Athletic Training Emergency Contact and Insurance Information Incomplete Forms Will Not Be Accepted

Transcription

1 Athletic Training Emergency Contact and Insurance Information Incomplete Forms Will Not Be Accepted Athlete Name ID #: Sport (s): HOME City State Zip Code Cell Phone ( ) Date of Birth: Local (if different than Home) City State Zip Code Allergies: Medications: Pertinent Medical History: (concussions, recent surgery, Asthma, Diabetes, heart murmur, other medical conditions, etc.) PERSONS TO NOTIFY IN CASE OF EMERGENCY (Parent/ Guardian or Relative): Parent/Guardian Relationship: : City, State, Zip Code: Phone Alternate Phone Parent/Guardian Relationship: : City, State, Zip Code : Phone Alternate Phone INSURANCE INFORMATION Please provide a copy of the front and back of the insurance card Policy Holder s Name (Name on Insurance Card) Policy Holder s Date of Birth: Relationship to Student Athlete: Insurance Company Phone Number ( ) Insurance Company Name Type (circle) HMO PPO Other Policy/ID # Group # IF YOU HAVE NO INSURANCE COVERAGE I have no medical coverage, either on my own or through my parents. I understand that this information may be verified. Date Signature of Student-Athlete Signature of Parent / Guardian AUTHORIZATION TO PROVIDE CARE AND TREATMENT I do hereby authorize the entire athletic medical staff, including athletic trainers, physicians, nurses, and coaches to provide care and treatment, including emergency transport to the hospital or nearest medical facility. The authorization applies to the Morton College staff as well as the staff at away events. I do hereby authorize the physicians at the nearest medical facility to perform procedures that may be necessary for the emergency diagnosis and treatment in the event that I am unable to provide verbal consent until my emergency contacts listed can be contacted. Date Signature of Student-Athlete Signature of Parent / Guardian of Minor AUTHORIZATION TO RELEASE MEDICAL INFORMATION I do hereby authorize any insurance company, hospital, physician, or other person who has attended or examined the claimant to disclose, when requested to do so, all information with respect to any injury, policy coverage, medical history, consultation, prescription, or treatment, and copies of all hospital medical records to the Morton Athletic Training Staff. A photocopy of this authorization shall be considered as valid as the original. This Authorization is valid for one year from the date below. Date Signature of Student-Athlete Signature of Parent / Guardian of Minor

2 Morton College Preparticipation Physical Evaluation Form Sport(s) (circle): Cross Country Men s Basketball Volleyball Women s Basketball Date of Birth (MM/DD/YY): Men s Soccer Baseball Women s Soccer Softball Medicines and Allergies: Please list all of the prescription and over-the counter medicines and supplements (herbal and nutritional) that you are currently taking Do you have allergies? Yes No If yes, please identify specific allergy below Medicines Pollens Food Stinging Insects Explain Yes answers below. Circle questions you don t know the answer to. GENERAL QUESTIONS YES NO MEDICAL QUESTIONS YES NO Has a doctor ever denied or restricted your participation in sports for any Do you cough, wheeze, or have difficulty breathing during or after reason? exercise? Do you have any ongoing medical conditions? If so, please identify below: Have you ever used an inhaler or taken asthma medicine? Asthma Anemia Diabetes Infections Is there anyone in your family who has asthma? Other: Were you born without or are you missing a kidney, an eye, a testicle (males), your spleen, or any other organ? Have you ever spent a night in the hospital? Do you have groin pain or a painful bulge or hernia in the groin area? Have you ever had surgery? Have you had infectious mononucleosis (mono) within the last month? HEART HEALTH QUESTIONS ABOUT YOU YES NO Do you have any rashes, pressure sores, or other skin problems? Have you ever passed out or nearly passed out DURING or AFTER exercise? Have you had herpes or MRSA skin infection? Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise? Have you ever had a head injury or concussion? Does your heart ever race or skip beats (irregular beats) during exercise? Have you ever had a hit or blow to the head that caused confusion, prolonged headache, or memory problems? Has a doctor ever told you that you have any heart problems? If so, check all that apply: Do you have a history of seizure disorder? High blood pressure High cholesterol Kawasaki disease A heart murmur A heart infection Other: Do you have headaches with exercise? Has a doctor ever ordered a test for your heart? (For example, ECG/EKG, echocardiogram) Have you ever had numbness, tingling, or weakness in your arms or legs after being hit or falling? Do you get lightheaded or feel more short of breath than expected during exercise? Have you ever had an unexplained seizure? Have you ever been unable to move your arms or legs after being hit or falling? Have you ever become ill while exercising in the heat? Do you get more tired or short breath more quickly than your friends during exercise? Do you get frequent muscle cramps when exercising? HEART HEALTH QUESTIONS ABOUT YOUR FAMILY YES NO Do you or someone in your family have sickle cell trait or disease? Has any family member or relative died of heart problems or had an unexpected or unexplained sudden death before age 50 (including Have you had any problems with your eyes or vision? drowning, unexplained car accident, or sudden infant death syndrome)? Does anyone in your family have hypertrophic cardiomyopathy, Marfan syndrome, arrhythmogenic right ventricular cardiomyopathy, long QT syndrome, short QT syndrome, Brugada syndrome, or catecholaminergic Have you had an eye injuries? polymorphic ventricular tachycardia? Does anyone in your family have a heart problem, pacemaker, or implanted defibrillator? Do you wear glasses or contacts? Has anyone in your family had unexplained fainting, unexplained seizures, or near drowning? Do you wear protective eyewear, such as goggles or a face shield? BONE AND JOINT QUESTIONS YES NO Do you worry about your weight? Have you ever had an injury to a bone, muscle, ligament, or tendon that caused your to miss a practice or game? Have you ever had any broken or fractured bones or dislocated joints? Have you ever had an injury that required x-rays, MRI, CT scan, injections, therapy, a brace, a cast, or crutches Have you ever had a stress fracture? Have you ever been told that you have or have you had an x-ray for neck instability or atlantoaxial instability? (Down syndrome or dwarfism) Do you regularly use a brace, orthotics, or other assistive devices? Do you have a bone, muscle, or joint injury that bothers you? Do any of your joints become painful, swollen, feel warm, or look red? Do you have any history of juvenile arthritis or connective tissue disease? Explain yes answers here: Are you trying to or has anyone recommended that you gain or lose weight? Are you on a special diet or do you avoid certain types of foods? Have you ever had an eating disorder? Do you have any concerns that you would like to discuss with a doctor? FEMALES ONLY YES NO Have you ever had a menstrual period? How old were you when you had your first menstrual period? How many periods have you had in the last 12 month? I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct. Signature of student-athlete: Date:

