Langston University Athletics New Student-Athlete Medical Packet

Transcription

1 Langston University Athletics New Student-Athlete Medical Packet May 2014 Dear Parent of a Langston University Student-Athlete: We are very pleased to have your son/daughter as a candidate for our Athletic Program. We believe strongly in our program and will make every effort to make it competitive and educationally sound. This athlete registration packet is to assist the Athletic Training staff in providing comprehensive, efficient, and cost effective medical services. It is imperative that you provide accurate and complete information regarding your son/daughters medical history and his/her insurance coverage. The Langston University Medical Staff would like to have a complete medical history for all athletes. This will assist us in providing the best possible health care for your son/daughter while he/she participates as an LU student-athlete. Please submit medical records for ALL major injuries or illnesses that have occurred in the past five years. Langston University requires all students to carry a personal health insurance plan, or be included on a family full medical health policy. Langston defines a primary insurance as insurance with no more than a $1,000 deductible. (Sooner Care, Medicaid, All Military insurance including but not limited to, Champus/Tricare/Humana etc., and AFLAC are not considered primary insurance). However, if the athlete does have military insurance, they can sign a waiver of secondary insurance and the athlete would be responsible for any charges not covered by the primary insurance plan. Please read through the information in this packet carefully and retain copies for future references for filing claims. Please notify the LU Athletic Training Department of any modifications in YOUR insurance coverage, employment status, home address or other personal demographics that may change during the course of the year. This will expedite the process of contacting you in the event of an emergency or the processing of insurance claims. Please review the enclosed materials (Medical Services Form, Primary Insurance Form, Medical Consent and Medical Care Statement Form, HIPAA Release, Authorization Form, Medical History Form, Drug Testing Consent Form), which may require signatures for each separate item. Thank you for your cooperation. Ross McCulloh MS, ATC, LAT Head Athletic Trainer office/fax cell wrmcculloh@langston.edu DEADLINE FOR REGISTRATION PACKET RETURN IS AS FOLLOWS: Football and Volleyball: July 18 th All other Sports: August 4 th No Exceptions. Failure to return proper information prohibits your child from participating in Intercollegiate Athletics at Langston University

2 Langston University Athletic Pre-participation Registration Check List This check list is provided to the athletes, parents or guardians of all Langston University Student-Athletes. We hope this simplifies the registration process of your son/daughter for LU athletics. We want to provide the best possible medical care with the least amount of difficulty to you. This will be ensured if you carefully read the enclosed material, provide a complete and accurate medical history and insurance information. Please return the following necessary information at your earliest convenience. Your son/daughter will NOT be allowed to participate in LU athletics until these documents are on file in the Athletic Training Room. Langston University Medical Services Program Form. Athletes Primary Insurance Information Form. A Current Copy of your insurance card FRONT and BACK. Langston Medical Consent and Medical Care Statement Form. Langston University HIPAA release for medical records. Langston University Athletics Authorization Form. For uses and disclosures of patient protected Health information. Medical History Form: Please complete as accurately as possible. There is a medical UPDATE FORM for returning athletes only and a COMPREHENSIVE Medical Form for New Athletes. Please make sure you have completed the proper form. Langston University Athletic Department Drug Testing Consent Form. We only need a copy of the consent form on the last page of policy; the rest is for YOUR INFORMATION ONLY. Please direct further inquiries to: Ross McCulloh MS, ATC, LAT Head Athletic Trainer Langston University Office phone/fax Cell phone wrmcculloh@langston.edu

3 Langston University Athletics Medical Services Program -Signature Required- Please read the following information carefully, discuss these procedures with your studentathlete, sign your name at the bottom indicating that you have read these procedures, and return this form to: Langston University Athletics, Attn: Head Athletic Trainer, Langston University, P.O. Box 175 Langston, OK or Fax to The Medical Services Program is a self-contained program that uses a network of providers and specialists. In the event of an athletically related injury, our sports medicine staff evaluates and recommends a treatment plan. When services are pre-authorized, our program covers any expense with the LU network that the family s insurance does not cover (i.e., co-payments, and deductibles). Our program is secondary or excess support to the family s insurance, which means that the family s insurance is primary and will be billed in every circumstance. Outside services will be authorized at the discretion of the Director of Athletic Training, but are covered only if they are unavailable within the LU Network. Langston University Athletic Training staff makes every effort to create the safest environment possible for athletic participation, unfortunately, injuries do occur. As a result, Langston has purchased a secondary insurance policy for all student-athletes. Please note that our insurance policy only covers injuries sustained during supervised participation in intercollegiate athletics. It is mandatory that every athlete have primary insurance. Langston defines a primary insurance as insurance with no more than a $1000 deductible. (Sooner Care, Medicaid, All Military insurance including but not limited to, Champus/Tricare/Humana etc., and AFLAC are not considered primary insurance). Langston Athletics will cover only those injuries, which are a direct result of or will affect intercollegiate athletic practice or play. This means that non-athletically related injuries (car accidents, serious illness such as appendicitis or cardiac related illnesses) WILL NOT BE COVERED. Such injuries must be covered by other insurance. Also, Langston Athletics will not be responsible for the medical cost of previous injuries, regardless if they were or were not cared for properly, that were incurred before your child was enrolled at Langston University. Prescription medications are also not covered by Langston Athletics. If your child is injured and prescription medications are required, all incurred cost will be the sole responsibility of the student-athlete. If your child is injured while participating in intercollegiate athletic practice or play, the following procedures must be followed to ensure quick processing of the claim and prompt payment of all bills:

