ATHLETE DEMOGRAPHIC INFORMATION

Transcription

1 Please Print Clearly! ATHLETE DEMOGRAPHIC INFORMATION NAME: LAST FIRST MIDDLE SPORT SOCIAL SECURITY/ID#: BIRTHDATE (MM/DD/YYYY): / / ALLERGIES: LOCAL ADDRESS: CITY: STATE: ZIP CODE: LOCAL PHONE #: CELL PHONE #: PERMANENT ADDRESS: PERMANENT PHONE #: CITY: STATE: ZIP CODE: BANNER ID #: AUBURN EMERGENCY CONTACT (IN USA): NAME: RELATIONSHIP: ADDRESS: CITY: STATE: ZIP CODE: HOME PHONE #: WORK PHONE #: CELL PHONE #: FATHER/GUARDIAN: SOCIAL SECURITY/ID#: BIRTHDATE (MM/DD/YYYY): / / ADDRESS: CITY: STATE: ZIP CODE: HOME PHONE #: WORK PHONE #: CELL PHONE #: MOTHER/GUARDIAN: SOCIAL SECURITY/ID#: BIRTHDATE (MM/DD/YYYY): / / ADDRESS: CITY: STATE: ZIP CODE: HOME PHONE #: WORK PHONE #: CELL PHONE #:

2 MEDICAL RELEASE TO: All Universities, Colleges, High Schools, Physicians, Athletic Trainers, Registered Dietician, Hospitals, Clinics, Dispensaries, Sanatoriums and all other agencies. FROM: Auburn University Sports Medicine Department Office of the Team Physician 349 S. Donahue Drive Auburn, AL Phone: Fax: RE: (Student-Athlete) SOCIAL SECURITY/ID #: BIRTHDATE: You are hereby authorized and requested to send Auburn University Sports Medicine Department: Attention Michael Goodlett, MD, a complete copy of all your records pertaining to my medical condition, including all physicals, athletic trainer s records, any diagnosis, treatment, history, prognosis of any and all injuries together with all other information pertaining to my past or present medical condition, diagnosis, treatment, history, prognosis, from your personal knowledge and/or records. A copy of this authorization shall be considered as effective and valid as the original. Student-Athlete Signature Witness Signature

3 INSURANCE INFORMATION Dear Parent or Guardian: I hope this letter finds you well as the end of the school year and summer are approaching. We are pleased to have your son/daughter as a student athlete in our Auburn University Athletic Program and want to take care of your child as best as possible while he/she is here at Auburn. Our insurance policy states that any athletic medical claim will be billed to the parents insurance as a primary provider (per NCAA compliance) with Auburn University Athletics as a secondary provider. Auburn University s Athletic Insurance will take effect as secondary and pay any remaining balances that are not covered, partially paid, denied or applied to your deductible for athletic sustained injuries/illnesses. If an athletic claim is filed through your insurance, like all claims, you will receive a Statement of Billing. This is for your records. If you or your son/daughter receive any type of billing or check from your insurance company for medical services originating from your son/daughter s participation at Auburn University, you should forward these bills/checks to: Joe-Joe Petrone, ATC Auburn University Sports Medicine Department PO Box 351 Auburn, AL (334) OFFICE (334) FAX jap0017@auburn.edu To assist us in providing medical coverage for your son/daughter, please fill out and return the accompanying forms. If you do not have insurance, or your insurance does not cover your son/daughter, please fill out and sign the form accordingly. All non-scholarship athletes MUST have a 12 month healthcare insurance policy that covers athletic injuries (such as Cigna, Aetna, BCBS, Tricare, etc). This cannot be a life insurance policy. If your insurance does cover your son/daughter, please complete the form and return with a copy of the front and back of your insurance card(s) and a copy of the photo ID of the policy holder as well as photo ID of your son/daughter. If you have any questions about this please feel free to call. Thank you for your cooperation in this matter. Sincerely, Joe-Joe Petrone, MS, ATC/L Director of Sports Medicine (334)

