Return sports medicine paperwork ASAP. It is due August 1.

Transcription

1 Return sports medicine paperwork ASAP. It is due August 1. Do not give this packet to anyone else on campus except someone in ATHLETICS or SPORTS MEDICINE. You are responsible for ensuring your packet gets to us. A Helpful Did you... Checklist Do not send the packet the week of camp! Bring it with you to ensure its arrival on time. All paperwork must be completed in full in order to practice! make copies of all documents in this packet in case something is misplaced? have your child sign/initial/date all forms? include an ENLARGED front and back copy of your insurance cards? make sure the Physician include his signature/date/stamp on the physical form? fill out the Asthma/ADHD forms if your child takes medication? Found on Athlete Forms website acquire documentation on the status of sickle cell trait? Or signed the waiver? First years/ transfer students ONLY include a Physician s release for significant illness within the past year? include a Physician s release for an injury that occurred within the past year requiring an office visit? PT, surgery too have your child complete the online sports medicine presentation (located in Moodle) and take the quiz? They will not be allowed to participate without having completed it. Students MUST have visited campus and set their online accounts up to access Moodle.

2 EMERGENCY INFORMATION CARDS Name Sport D.O.B. Cell Phone Parents/Guardian Names Home Address City St Zip Emergency Contact Names & Cell Phone #s Mom Dad Other Insurance Name Phone Group # Policy # Augustana Insurance Yes No Important health issues (asthma, allergies etc) Return Sports Medicine Packet to: Augustana College Sports Medicine th St Rock Island, IL 61201

3 Greetings from the Augustana Athletic Training Staff! DO NOT GIVE ANY PORTION OF THIS PAPERWORK TO ANYONE ELSE ON CAMPUS! Only give it only to someone who works in Sports Medicine or Athletics. NO ONE ELSE! It will get lost. A few required items that MUST be completed before your son or daughter will be allowed to participate in NCAA athletics at Augustana College: 1. Complete the Sports Medicine paperwork in BLACK/BLUE ink only and make a copy of entire packet to keep in case it gets misplaced. Print & fill out ALL paperwork completely & mail it ASAP to Augustana Sports Medicine th St, Rock Island, IL DO NOT GIVE ANY PORTION OF THIS PAPERWORK TO ANYONE ELSE ON CAMPUS! Only someone who works in Sports Medicine or Athletics! Please make a copy of the completed packet in case it gets lost in the mail. Only first year/transfer student-athletes will receive a return envelope in early June. 2. ALL student athletes are required to have a yearly physical examination. The exam form is located in the online sports med packet & also requires taking the health questionnaire with them to the office visit. If your student-athlete does not return a completed physical form prior to the beginning of practice they will not be allowed to participate. The student-athlete will then be responsible for scheduling & payment of a physical exam either from an area physician or a physician of your choice. Only physicals performed by MD, DO, PA or nurse practitioners (NP) will be accepted. Physicals from chiropractors will not be accepted. 3. Sickle cell trait status documentation is ONLY required for first year/transfer student athletes. Student-athletes (regardless of ethnic background) must provide sickle cell trait test results or sign the waiver before they may be medically cleared to participate (includes practices, games/matches or races). These results are requested only once. Further information is provided in your first year/transfer sports med packets and also online. 4. All student-athletes are required to view the online Sports Medicine Presentation. The presentation/quiz is available at end of May for returning student athletes. First year/transfer student-athletes must have registered for classes & set up their accounts to access Moodle. The presentation will provide an overview of the policies & procedures of Augustana Sports Medicine & how it functions & how to seek assistance from the Sports Medicine Staff. Directions on how to access Moodle is located on the Athlete Forms on the Augustana Athletics page. Augustana College Department of Athletics th Street Rock Island, Illinois Telephone