4 1) The student-athlete must report any and all injuries to the Langston Athletic Training Staff immediately. Medical expenses will only be covered if a member of Athletic Training Staff refers the athlete. Non-referred visits or expenses will not be covered by this policy and as such, will be considered the athlete s responsibility. 2) If you are a member of an HMO or PPO, you must provide us with authorized medical vendors from your list. If you choose not to use the plan s authorized medical vendors, be aware that our coverage will not pay the bills that otherwise would have been honored had you used the proper medical vendors. 3) During the course of the school year, should an athlete s insurance coverage change, the Athletic Training Department must be notified immediately. Failure to do so will terminate Langston s financial responsibility for any medical expenses incurred. 4) The student-athlete must provide the medical facility or specialist with all appropriate insurance information, which will be available in our office. 5) The LU Athletic Insurance will not process a claim until all primary insurance claim procedures have been completed. Failure to do this will result in your responsibility of unpaid bills. 6) All subsequent bills/explanation of Benefits (EOB) must be submitted to the Athletic Training Staff within 10 days from the time you receive them. If you fail to submit them during this time period, you will be responsible for the remaining balances. The Athletic Department does not receive copies of the bills. 7) Certifies that the answers given in the medical history questionnaire are correct and true. Any information intentionally withheld by the student-athlete or provided by the student-athlete and later found to be false will be grounds for dismissal from the athletic team and may result in any Langston insurance coverage for the student-athlete being voided. 8) If information is incomplete or inaccurate, the parents/identified policyholder or guardians will be responsible for bills incurred as a result of injury. I hereby certify that I have read and understand the above information and policies. Signature of Parent or Guardian (REQUIRED, regardless of age of student-athlete) Printed Name of Parent or Guardian Signature of Student-Athlete (REQUIRED) Printed Name of Student-Athlete Sport *We recommend that you make a photocopy of this signed document for your records.

5 Langston University Department of Athletics Athletes Primary Insurance Information Name of Student: Sport: SSN: : of Birth: M / D/ Y M / D / Y Father: Mother: Name: Name: SSN: SSN: Employed: Yes No Employed: Yes No Employer: Employer: Parent s Address: Parents Address: Street Street City State Zip City State Zip Home phone #: Home phone #: Work phone #: Work phone #: Cell phone #: Cell phone #: DO YOU HAVE GROUP ACCIDENT OR HOSPITAL INSURANCE TO COVER YOUR SON/DAUGHTER? Yes No PLEASE FILL IN THE FOLLOWING BLANKS IF YOUR SON/DAUGHTER IS COVERED UNDER A GROUP INSURANCE, IT IS VERY IMPORTANT THAT YOU COMPLETE ALL THE INFORMATION BELOW. *** Please include a copy of both sides of the insurance card. *** Insurance Company Name: Insurance Company claims address: Insurance Company phone #: Policy Holders Name: of Birth: Identification Number: Group #: Deductible: Effective of Policy: Do you have any pre-existing conditions that are excluded from this policy? If yes, Explain: Is this Military Insurance? Yes No Please check the correct response: Is this an HMO or PPO Does it require you to use a network provider? Yes No If yes, please provide following information. Primary Care Physician Name: Primary Care Physician phone #: I/WE AGREE THAT ALL INFORMATION PROVIDED IN THIS DOCUMENT IS ACCURATE AND COMPLETE TO THE BEST OF MY/OUR KNOWLEDGE. I/WE UNDERSTAND THAT ANY INCORRECT OR UNDISCLOSED INFORMATION MIGHT RESULT IN DUPLICATED PAYMENTS CREATING A SUBSTANTIAL OVERPAYMENT. THE RESPONSIBILITY OF SUCH OVERPAYMENT WILL BE THE OBLIGATION OF THE UNDERSIGNED TO REIMBURSE IN FULL, UPON REQUEST, AMOUNTS DEEMED REFUNDABLE. Signature of Mother/Guardian: : Signature of Father/Guardian: :