3 Morton College Preparticipation Physical Evaluation Form Date of Birth (MM/DD/YY): EXAMINATION Height: Weight: Male Female BP / ( / ) Pulse: Vision: R20/ L20/ Corrected: Y N MEDICAL NORMAL ABNORMAL FINDINGS Appearance Marfan stigmata (kyphoscoliosis, high-arched palate, pectus excavatum, arachnodactyly, arm span > height, hyperlaxity, myopia, MVP, aortic insufficiency) Eyes/ears/nose/throat Pupils equal Hearing Lymph nodes Heart a Murmurs (auscultation standing, supine, +/- Valsalva) Location of point of maximal impulse (PMI) Pulse Simultaneous femoral and radial pulses Lungs Abdomen Genitourinary (males only) b Skin HSV, lesions suggestive of MRSA, tinea corporis Neurologic c MUSCULOSKELETAL Neck Back Shoulder/arm Elbow/forearm Wrist/hand/fingers Hip/thigh Knee Leg/ankle Foot/toes Functional Duck-walk, single leg hop a Consider ECG, echocardiogram, and referral to cardiology for abnormal cardiac history or exam. b Consider GU exam if in private setting. Having third party present is recommended. c Consider cognitive evaluation or baseline neuropsychiatric testing if a history of significant concussion. Based on my examination on this date, the athlete is cleared without restrictions for all sports: Recommendations: Yes Recommend further treatment or evaluation (see below) Limited Participation (see below) No Pending further treatment/evaluation (see below) Not Cleared for any Sports (see below Physician Signature: Date: Doctor Office / Clinic Stamp:

4 First Agency, Inc West H Avenue Kalamazoo, MI PARENT/ GUARDIAN/STUDENT INFORMATION FORM RETURN FORM WHEN COMPLETE TO Name of College/University Attention This form is to be completed by the Parents, Guardians or Student. City State 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 Social Security No. or Passport No. Date of Birth Please note that the Injured Person s Social Security Number MUST be provided as required by the Center for Medicare Services pursuant to Section 111 of the Medicare, Medicaid and SCHIP Extension Act of College College Phone ( ) Home Home Phone ( ) City State Zip FATHER /GUARDIAN INFORMATION MOTHER /GUARDIAN INFORMATION Father s Name Social Security No. Date of Birth Mother s Name Social Security No. Date of Birth Employer Employer Medical Insurance Company or Plan Medical Insurance Company or Plan Policy Number Policy Number Is this plan an HMO or PPO? Yes No Is pre-authorization required to obtain treatment? Yes No Is a second opinion required before surgery? Yes No Is this plan an HMO or PPO? Yes No Is pre-authorization required to obtain treatment? Yes No Is a second opinion required before surgery? Yes No PLEASE COMPLETE AUTHORIZATION ON REVERSE SIDE OF THIS FORM Berkley OS /10

5 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 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 or Next of Kin Date Relationship of Authorized Representative or Next of Kin to Claimant