4 INSURANCE COVERAGE--CLAIM PROCEDURE NOTE: KEEP THIS FOR EASY REFERENCE ABOUT INSURANCE Injuries may occur & we attempt to provide our student-athletes with the very best possible care. Referrals to a physician may be necessary after an injury & medical bills may incur, whether locally, on a road trip, or even at home with the family. Injuries that require physical therapy, as prescribed by a physician, may be treated at his/her home physical therapy setting or a physical therapy setting in our area (we have a clinic on campus through Genesis Health Systems if you so choose). But it is the responsibility of your child to discuss these options with you. We are unable to contact you regarding treatment due to healthcare laws. INSURANCE COVERAGE: Medical insurance is a requirement for participation in intercollegiate athletics. There are three options for insurance that may be used individually or in combination with each other. 1. Your PERSONAL FAMILY POLICY that you receive through your employment or through personal acquisition will always serve as your primary policy. In addition please make sure you attach a magnified front/back copy of your insurance cards. This will allow for ease in insurance processing. 2. The AUGUSTANA STUDENT ACCIDENT & SICKNESS INSURANCE PLAN is available through your son/daughter's tuition bill at a cost of $1693 per academic year. All students will receive additional policy information concerning the Student Accident and Sickness Insurance through Gallagher Student Health & Special Risk. Plan information is also available at If you decide to not carry this insurance, you must decline it by 9/6/17 online at the above web address. 3. The ATHLETIC ACCIDENT INSURANCE policy through Gallagher Student Health & Special Risk is provided for your son/daughter by Augustana College through their participation in intercollegiate sports at no cost to you. The $2500 deductible for this plan is the responsibility of the athlete. This deductible may be picked up by your personal family policy, the Augustana Student Accident & Sickness Plan or may be paid in cash out of your pocket. CLAIM PROCEDURE: How do I handle the bills? All medical bills for your son/daughter incurred as the result of an injury in intercollegiate sports should be sent to your personal family insurance provider first, as this is their primary insurance. To activate the Augustana Student Accident & Sickness Insurance Plan the athlete must show their student insurance id card to the medical vendor at their appointment. (Students participating in this plan will be able to download and print a copy of their id card from the insurance company shortly after arriving on campus). Many medical facilities will submit your bills directly to the insurance company(s). Please instruct your son/daughter to present the following information at the time of their appointment(s). Your family medical insurance card, & their Augustana Student Accident & Sickness card (if participating in this plan), & lastly the Athletic Accident Insurance information (card will be provided by the athletic trainers). Any bills sent to you or your child should be submitted to all insurance policy providers. Contact the Sports Medicine Department deniseyoder@augustana.edu or Tammy Sullivan in the Business Office (309) if you have further questions regarding unpaid bills. Retain this letter for future reference. In addition, we ask that you complete the online sports medicine forms IN DETAIL & return all paperwork to us prior to any athletic participation. Your cooperation in this important area will help insure your son/daughter will begin their upcoming sports season without delay Augustana College Department of Athletics th Street Rock Island, Illinois Telephone

5 BLACK/BLUE PEN ONLY Student-Athlete DOB Sport(s) Augie ID # Augustana Returners Health Questionnaire Circle one: So Jr Sr 5 th Answer all questions below: Include dates, surgery, medications and all relevant information below 1. Allergic to any medications 2. Suffer from environmental or food allergies which require medication 3. Require use of an Epi-pen for any allergies Provide the AT staff with name labeled on Epi-pen 4. Ever tested positive for the sickle cell anemia trait YES NO If not tested or did not release results, did you sign the waiver YES NO 5. Been hospitalized in the last 12 months 6. Had any major illnesses which needed to see a physician in the last 12 months 7. Do you have any NEW health problems diagnosed since your last physical 8.Taking medication for diabetes Circle one Type I or II LIST MEDS Provide AT staff with anything you will need 9. Had an injury since your last physical or in the last 12 months 10. New concussions this year 11. Visited a physician for injuries (includes concussion) 12. Have surgery within the last 12 months 13. Require physical therapy Y N Did you complete PT Y N 14. Suffer off season or summer injuries 15. Any problems now with injury or illness 16. Are you under a physician s care at the present time for anything 17. Within the last year, did you have changes to or begin taking NEW MEDICATIONS including: high blood pressure, birth control, allergies meds, supplements, dietary aids, vitamins or herbal remedies LIST * If you answer yes to questions 18 or 19 below, you will need to fill out an NCAA Medication Exception Form with your physician. (The form is located on the Augustana Athlete Forms website regarding ASTHMA or ADHD/ADD medications.) 18. Are you currently taking any medications to treat asthma/eia? PROVIDE EXTRA INHALER TO AT STAFF LABELED CLEARLY WITH YOUR NAME List. 19. Are you currently taking any medications to treat ADHD/ADD? List All injuries and/or illnesses which required a physician visit within the last year MUST have a medical release from treating physician. Please fax the clearance letter to By signing below I certify that the answers to the questions above are correct and true. Student Athlete Signature Sport(s) Date Physician Review Augustana AT review initials date initials date *Know that any incomplete questions will result in prolonged check in when arriving on campus. Include ALL dates, body parts or other relevant information* 17-18

6 AUGUSTANA COLLEGE PRE-PARTICIPATION PHYSICAL EVALUATION (Must be performed by a MD, DO, PA or NP only-we are unable to accept chiropractic physicals) Athletic Name Sport Circle one: So Jr Sr 5 th DOB Height Weight Vision (R) (L) Hearing B/P (R) (L) Pulse Temperature MEDICAL OK Abnormal Findings Ears ( ) Nose ( ) Throat ( ) Lungs ( ) Heart ( ) Lymph Nodes ( ) Eyes ( ) Skin ( ) Abdomen ( ) Genitourinary ( ) Hernia ( ) BONE/JOINT OK Abnormal Findings Head ( ) Neck ( ) Spine ( ) Shoulder/Arm ( ) Elbow/Forearm( ) Wrist/Hand ( ) Hip/Thigh ( ) Knee ( ) Leg/Ankle ( ) Foot ( ) Reflexes ( ) *A PHYSICAL WILL BE ACCEPTED- ONLY IF ALL TESTS ARE COMPLETED* Current Medications: Allergies to Medications or Other: Comments/Recommendations: I certify that I have reviewed the history and examined the above student and I recommend: Clearance with no limitations COMMENTS: Clearance pending further evaluation or testing. Referral to other health care professional prior to clearance. Disqualified from competition. Physician's Name (print): Phone: Address: (Street) (City) (State) (Zip) Practitioner s Signature MD / DO / NP / PA Office Stamp Below (if available) Date: physical completed