6 COPY OF INSURANCE CARDS FRONT BACK Please copy the Front and Back of your insurance card and affix it above

7 LANGSTON UNIVERSITY MEDICAL CONSENT I,, consent to medical treatment for athletic related injuries/ illness by the Langston University Sports Medicine Staff or Team Physician(s). I authorize treatment by such personnel in the event of any athletic related injury/illness. Signature of Student-Athlete Print Name of Student-Athlete Sport As a parent or legal guardian of, who is under the age of 18, I hereby authorize medical treatment of him/her in the event of an athletic related injury/illness by the Langston University Sports Medicine Staffer Team Physician(s). MEDICAL CARE STATEMENT: The undersigned, A. Understands that by participating in athletics, the potential of catastrophic injury to him/her exists. Following the rules and procedures set forth by coaches and using proper techniques may prevent catastrophic injury, but cannot be guaranteed to do so. B. Understands that any medical expenses incurred due to pre-existing conditions and not directly attributable to athletic participation at Langston University is their personal responsibility. C. Understands that the athlete must have primary insurance coverage and proof of insurance before he/she can participate in practice or intercollegiate play. Any falsification of insurance information will be grounds for dismissal from the team. Langston s athletic medical insurance is a secondary coverage, which will aid in the coverage of any remaining balance on an athletic related injury only. D. Understands that it is his/her responsibility to report all injuries/illnesses to an Athletic Trainer or Team Physician as soon as possible. E. Understands that he or she must refrain from practice while ill or injured, as per Athletic Trainer or Physician until he or she is discharged from treatment or is given permission to return to participation by the attending Athletic Trainer or Physician. F. Understands that having passed a physical examination does not necessarily mean that he or she is physically qualified to engage in athletics, but only the evaluator did not find a medical reason to disqualify him or her at the time of the examination. G. Certifies that the answers given in the medical history questionnaire are correct and true. Any information intentionally withheld by the student-athlete or provided by the student-athlete and later found to be false will be grounds for dismissal from the athletic team and may result in any Langston insurance coverage for the student-athlete being voided. Signature of Student-Athlete

8 HIPAA RELEASE FOR MEDICAL RECORDS As required by the Health Insurance Portability and Accountability Act (HIPAA) of 1996, all of your medical, insurance, and health information is protected. It cannot be shared without your permission. Situations may arise during your time at Langston University that require the medical staff to have access to your medical history, insurance information, or physicians notes. Because this information is protected you must release the information to a representative of the University. This form will serve as a release of that information. It will only be released to the person named and will not be shared with other athletic department personnel unless further permission is given. I hereby authorize any insurance company, healthcare provider or other party involved in my medical care to release my medical information to Langston University Athletic Training Department. I understand that this information will be used only to facilitate my care at Langston University and will not be released to any others without further authorization. Furthermore, I authorize Ross McCulloh or Sports Medicine Staff to speak with healthcare providers and insurance agents on my behalf. I understand that I may revoke this authorization at any time by submitting a written request to the office of the Athletic Trainer at Langston University. This authorization will expire 180 days after I am no longer a member of the institution or the athletic program unless there is prior revocation. Signature of student-athlete Signature of Parent/Guardian if under age of 18 The following release is necessary in order to allow the Athletic Training Staff to speak with coaches and administrators in the Athletic Department about your medical information. If you become injured during your time at Langston University, the Athletic Training Staff will need to discuss your participation status with these individuals. I hereby authorize members of the Athletic Training Staff to discuss my medical and health information with other members of the Athletic Department as it pertains to my athletic participation. I release this information to be discussed in order to help determine my level of participation in the athletic program at Langston University. I understand that this release allows the Athletic Training Staff to speak with sport coaches, strength coaches, and members of the Athletic Administration concerning my medical and injury information. I agree that this information will be presented in the form of an injury report and that these individuals will not have access to my personal records. Further, I agree that all members of the Athletic Training Staff may have access to my medical files kept by the Head Athletic Trainer, as it may be necessary to facilitate my care. Signature of Student-Athlete Signature of Parent/Guardian if under age 18

