY. Therefore, only those injuries sustained while participating in a supervised practice or event will be covered. This does include off-season conditioning programs, but not include events such as summer leagues, intramurals, pick-up games, recreational activities, etc. 6. If the insurance coverage you have is out of state, a HMO, a PPO or anything else, IT IS YOUR RESPONSIBILITY TO DETERMINE COVERAGE IN THE NASHVILLE AREA. If the athlete loses insurance coverage for any reason or if the insurance provider changes during the school year, it is the responsibility of the athlete or parent/guardian to notify the athletic trainer. Sports participation will cease until the athlete is covered by a primary insurance policy. The athlete or parent/guardian will be responsible for any uncovered costs. 7. Guidelines for claim resolution are as follows: a. The student athlete must present their Primary Insurance card in the doctor s office before each visit. You should ask if: The provider will file a claim with your insurance company for today s DOS charges Or, if you, are responsible for filing today s DOS charges with your insurance company. If after 21 days from that DOS, you have not received any documentation of those charges from your insurance company: You should call your insurance company and check the status of your claim. TNU needs specific claim forms provided by your primary insurance company for each DOS charges, within 30 days of your visit to each provider. b. The student-athlete is responsible for giving the medical provider of service TNU s address as secondary insurance provider. In all cases, Trevecca Nazarene University s secondary insurance can only be applied to these bills: Where services are rendered for the treatment of an athletic injury Where prior approval of that referral was granted through the athletic trainer Where the care has been coordinated through the athletic training department When the primary insurance company has responded to and resolved all claim processes (Usually within 3 weeks from DOS) - 5 -

7 ATHLETIC CARE POLICY c. Once your primary insurance coverage has paid all covered expenses, you must then forward the following documents to the address below: A copy of the HCFA (Health Insurance Claim Form) and a copy of the corresponding EOB (Explanation of Benefits) received from your primary insurance, for each provider s DOS charges. Trevecca Nazarene University Attn: Rebecca Scott 333 Murfreesboro Road Nashville, TN TNU s Insurance Coordinator cannot submit your DOS charges for consideration of payment by TNU s secondary insurance provider, without these documents. d. These Claim Forms are to be sent to TNU within 30 days from the DOS, for timely submission for secondary insurance filing. Questions regarding secondary claim status should be addressed to: Trevecca Nazarene University Rebecca Scott Student and Parent agreement to adhere to TNU Athletic Care Policy We understand that we have the responsibility to provide primary insurance coverage and agree to follow the proper procedures set before us concerning primary medical insurance claim procedures and in secondary claim procedures; in order to access TNU s secondary (excess) insurance coverage policy for any and all athletic related injuries. We understand that all medical expenses related to the student athlete s injuries that are not paid by these insurance carriers are ultimately the sole responsibility of the student-athlete. Athletic Care Policy Agreement and Personal Representative Appointment: I fully understand and agree to the above policies and appoint (Student-Athlete s Printed Name) Rebecca Scott as my personal representative to act on my behalf in the matters of health insurance with Student Insurance. I, understand this is a voluntary designation and that this designation gives the personal representative the same rights to my health insurance information as myself. This appointment will expire at the end of the current academic/policy year. X Student-Athlete s Signature X Date If athlete is under the age of 18 a parent or guardian must also sign below: I fully understand and agree to the above policies. (Parent s Printed Name) X Parent s Signature X Date - 6 -