7 Augustana College Student Athlete Authorization/Consent For Disclosure of Protected Health Information (PHI) I,, hereby authorize Augustana College and its physician affiliates, athletic (student athlete) and other health care personnel to disclose my protected health information and any related information regarding any injury or illness during my training for and participation in intercollegiate athletics to the following: Your initials below indicate your agreement to the release of your (PHI) in each category: Initials My Personal Medical Insurance: For the use of electronic transmission, US post mail, or facsimile involving billing, reimbursement, benefits eligibility and plan-eligibility issues. Authorization is required to participate in athletics at Augustana College. Initials I hereby authorize Augustana Sports Medicine to release information pertaining to a concussion sustained whether related or unrelated to athletic participation. The following campus personnel may be informed including Dean of Students, Dean of Academics, Learning Commons, Communication Sciences, current professors and coaching staff. I understand the information will be distributed by the Medical Liaison s office via and Starfish then used to create reasonable temporary academic accommodations for your classes. Authorization is required to participate in athletics at Augustana College. Initials Parents/Guardian: Should the parents/guardian inquire as to the extent of an injury or illness, you are allowing Augustana College athletics representatives to discuss your condition. Initials I also allow any treating physicians or other medical facilities to disclose my medical records to Augustana College Sports Medicine for purposes of continued quality of care during my athletic participation at institution. Fax to: I understand that my injury/illness information is protected by federal regulations under either the Health Information Portability and Accountability Act (HIPAA) or the Family Educational Rights and Privacy Act (FERPA) of 1974 (the Buckley Amendment) and may not be disclosed without either my authorization under HIPAA or my consent under the Buckley Amendment. This authorization/consent expires 380 days from the date of my signature below, but I have the right to revoke it in writing at any time by sending written notification to the athletic director at my institution. I understand that a revocation is not effective to the extent action has already been taken in reliance on this authorization/consent. Printed Name of Student Athlete Signature Date Sport 17-18

8 Parent/Guardian/Student Insurance Information Form This form must be completed & in blue or black pen in order to participate in Augustana Athletics. Name of Athlete Sport Date of Birth Cell Phone Home Phone Home Address City St Zip YOU MUST ANSWER THIS QUESTION: Have you purchased the Augustana Student Accident & Sickness Insurance Plan for the current school year? Yes No This charge appears on your fall term tuition statement. To waive/refuse the coverage you must submit a Petition to Waive on-line at prior to the September 6, 2017 deadline. Primary Insurance Information Circle one: Father / Mother / Guardian Name Phone ( ) Date of Birth Address City/ST/Zip Employer Address City/ST/Zip Phone ( ) Secondary Insurance Information Circle one: Father / Mother / Guardian Name Phone ( ) Date of Birth Address City/ST/Zip Employer Address City/ST/Zip Phone ( ) Insurance Company: Address City/St/Zip Policy # Group # Phone ( ) Insurance Company: Address City/St/Zip Policy # Group # Phone ( ) Please attach an enlarged front & back copy of ALL insurance cards to aid in the claims process. NOT UNDER YOUR PARENTS INSURANCE? Please include your personal insurance policy (includes Augie) information below. Insurance Company: Policy # Address Group # City/St/Zip Phone ( )

9 MEMORANDUM To: From: Athletic Program Participants Mike Zapolski, Athletic Director Date: May 8, 2017 RE: Insurance Coverage It is recommended that all students obtain the coverage provided under the Augustana Student Accident and Sickness Insurance Plan unless the student or parent is carrying equivalent protection. The Student Accident and Sickness Insurance Plan provides coverage 24-hours a day, within the plan s limits, for sickness and accidents. The cost for this coverage is $1,693 per plan year and is fully compliant with the provisions of the Affordable Care Act (ACA). (This charge appears on your fall term tuition statement. To waive/refuse the coverage you must submit a Petition to Waive on-line at prior to the September 6, 2017 deadline.) Intercollegiate sport injuries resulting in expenses over $2,500 during the 2017/18 plan year are covered, within the plan limits, under a master athletic insurance contract sponsored by Augustana College. The deductible is $2,500 for the 2017/18 plan year. (This is separate from the Student Accident and Sickness Insurance Plan you are offered.) Please sign the lower portion of this sheet in the space indicated and return it to your coach prior to participation in the athletic program you plan to participate in. (Signing this form does NOT enroll you in the Student Accident and Sickness Insurance Plan. It merely confirms that you understand your options.) I understand that payment for intercollegiate sports injuries is provided up to $2,500 for each Injury under the Augustana Student Accident and Sickness Insurance Plan. The cost for this optional plan is $1,693 per academic year and is offered to me on my fall term tuition statement. I further understand, should I choose not to participate in the plan, that it is my own responsibility (under equivalent or similar protection) to pay for all expenses up to $2,500 for each injury incurred while participating in intercollegiate sports. SIGNATURE (required prior to participation) PRINTED NAME DATE SPORT(S)