9 Langston University Athletics Authorization Form For Uses and Disclosures of Patient Protected Health Information Student-Athlete: Sport: Social Security Number: of Birth: I hereby authorize the Langston University Athletic Department to release my protected information. Protected health information may include: a. Injury or illness relevant to past, present, or future participation in intercollegiate athletics at Langston University; b. Information contained in my personal medical records unrelated to my participation in intercollegiate athletics at Langston University; c. Information concerning my medical status, medical condition, injuries, prognosis, diagnosis and other related personally identifiable health information, including but not limited to: Injury reports, test results, x-rays, progress, counseling reports, and any other documentation regarding my health status. Authorization is granted for release of my protected health information to: My parents/guardian and/or spouse for the purpose of assisting me in making healthcare decisions while I am a student-athlete. The coaches, assistant coaches, and other athletic staff so that they may make decisions regarding my athletic ability and suitability to compete while I am a studentathlete. My teammates so that they may be aware of limitations that I may be under while I am a student- athlete. Academic departments for the purpose of making decisions regarding my ability and suitability to perform academically while I am a student-athlete. The red river conference, central states football league, National Association of Intercollegiate Athletics for the purpose of making determinations regarding my eligibility status while I am a student-athlete. Applicable insurance providers for the purpose of processing insurance claims while I am a student-athlete. This authorization expires one year from the date of my signature below. The persons or entities that are authorized to receive the information above are not health care providers or health plans covered by federal health privacy laws; they may re-disclose the information and those laws would no longer protect the disclosed health information. Once you sign this authorization, we can rely on it until you revoke it or, if you have not revoked it, until it expires. Any revocation will not be effective as to information already disclosed in reliance on the authorization. You can revoke this authorization by delivering a dated and signed letter to the Director of Athletics. Printed Name of Student-Athlete Signature of Student-Athlete

10 Langston University Athletic Department Medical History : Sport: Athlete Name: Last First Middle S.S# - - D.O.B. / / Age Sex Marital Status Local Address (at school) Address: City: State: Zip: Phone # Cell: Parents Address (Please mark with an asterisk by which parent you reside with) Mother/Guardian: Address: City: State: Zip: Phone #: Cell: Work: Father/Guardian: Address: City: State: Zip: Phone #: Cell: Work: Allergies Are you Allergic to: Aspirin: Penicillin: Codeine: Sulfa: Hay Fever: Yes No Yes No Insect Bites/Stings: Anti-Inflammatory: Iodine Topical: Iodine Injectable: Other Allergies: Please check Yes or No for each question and explain yes. Are you currently being seen by a physician for a medical problem? Have you ever been diagnosed with a medical condition such as diabetes, or sickle cell? Have you been hospitalized overnight in the past year? Have you had surgery in the past year? Have you had any history of surgery? (Excluding Wisdom Teeth) Are you currently taking any prescription or non-prescription (over-the-counter) medication or pills or using an inhaler? Vitamins? Supplements? Do you frequently pass out or become dizzy during or after exercise? Do you have a known cardiac (heart) condition? If yes has a physician ever denied or restricted your participation in sports? Have you ever had chest pain during or after exercise? Do you get tired more quickly than your friends do during exercise? Yes No

11 Have you had high blood pressure or high cholesterol? Have you ever been told you have a heart murmur? Has any family member or relative died of heart problems before age 50? Has any family member been diagnosed with an enlarged heart, hypertrophic Cardiomyopaty, long QT syndrome, Marfan s Syndrome, or abnormal heart rhythm? Have you had a severe viral infection (for example, myocarditis or mononucleosis) Within the last month? Has a physician ever denied or restricted your participation in sports? Do you have any current skin problems (for example: itching, rashes, acne, warts, fungus, or blisters)? Have you ever had a head injury or concussion? Have you ever been knocked out, become unconscious, or lost your memory? If yes, how many times? When was the last concussion? 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? Have you ever had a stinger, burner, or pinched nerve? Have you ever become ill from exercising in the heat? Have you ever gotten unexpectedly short of breath during exercise? Do you cough, wheeze, or have trouble breathing during or after activity? Do you have asthma? Do you have seasonal allergies that require medical treatment? Have you had any problems with your eyes or vision? (Excluding Glasses or contacts)? Are you missing any paired organs? Yes No EATING DISORDERS Have you ever had a problem with food bingeing? If yes, when? Has it ever been suggested or have you ever been diagnosed as being anorexic? If yes, when? Have you ever been diagnosed as bulimic or having bulimia? If yes, when? Do you sometimes or often induce vomiting after eating? Have you or do you take laxatives to prevent being overweight? Have you ever had a sprain, strain, or swelling after injury? (Check all that apply) Head Elbow Hip Neck Forearm Thigh Back Wrist Foot Knee Chest Hand shin/calf Shoulder Finger Ankle Upper arm Have you broken or fractured any bones or dislocated any joints? (Check all that apply) Head Elbow Hip Neck Forearm Thigh Back Wrist Foot Knee Chest Hand shin/calf Shoulder Finger Ankle Upper arm