8 Sickle Cell Testing Waiver About Sickle Cell Trait: Sickle cell trait is an inherited condition of the oxygen-carrying protein, hemoglobin, in the red blood cells. Sickle cell trait is a common condition (> three million Americans) Although sickle cell trait is most predominant in African-Americans and those of Mediterranean, Middle Eastern, Indian, Caribbean, and South and Central American ancestry, persons of all races and ancestry may test positive for sickle cell trait. Sickle cell trait is usually benign, but during intense, sustained exercise, hypoxia (lack of oxygen) in the muscles may cause sickling of red blood cells (red blood cells changing from a normal disc shape), which can accumulate in the bloodstream and logjam blood vessels, leading to collapse from the rapid breakdown of muscles starved of blood. Sickle Cell Trait Testing: The NCAA mandates that all NCAA student-athletes have knowledge of their sickle cell trait status before the student-athlete participates in any intercollegiate athletics events. The Trevecca Nazarene University Athletic Department encourages all student-athletes to be tested before participation I,, understand and acknowledge that the NCAA and the TNU Student-Athlete s Printed Name Department of Athletics mandate that all student-athletes have knowledge of their sickle cell trait status. Additionally, I have read and fully understand the aforementioned facts about sickle cell trait and sickle cell trait testing. Recognizing that my true physical condition is dependent upon accurate medical history and a full disclosure of any symptoms, complaints, prior injuries, ailments, and/or disabilities experienced, I hereby affirm that I have fully disclosed in writing any prior medical history and/or knowledge of sickle cell trait status to the TNU Sports Medicine staff. I do not wish to undergo sickle cell trait testing as part of my pre-participation physical examination and I voluntarily agree to release, discharge, indemnify and hold harmless Trevecca Nazarene University, its officers, employees and agents from any and all cost, liabilities, expenses, claims, demands, or causes of action on account of any loss or personal injury that might result from my non-compliance with the mandate of the NCAA and the Trevecca Nazarene University Department of Athletics. I have read and signed this document with full knowledge of its significance. I further state that I am at least 18 years of age and competent to sign this waiver. Student-Athlete s Printed Name Sport Date Student-Athlete s Signature Witness Signature Date Parent/Guardian s Name Parent/Guardian s Signature (if under 18 years of age) Date

9 Dietary Supplement Disclosure and Review Form Trevecca Nazarene University Student-Athlete Dietary Supplement Disclosure and Review Form I, am taking or intend to take the following dietary supplements. I acknowledge the risk of losing my eligibility to participate in intercollegiate athletics If I test positive for a NCAA or Trevecca Nazarene University banned substance that may be found in any substance that I take, regardless of the reason or purpose for taking such supplements. I acknowledge and understand that the labeling on these products can be misleading and inaccurate, and that sales personnel are neither motivated nor qualified to accurately certify that these products contain no banned substances. Healthy or naturally occurring are terms often used to market sales of dietary supplements, but do not necessarily mean they are safe. Before taking or suing any dietary supplement, I am responsible for ensuring the product does not contain any banned substance. By making this disclosure, I am requesting that these products and their ingredients be reviewed by Trevecca Nazarene University s sports medicine staff for the purposes of determining whether they are medically safe to use and do not contain banned substances. I understand that I should not take or use these products until their usage has been reviewed by Trevecca Nazarene University s sports medicine staff. Brand Name: Listed Ingredients: (Athletic Trainer to review, circle banned substances and notify student athlete) Student Athlete Signature Date Athletic Trainer Signature Date

10 First Agency, Inc West H Avenue Kalamazoo, MI Phone (269) Fax (269) PARENT/GUARDIAN/STUDENT INFORMATION FORM RETURN FORM WHEN COMPLETED TO Name of College/University Trevecca Nazarene University / TN Attention Casey Umstetter First Agency This form is to be completed by the Address 5071 West H Ave Parents, Guardians or Student City Kalamazoo State MI Zip Note: Complete all blanks on this form. Failure to complete all blanks will result in claims processing delays. If information is not applicable, indicate the reason it is not (e.g., deceased, divorced, unknown). Name of Athlete Sport College Address Date of Birth Home Address College Phone ( ) City State Zip Home Phone ( ) FATHER/GUARDIAN INFORMATION Father's Name Date of Birth Address MOTHER/GUARDIAN INFORMATION Mother's Name Date of Birth Address Employer Address Employer Address Telephone ( ) Telephone ( ) Medical Insurance Company or Plan Address Medical Insurance Company or Plan Address Policy Number Policy Number Telephone ( ) Telephone ( ) Is this plan an HMO or PPO? Yes No Is this plan an HMO or PPO? Yes No Is pre-authorization required to obtain treatment? Yes No Is pre-authorization required to obtain treatment? Yes No Is a second opinion required before surgery? Yes No Is a second opinion required before surgery? Yes No PLEASE COMPLETE AUTHORIZATION ON REVERSE SIDE OF THIS FORM

11 First Agency, Inc West H Avenue Kalamazoo, MI AUTHORIZATION - To Permit Use and Disclosure of Health Information This Authorization was prepared by First Agency, Inc. for purposes of obtaining information necessary to process a claim for benefits. Upon presentation of the original or a photocopy of this signed Authorization, I authorize, without restriction (except psychotherapy notes), any licensed physician, medical professional, hospital or other medical-care institution, insurance support organization, pharmacy, governmental agency, insurance company, group policyholder, employer or benefit plan administrator to provide First Agency, Inc. or an agent, attorney, consumer reporting agency or independent administrator, acting on its behalf, all information concerning advice, care or treatment provided the patient, employee or deceased named below, including all information relating to, mental illness, use of drugs or use of alcohol. This Authorization also includes information provided to our health division for underwriting or claim servicing and information provided to any affiliated insurance company on previous applications. If this Authorization is for someone other than myself, that individual has given me the authority to act on his/her behalf as explained below. I understand that I have the right to revoke this Authorization, in writing, at any time by sending written notification to my agent or to us at the above address. I understand that a revocation will not be effective to the extent we have relied on the use or disclosure of the protected health information or if my Authorization was obtained as a condition to determine my eligibility for benefits. Revocation requests must be sent in writing to the attention of the Claims Supervisor. I understand that First Agency, Inc. may condition payment of a claim upon my signing this authorization, if the disclosure of information is necessary to determine the level or validity of the claim payment. I also understand, once information is disclosed to us pursuant to this Authorization, the information will remain protected by First Agency, Inc. in accordance with federal or state law. I understand that I or my authorized representative is entitled to receive a copy of this authorization upon request. This Authorization is valid from the date signed for the duration of the claim. Name of Claimant (please print) Name of Authorized Representative, or Next of Kin (please print) Signature of Claimant (if claimant is 18 or older) Date Signature of Authorized Representative of Next of Kin Date Relationship of Authorized Representative or Next of Kin to Claimant

12 NCAA Medical Exception Documentation Reporting Form to Support the Diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) and Treatment with Banned Stimulant Medication Complete and maintain (on file in the athletics department) this form and required documentation supporting the medical need for a student-athlete to be treated for ADHD with stimulant medication. Submit this form and required documentation to Drug Free Sport in the event the student-athlete tests positive for the banned stimulant (see Drug Testing Exceptions Procedures at To be completed by the Institution: Institution Name: Institutional Representative Submitting Form: Name Title Phone Student-Athlete Name Student-Athlete Date of Birth To be completed by the Student-Athlete s Physician: Current Treating Physician (print name): Specialty: Office address Physician signature: Date Check off that documentation representing each of the items below is attached to this report o Diagnosis. o Medication(s) and dosage. o Blood pressure and pulse readings and comments. o Note that alternative non-banned medications have been considered, and comments. o Follow-up orders. o Date of clinical evaluation: o Attach written report summary of comprehensive clinical evaluation. Please note that this includes the original clinical notes of the diagnostic evaluation. The evaluation should include individual and family history, address any indication of mood disorders, substance abuse, and previous history of ADHD treatment, and incorporate the DSM criteria to diagnose ADHD. Attach supporting documentation, such as completed ADHD Rating Scale(s) (e.g., Connors, ASRS, CAARS) scores. The evaluation can and should be completed by a clinician capable of meeting the requirements detailed above. DISCLAIMER: The National Collegiate Athletic Association shall not be liable or responsible, in any way, for any diagnosis or other evaluation made, or exam performed, in connection herewith, or for any subsequent action taken, in whole or in part, in reliance upon the accuracy or veracity of the information provided hereunder.