4 ATHLETE INSURANCE INFORMATION Please Print Clearly! DATE: If you have any questions regarding this form contact: Karen Straub-Stanton, MS, ATC Auburn University Sports Medicine 349 S. Donahue Fax #: (334) Auburn, AL Phone #: (334) ATHLETE: SOCIAL SECURITY/ID #: BIRTHDATE (MM/DD/YYYY) SPORT: BANNER ID #: PRIMARY MEDICAL INSURANCE INSURANCE COMPANY NAME: INSURANCE CO CLAIMS ADDRESS: CITY: STATE: ZIP: PHONE: POLICY/ID #: GROUP #: EFFECTIVE DATE: HMO: PPO: TRICARE/CHAMPUS OTHER POLICY EXEMPTIONS or REQUIREMENTS: PRECERTIFICATION REQUIRED? YES NO IF YES, PLEASE EXPLAIN: PRECERTIFICATION PHONE #: INFORMATION ON POLICY HOLDER (THE ONE WHO PAYS THE PREMIUM): NAME: RELATIONSHIP TO ATHLETE: SOCIAL SECURITY/ID #: BIRTHDATE (MM/DD/YYYY): ADDRESS: CITY: STATE/ZIP: PRIMARY ADDRESS: HOME PHONE #: CELL PHONE #: EMPLOYED BY: WORK PHONE #: EMPLOYER ADDRESS: (CITY/STATE/ZIP): ***PLEASE ATTACH LEDGIBLE FRONT AND BACK COPY OF THIS INSURANCE CARD, AS WELL AS A COPY OF POLICY HOLDER S PHOTO ID***

5 SECONDARY INSURANCE (MEDICAL, DENTAL, or PHARMACY) INSURANCE COMPANY NAME: INSURANCE CO CLAIMS ADDRESS: CITY: STATE: ZIP: PHONE: POLICY/ID #: GROUP #: POLICY EXEMPTIONS or REQUIREMENTS: PRECERTIFICATION REQUIRED? YES NO IF YES, PLEASE EXPLAIN: PRECERTIFICATION PHONE #: INFORMATION ON POLICY HOLDER (THE ONE WHO PAYS THE PREMIUM): NAME: RELATIONSHIP TO ATHLETE: SOCIAL SECURITY/ID #: BIRTHDATE (MM/DD/YYYY): ADDRESS: CITY: STATE/ZIP: PRIMARY ADDRESS: HOME PHONE #: CELL PHONE #: EMPLOYED BY: WORK PHONE #: EMPLOYER ADDRESS: (CITY/STATE/ZIP): ***PLEASE ATTACH LEDGIBLE FRONT AND BACK COPY OF THIS INSURANCE CARD, AS WELL AS A COPY OF POLICY HOLDER S PHOTO ID*** I certify that all the above information is correct. If any incorrect or incomplete information has been given, then I am responsible for the payment of charges. (Initials) I authorize Auburn University Athletic Department to file claim in my behalf for all claims classified as Athletic. I understand that I am responsible for payments of all charges incurred for claims classified as Non-athletic or Pre-existing injuries. (Initials) THE FOLLOWING AUTHORIZATION MUST BE SIGNED BEFORE AUBURN UNIVERSITY CAN COVER ANY MEDICAL EXPENSES INCURRED BY THIS ATHLETE: Thereby authorize the Auburn University Athletic Department to file a claim on my behalf for the athletic injury/illness sustained by (dependent) under the above group medical policy. Further, I agree and consent that any amounts payable under this policy be paid to the medical provider or Auburn University Athletic Department as shown below. My son/daughter is not covered under my personal health insurance. I, the undersigned, do hereby agree and give my consent for the Auburn University Athletic Department or its designates to furnish medical care and treatment to my son/daughter as considered necessary and proper in diagnosing or treating their physical and mental condition. Further, I hereby authorize Auburn University Athletic Department and its representatives to inspect or secure copies of case history, laboratory reports, diagnosis, x-rays, and any other data in relation to this medical claim. This authorization may be photocopied and any photocopies should be deemed as valid and applicable to the original. Signature of Policy Holder Signature of Athlete

6 AUBURN UNIVERSITY SPORTS MEDICINE INSURANCE INFORMATION Please copy the front and back of your insurance card and affix it below. Front Back Please copy the policy holder s Photo ID and affix it below Photo ID Please copy the student athlete s Photo ID and affix it below