12 FEMALES ONLY When was your first menstrual period? When was your most recent menstrual period? How much time do you usually have from the start of one period to the start of another? How many periods have you had in the last year? Do you take birth control pills or hormones? Do you have frequent urinary tract infections? Have you ever had an abnormal pap smear? Any past pregnancies? Births? If any yes answers please make comments: All statements and answers in the above medical history questionnaire are true and complete to the best of my knowledge. I have no abnormality, limitation or restriction not mentioned in this record. I understand that this information is to help determine my fitness to participate in athletics, and to aid in the treatment and diagnosis of future injuries/illnesses that I may incur. DATE: Printed Name of Student-Athlete: DATE: Signature of Student-Athlete: STOP HERE! Please do not complete anymore. The remainder of this form is for the Langston Sports Medicine Staff to complete. (Unless you will have your physical done before you come on campus, the next (2) forms are for your physician.)

13 HEALTH EXAMINATION FORM (To be completed by the examining physician) Vital Information: Height: Weight: Blood Pressure: / Pulse: Vision: Right 20/ Left 20/ Corrected- YES NO Physical Exam: Head & Neck Skin Eyes Ears Nose Mouth/Throat Lymph Nodes Cardio Pulmonary Heart/Cardiovascular Pulmonary/Lungs GI/GU Abdomen/Gastrointestinal Genitalia (Hernia/Vesicles) NORMAL ABNORMAL FINDINGS Recommendations/Comments: Status: Pass Without Restrictions Pass With Restrictions: Further Evaluations Needed - Appt. with: Appt. : Request for Medical Information Signatgure of Examiner Printed Name of Examiner

14 Physical Exam: ORTHOPEDIC EXAMINATION FORM (To be completed by the examining physician) Ankle Left Right Wrist Left Right Back Scoliosis Muscle Flexibility Hamstring Quadriceps Knee Stability Left Right Shoulder ROM Left Right Shoulder Strength Left Right G-H Stability Left Right NORMAL ABNORMAL FINDINGS Comments: Status: Pass Without Restrictions Pass With Restrictions Further Evaluations Needed - Appt. With: Appt. : Athletic Trainer Follow-Up Signature of Examiner Printed Name of Examiner

15 Langston University Drug Testing Consent Form For and in consideration of my being permitted to participate in varsity athletics at Langston University, I hereby agree to abide by the drug-testing program that has been set forth in the Langston University Athletic Department Drug Testing Policy. By signing this form, I affirm that I am aware of the Langston University Athletic Department Drug Testing Policy, which provides in part that: 1. A student-athlete who tests positive on the drug screen test must attend mandatory counseling sessions after the first positive test. Additionally, he or she will be subject to subsequent drug tests, the student s parents/guardian will be notified of the positive test, and there will be discipline of the student-athlete directed by the head coach. There are more severe penalties for subsequent positive drug tests. 2. The penalty for missing a drug test is the same as the penalty for testing positive, unless there are extenuating circumstances. 3. I agree to allow Langston University s Athletic Department to drug test me in relation to my participation in intercollegiate athletics sanctioned by Langston University. Also, I understand that the University s Athletic Department can request a drug screen on me at any time when there is reasonable suspicion. 4. I understand that this consent and the results of my drug tests may be disclosed to my parents, the Athletic Director, the Head Coach, faculty athletic representative, my treating physician and Langston University Sports Medicine Staff. 5. I agree that the Langston University Counseling Center may discuss my drug counseling with the Athletic Director, the Head Coach, faculty athletic representative, my treating physician, and Langston University Sports Medicine Staff. 6. I voluntarily agree to follow all of the criteria outlined in the Langston University Athletic Department Drug Testing Policy. I specifically consent to have my urine collected and tested for the substances pursuant to this policy and I authorize the Langston University Athletic Department and/or the counselor to notify and discuss the results of my drug(s) with my parents or guardian. Signature of Student-Athlete Signature of Parent/Guardian (if student-athlete is under age of 18) Printed Name of Student-Athlete of birth Intercollegiate sport(s) participating in