INSURANCE INFORMATION

Transcription

1 INSURANCE INFORMATION Dear Parent or Guardian: We are pleased to have your son/daughter as a student athlete in our UAB Athletic Program. Our athletic accident policy, entitled Excess coverage, provides insurance for your son/daughter for in season injuries/illnesses that occur while participating in the play/practice of intercollegiate sports at UAB and nothing outside of their athletic participation. Excess coverage simply means that the policy pays benefits only after taking into consideration those amounts payable under any other insurance plan. The university does not have the option of waiving this provision. However, this will not cost you anything. The healthcare provider would submit you son s/daughter s medical bills to your family health insurance company and they would pay that part for which your son/daughter was covered. We would pay any remainder including meeting your deductible. This will not affect your group insurance premiums. Should a claim be filed against your insurance and you receive any type of billing or checks from your insurance company for medical services originating from your son/daughter s participation at UAB, you should send these bills/checks to: Mike Jones, MAE, ATC Office: (205) Director of Sports Medicine Fax: (205) Wallace Building Jones65@uab.edu th Street South Birmingham, AL 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 check the appropriate box on the bottom of the form. 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. I have enclosed a self addressed, postage paid envelope for your convenience. Thank you for your cooperation in this matter. Sincerely, UAB Sports Medicine Staff

2 Please Print Clearly! ATHLETE INSURANCE INFORMATION If you have any questions regarding this form contact: Mike Jones, MAE, ATC Director of Sports Medicine UAB Sports Medicine Wallace Building th Street South Birmingham, AL (205) DATE: ATHLETE: BIRTHDATE: (MM/DD/YYYY) SOCIAL SECURITY/ID #: SPORT: 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 #: EMPLOYED BY: CELL PHONE #: WORK PHONE #: EMPLOYER ADDRESS: (CITY/STATE/ZIP):

3 SECONDARY INSURANCE (MEDICAL, DENTAL, OR PHARMACY) 04/09 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 #: EMPLOYED BY: CELL PHONE #: 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 of the above information is correct. If any incorrect information has been given, then I am responsible for the payment of charges. I authorize UAB 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) (Initials) THE FOLLOWING AUTHORIZATION MUST BE SIGNED BEFORE UAB CAN COVER ANY MEDICAL EXPENSE INCURRED BY THIS ATHLETE: Thereby authorize the UAB 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 UAB 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 UAB 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 conditions. Further, I hereby authorize UAB 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

4 UAB SPORTS MEDICINE INSURANCE CARD INFORMATION Please copy the front and back of your insurance card and attach it below. Front Back Please copy the policy holder s Photo ID and attach it below Photo ID

5 BENEFICIARY DESIGNATION 04/09 As an insured intercollegiate student-athlete enrolled in UAB the UAB Athletic Department is pleased to provide you with Catastrophic Injury coverage. Under this coverage, as an insured student-athlete you are provided with accident death benefits while participating in intercollegiate athletics at UAB. 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 name 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