7 BENEFICIARY DESIGNATION As an insured intercollegiate student-athlete enrolled in Auburn University, the Auburn University Athletic Department is pleased to provide you with NCAA Catastrophic Injury coverage. Under this coverage, as an insured student-athlete you are provided with accidental death benefits while participating in intercollegiate athletics at Auburn University. The purpose of this beneficiary designation is to provide you your right under the policy to designate a beneficiary to whom any death benefit shall be payable and, at your option, the beneficiary designation may be changed by you at any time. DESIGNATION OF BENEFICIARY If I,, do not name a beneficiary or if my named beneficiary does not survive me, I understand that the payment of any benefits will be made to my estate, or at the option of the underwriting company, to the following: a) My spouse, if living; otherwise b) My then living children, if any; otherwise c) My surviving parent(s); otherwise d) My surviving brothers and/or sisters, equally. I name as beneficiary(ies) the person(s) named below: Name of Beneficiary Relationship Name of Beneficiary Relationship EXECUTED this day of, 20. Signature of Student-Athlete Signature of Student-Athlete s Parent or Guardian

8 AUBURN SPORTS MEDICINE NUTRITIONAL SUPPLEMENT WAIVER I will not take any nutritional supplement* other than those provided by Auburn Athletics without written approval of Scott Sehnert, Sports Dietitian or Dr. Michael Goodlett, Head Team Physician. I understand that nobody can guarantee that a supplement is 100% pure. If I decide to take a supplement, I understand that it is at my own risk. *Nutritional supplement: any product (pill, tablet, powder, liquid, beverage, etc.) designed to supplement the diet and including one or more of the following ingredients: vitamins, minerals, herbs or botanicals, amino acids, calorie boosters, or a concentrate, metabolite, constituent, extract, or combination of these ingredients. Signed: Printed name: : Athletes who wish to take supplements purchased on their own should bring these supplements to their initial nutrition consultation. ALL supplements you are taking must be approved by Scott Sehnert or Dr. Michael Goodlett (even if you have used them in the past). Please list below which supplements you are currently taking or have taken in the past 3 months:

9 LIFESTYLE QUESTIONNAIRE FOR AUBURN UNIVERSITY ATHLETES NAME: SPORT: FR SO JR SR 1. What is your current body weight? What is your highest adult body weight? What is your lowest adult body weight? 2. Would you like to change your weight? Y( ) N( ) If so, what would you like to weigh? 3. Have you ever used any technique other than dieting to change your weight? Y( ) N( ) 4. How many hours per week do you exercise outside of practice? 5. Do you, or have you ever been told, you have an eating disorder? Y( ) N( ) 6. How many meals per day do you eat? How many snacks per day do you eat? 7. Please list any food groups you avoid eating for any reason, (or find yourself eating less of, i.e. meats, dairy, etc.) 8. Have you changed the way you eat over the past year, (i.e. eating out more, vegetarian, no red meat, etc.) Y( ) N( ) Please list 9. Please list any vitamin or mineral supplements you are currently taking 10. In the past year, have you taken a nutritional supplement for weight gain, weight loss, or performance enhancement? Y( ) N( ) Please list 11. In the past year, have you taken any other supplement or herbal product? Y( ) N( ) Please list 12. Do you consume caffeine (soda, coffee, tea, energy drinks/shots, etc.)? Y( ) N( ) If yes, approximately how much in a day, when do you consume it, and in what form? 13. Do you smoke, dip or chew, or use other tobacco products? Y( ) N( ) If yes, approximately how much in one day? 14. Do you consume alcoholic beverages? Y( ) N( ) If yes, approximately how many drinks per week?

10 NAME: SPORT: FR SO JR SR 20. Please circle on the scale below how frequently you experience the following symptoms: Never Rarely Sometimes Often Always Extreme Sadness Anxiety Difficulty getting up in the morning Crying episodes Irritability Tiredness Difficulty falling asleep Wide mood fluctuation 21. Please circle on the scale below the quality of your relationship with each of the following persons: Terrible Poor Fair Good Excellent N/A Mother Father Significant other Male friends Female friends Coach Teammates