13 Pre-participation Physical Form ***THIS FORM MUST BE COMPLETED AND RETURNED TO THE TREVECCA SPORTS MEDICINE STAFF PRIOR TO PARTICIPATION OF ANY KIND*** Last Name First Name Middle Name Sport Birthdate Social Security # Address Home Address City State Zip Phone # Medical History Information Yes No 1. Have you had any serious injuries since your last check-up or sports physical? Do you have a chronic or ongoing illness?..... If yes, explain 3. Have you ever been hospitalized overnight? Have you ever had surgery?... Type of surgery Body part/injury Date of surgery 5. Are you presently taking any prescribed or over the counter medication?... Name of medication Purpose of medication 6. Have you ever had a head injury or concussion?... Total # of concussions Date of concussion(s) Amount of time missed from sports 7. Have you ever been knocked out, become unconscious, or lost your memory? Have you ever had high blood pressure or cholesterol? Have you ever become ill from exercising in the heat? Have you ever been told you have a heart murmur? Have you ever passed out or become dizzy during or after exercise? Have you ever experienced chest pain, discomfort, or unexplained shortness of breath with exercise? Have you ever experienced racing of your heart or skipped heartbeats? Has any family member or relative had a significant cardiac event or sudden death?... Who? Their age at time of cardiac event 15. Has a physician ever denied or restricted your participation on sports for any heart problems?... If yes, explain 16. Have you ever had a seizure? Do you have frequent or severe headaches? Have you ever had numbness or tingling in your arms, hands, legs or feet? Do you have asthma? Are you currently using an inhaler? Has a doctor ever told you that you have Sickle Cell Anemia or that you are a carrier? Do you wear glasses, contact, or protective eye wear? Have you had a dental checkup in the last six months? Have you ever had a CT Scan/MRI/X-Ray/Bone Scan or other diagnostic test?... Type of testing Body part/injury Date of testing 25. Have you ever broken or fractured any bones or dislocated any joints?... Body part/injury Date of injury 26. Have you ever had any problems with pain or swelling in any of the following muscles, tendons, bones, or joints?... Head Neck Back, Chest Shoulder Elbow, Forearm Wrist, Hand, Finger Hip, Thigh Knee Ankle Foot

14 For questions 1-26, please explain all YES answers in the area below. List Allergies (Medicine, Bees, Other Stinging Insects, Foods) For Medical Personnel Only: Height: Weight: Pulse: Blood Pressure: Please place an X in each blank indicating the item examined. Eyes Lungs Shoulder/Arm Knee Ears Heart Elbow/Forearm Foot Nose Heart Murmur Wrist/Hand Neck Throat Pulses Hip/Thigh Back Lymph Nodes Abdomen Legs/Ankles Skin Comments: CLEARED for Participation CLEARED for participation AFTER follow up by the indicated specialist: Family/PCP Cardiologist Ophthalmologist Allergist Dentist Orthopedist Athletic Trainer Internist Physical Therapist Other: Reason: NOT CLEARED: Due to Printed Name of MD/RN/PA/NP MD/RN/PA/NP SIGNATURE Date

15 Before turning in this packet, please go through the following check list to ensure all the forms are filled out in their entirety. Remember, you will not be allowed to participate in any team related activities until all forms are filled out and turned in to your athletic trainer. Check List: Athlete Info Page HIPAA Medical Release Signed & Dated Athletic Health Insurance Info Signed & Dated Copy of Front & Back of Insurance Card ACP/PRA form Signed & Dated Pre-Participation physical before arriving on campus Sickle Cell Waiver ADD/ADHD Reporting form (if applicable) Dietary Supplement Disclosure Form First Agency (Secondary Insurance) Information/Consent Again, if there are any questions or concerns, please do not hesitate to contact us: Stephanie Scott - snscott@trevecca.edu We look forward to working with you! TNU Sports Medicine Department 333 Murfreesboro Road Nashville, TN 37210