6 Athletic Injury Waiver and Insurance Claims Policy *This form must be signed by all Student-Athletes* Morton College ( Morton ) fields several intercollegiate athletic teams that are available to all eligible student-athletes. When voluntarily participating in athletics/athletic travel (the Program ) at Morton, student-athletes understand that there are inherent risks and hazards. Injuries incurred could be severe, including but not limited to fracture, paralysis or even death. Morton takes the health and safety of our student-athletes very seriously; the health, welfare and safety of our studentathletes is of top priority. I, acknowledge that I will engage in activities that involve risk or serious injury Student-Athlete s Name including permanent disability and death, which might not only result from my actions, inactions or negligence, but the action, inactions, or negligence of others, the rules of play, the conditions of the premises, or any equipment used. I assume and accept all the foregoing risks associated with my participation in Morton s Program. For and in consideration of myself taking part in Morton s Program, I, for myself and my respective personal representatives, heirs, administers, assigns, and next of kin, hereby release, waive, discharge, and covenant not to sue Morton, its officers, trustees, employees, agents, advisors, administrators, representatives, heirs or assigns (hereinafter referred to as Released Parties ) of and from any and all claims, losses, demands, liabilities, penalties, liens, encumbrances, obligations, causes of action, costs and expenses (including reasonable attorneys fees and court costs) suits and damages (whether actual or punitive) on account of any injury to myself or my property, including death, that may be caused by the negligence of the Released Parties, or otherwise, while I am involved in Morton s Program, or that occurred or is alleged to have occurred, in whole or in part, in connection with Morton s Program, or my use of Morton s facilities, equipment, or property. I am encouraged to have Personal Primary medical insurance coverage. If I do not have personal primary medical insurance coverage, all injury claims incurred during official Morton College athletic participation will fall under Morton College s Excess/Secondary Insurance Policy. I am responsible for immediately reporting all injuries sustained as a direct result of Morton College athletic participation to the Head Coach or Athletic Trainer. I will confirm that an injury/accident report has been filed by the Head Coach or Athletic Trainer to the Morton College Athletic Department and Morton College Business Office in order to justify any future medical payments that may need to be considered for payment by Morton College s Excess/Secondary Insurance Policy. - Student-athletes are required to have a physical examination prior to participation in any practice, scrimmage or official game at Morton College. - If a student-athlete has Personal Primary medical insurance coverage, all medical claims must first be submitted to that policy. - Morton College s Excess/Secondary Insurance Policy does not cover off season workouts, open gyms, or any other injury incurred in the offseason. - Morton College s Excess/Secondary Insurance Policy does not cover expenses related to illnesses or conditions not sustained as a direct result of participation in Morton College athletics - Morton College s Excess/Secondary Insurance Policy does not cover non-athletic injuries. - Student-athletes who DO NOT turn in the insurance form will not be allowed to submit injury bills to be covered by Morton College s Excess/Secondary Insurance Policy I acknowledge that I am able to speak and read English and that I have carefully read the contents of this waiver or have had this wavier translated and understand the translation. I further acknowledge that I am competent, over eighteen years of age, and have authority to enter into this waiver and that I have not been given any promise or inducement to sign this waiver. I further acknowledge that I have signed this waiver on my own free and voluntary act. I have read the foregoing Waiver and Insurance Claims Policy and fully understand the terms contained herein. Student-Athlete Student-Athlete Signature: Date of Birth: Today s Date: Name of primary insurance holder: Signature of primary insurance holder: Relationship: Today s Date:

7 CIRCLE SPORT(S) OF PARTICIPATION CROSS COUNTRY MEN S SOCCER WOMEN S SOCCER VOLLEYBALL MEN S BASKETBALL WOMEN S BASKETBALL BASEBALL SOFTBALL PERSONAL INFORMATION [PRINT CLEARLY] NAME: MC ID#: 0 ADDRESS: DOB: / / CITY: STATE: ZIP CODE: CELL PHONE: MOTHER/ GUARDIAN NAME: FATHER/ GUARDIAN NAME: CELL PHONE: - - CELL PHONE: - - EDUCATIONAL HISTORY: HIGH SCHOOL NAME: GRADUATION DATE (MM/YYYY): 1. HAVE YOU EVER SIGNED A NJCAA LETTER OF INTENT WITH ANY INSTITUTION OTHER THAN MORTON COLLEGE? YES NO IF YES, FROM WHAT COLLEGE(S): 2. HAVE YOU EVER PLAYED ON A COLLEGE OR UNIVERSITY TEAM? YES NO IF YES, LIST THE SPORT(S) AND COLLEGE(S): LIST PREVIOUS COLLEGE(S) ATTENDED DATES: FROM TO FULL-TIME OR PART-TIME DATES: FROM TO FULL-TIME OR PART-TIME DATES: FROM TO FULL-TIME OR PART-TIME IF YOU DID NOT ENROLL IN COLLEGE AFTER HIGH SCHOOL, LIST WHAT YOU DID (WORK, UNEMPLOYED, MILITARY, ETC.) DATES: FROM DATES: FROM TO TO I UNDERSTAND THAT INFORMATION FALSIFIED OR OMITTED CAN MAKE ME INELIGIBLE FOR COLLEGE COMPETITION. STUDENT-ATHLETE SIGNATURE: DATE: