Methodist University Athletic Training

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					              Methodist University Athletic Training
         Returning Participant Medical Information Form
***Required for Participation in Methodist University Athletics***

Name: ________________________________ Sport(s):_____________________________ Date: _____________

    Preferred Name: ___________________________ Current School Year: ___________________________

  SSN: ___________________ Birth Date:_________________ Student ID Number:______________________

   Home Address: ___________________________________________________________________________
                         Street                               City                      State         Zip

  Home Phone: ___________________ Cell Phone:__________________ Email:__________________________




                            Emergency Contact Information
                        ** In case of emergency, please contact**

Name: __________________________________               Name: _____________________________________

Relationship: ______________________________           Relationship: _________________________________

Address: __________________________________            Address: ___________________________________

City/State/Zip: _____________________________          City/State/Zip: _______________________________

Cell Phone: _______________________________            Cell Phone: __________________________________

Home Phone: ______________________________             Home Phone: ________________________________




                                     Current Health Issues

   Known Allergies: __________________________________________________________________________

Known Medical Conditions (i.e. Diabetes, knee surgery, etc.): ____________________________________________

     ______________________________________________________________________________________

    Current Medications: ______________________________________________________________________
                                          Medical Consent
            I authorize the athletic training staff, coaching staff or other authorized medical personnel to
render any preventative, first aid, rehabilitative or emergency treatment they deem reasonably necessary
to my health and well-being. Also, when necessary for executing such case, I grant permission for
hospitalization and treatment at an accredited hospital. I also understand that the athletic trainers
and/or medical staff at Methodist University have the authority to eliminate or restrict me from
further participation because of an injury or illness and/or because of undue liability risk to
Methodist University.

Athlete Signature: _____________________________ Date:___________________________

IF a MINOR, a Parent’s Signature is required:_______________________________________




                  SHARED RESPONSIBILITY FOR SPORTS SAFETY
        Participation in sport requires an acceptance of risk of injury. Athletes rightfully assume
that those who are responsible for the conduct of sport have taken reasonable precaution to minimize
such risk and that their peers participating in the sport will not intentionally inflict injury upon them.
However, to legislate safety via a rule book and equipment standards, while often necessary, seldom is
effective by itself; and to rely on officials to enforce compliance with the rule book is as insufficient as
to rely on warning labels to produce compliance with safety guidelines. “Compliance” means respect on
everyone’s part for the intent and purpose of a rule or guideline.
        I have read the above shared responsibility statement. I understand that there are certain inherent
risks involved in participating in intercollegiate athletics. I acknowledge the fact that these risks exist
and I am willing to assume responsibility for such risks while participating at Methodist University.

Athlete Signature: _____________________________ Date:___________________________

IF a MINOR, a Parent’s Signature is required:_______________________________________
                          CONFIRMATION OF RESPONSIBILITY

        I understand Methodist University and the Methodist University Athletic Accident Insurance
Plan will only pay for or cover intercollegiate athletic related injuries occurring as an athlete at
Methodist University. Injuries that occur during off season or voluntary workouts (ie. conditioning,
weightlifting) will not be covered by the athletic accident insurance plan and become the student-
athlete’s financial responsibility. I understand that due to the fact that the university’s athletic accident
insurance plan is a secondary policy, my personal health insurance will be filed with first following
medical care and may be asked to pay some or all portion(s) of medical expenses related to any
intercollegiate athletic related injury I might sustain while participating in intercollegiate athletic
competition. Once my personal insurance has been filed, and has been paid in full, denied, or partially
paid a claim, any remaining bill will be filed with the secondary insurance. Any injury sustained
before I began as a student at Methodist University is considered a pre-existing condition and I
will be solely responsible for any and all related expenses incurred in the treatment of said
condition(s). I also understand that I am solely responsible for any medical or other related
expenses incurred due to injury or illness not related to intercollegiate athletic participation at
Methodist University.

Athlete Signature: _____________________________ Date: ___________________________

IF a MINOR, a Parent’s Signature is required: _______________________________________




     AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION AND RECORDS


        I hereby authorize you to release to the Methodist University Certified Athletic Training/Medical
Staff or Student Insurance Coordinator, all information and records relating to any past, present, or
future medical condition(s) as deemed necessary by the Certified Athletic Training/Medical Staff. This
information includes but is not limited to: Physicians’ dictations and records; X-rays and related reports;
MRI/CT reports and related notes; emergency department reports; operative and follow-up notes; related
rehabilitative physical therapy or occupational therapy notes; and needed information to process
insurance claims associated with injuries, conditions, and sudden illness that occur as a result of
participation in intercollegiate athletics at Methodist University. I hereby waive any privilege I may
have in connection therewith. Methodist University, its Trustees, officers, employees and agents are
hereby released from legal responsibility or liability for the release of such records and information.

Athlete Signature: _____________________________ Date: ___________________________

SSN______________________________ Date of Birth ________________________________

IF a MINOR, a Parent’s Signature is required: _______________________________________
      ***Please read the Methodist University Athletic Training Policies and Procedures
and Filing Insurance Claims Procedures pages at the back of this packet and sign below.
You may keep those pages for you records. ***




      Methodist University Athletic Training Insurance Policies and Procedures
By signing below, I verify that I have read and understand the above policies and procedures for the
Methodist University Athletics Department, Athletic Training Department, and the Athletic Accident
Insurance Plan provided for the student-athlete.

Athlete Signature: _____________________________ Date: ___________________________

Parent’s Signature: ____________________________ Date: ___________________________
 (if under 18)




                           Filing Insurance Claims Procedures

By signing below, I verify that I have read the above policies and procedures for the Methodist
University Athletics Department, Athletic Training Department, and the Athletic Accident Insurance
Plan provided for the student-athlete. I understand that I must follow the proper outlined procedures for
filing insurance claims if I expect to receive the coverage from the institution’s Athletic Insurance Plan.

Athlete Signature: _____________________________ Date: ___________________________

Parent’s Signature: ____________________________ Date: ___________________________
 (if under 18)
                    Methodist University Athletic Department Insurance Information
                        ***You must complete this form to be eligible to participate***
                                                Please Print

Student-Athletes’ Name _______________________________________________________________
                                Last                          First                        Middle
Sport(s) __________________________________ Date of Birth ___________________________

SSN___________________________________ Student ID# _________________________________

Address where insurance information should be mailed:

____________________________________________________________________________________
  Address                                              City                      Sate        Zip


Primary Insurance Holder                               Secondary Insurance Holder/ Other
                                                       Parent/Guardian
Name                                                   Name

Relationship                                           Relationship

SSN                                                    SSN

DOB                                                    DOB

Home Address                                           Home Address

City                                                   City

Zip                                                    Zip

Phone #                                                Phone #

Insurance Co,                                          Insurance Co.

Is student insured under this policy? Yes No           Is student insured under this policy? Yes No
Insurance #                                            Insurance #

Group # (if applicable)                                Group # (if applicable)

Insurance Phone #                                      Insurance Phone #

Insurance Address                                      Insurance Address


Name of Employer                                       Name of Employer

Work #                                                 Work #


            ****Include copy of current insurance card with this packet, front and back copy****
                   General Medical Background Information
Name: ____________________________ Age: _____________________ Sex: Male Female


Have any new medical conditions or injuries occurred over the past year? Please list all new
injuries/conditions from the past year, even if your athletic trainer already knows about them.
___________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

Please list all current medications________________________________________________________
____________________________________________________________________________________

Are you allergic to any Medications? Yes No
Explain _____________________________________________________________________________

Are you allergic to foods, additives, fluids, supplements, etc? Yes No
Explain_____________________________________________________________________________

Are you allergic to bees, wasps, ants or other animal bites? Yes No
___________________________________________________________________________________

Have you ever been diagnosed with a concussion? Yes   No

During what activity?__________________________________ When? ______________________

If you have been diagnosed with more than one concussion, please explain further________________
_________________________________________________________________________________
__________________________________________________________________________________

Have you ever been knocked out or lost consciousness? Yes No
Explain____________________________________________________________________________

Do you require any special equipment (i.e. brace, oxygen, epi-pen, etc.)? Yes No
Explain _____________________________________________________________________________
      Methodist University Athletic Training Insurance Policies and Procedures
        The Certified Athletic Training Staff of Methodist University serves in the prevention,
evaluation, and treatment of athletic injuries of the student-athlete. For the insurance coverage of our
student-athletes to operate efficiently and effectively, it is important that the student-athletes and their
parents/guardians understand the guidelines and stipulations of our policy and the procedures we must
follow to expedite theses matters.

       Our Certified Athletic Training Staff has two main objectives:
             A. To provide the best possible medical care of athletic injuries for the student-athlete.
             B. To provide the student-athlete with the most efficient therapeutic program that will
                  enable them to return to playing as quickly as feasible to the highest degree of
                  independence and effectiveness of which the student-athletes are capable.

       The following policies are intended to aid the Certified Athletic Training Staff and Medical Staff
of Methodist University in striving for the above objectives. Each student-athlete is expected to follow
these policies and procedures. FAILURE TO DO SO WILL LEAVE MEDICAL FINANCIAL
RESPONSIBILITY FOR ATHLETIC INJURIES TO THE STUDENT-ATHLETE/PARENTS.

       1. The Certified Athletic Training Staff and physician have the responsibility only for the
          treatment and care for student-athletes who are participating in official practices and
          competition in a traditional or non-traditional intercollegiate sport season.

       2. In order to be cleared for participation in Methodist University Athletics, all student-athletes
          must have a completed copy of the Methodist University Student Health Services Physical
          Form, stating that they are cleared for participation, and an updated copy of their insurance
          card on file in the athletic training office. Incoming and returning student-athletes must also
          complete a Participant Medical Information Form at the beginning of each year of
          participation.

       3. The student-athlete may not bill the athletic department for charges associated with the
          treatment of an injury or illness unless authorized to do so by members of the Certified
          Athletic Training Staff or the Director of Athletics.

       4. The student-athlete will be financially responsible for the payment of medical expenses
          resulting from injury occurring at times or events other than officially recognized
          intercollegiate practices and competitions both traditional and non-traditional seasons.
          No financial responsibility will be taken, on part of the university, for an injury due to
          voluntary weightlifting, conditioning or other off-season workouts.

       5. The athletic department will assume no financial liability for cases in which permanent
          impairing has followed a sport induced affliction, except for the limits of our co-insurance
          accident coverage.

       6. The athletic department is not responsible for normal routine dental care.

       7. The athletic department does not purchase contact lens or eye glasses and is not responsible
          for normal routine eye examinations. Eye glasses worn during practices or contests must
          have shatterproof fire-polished type lenses.

       8. The insurance of the athletic department is financially responsible for medical referrals
          to specialists only when such referrals are handled through a certified athletic trainer
   or team physician. The coach or student-athlete responsible for an unauthorized
   referral shall be held responsible for all involved expenses.

9. The Methodist University insurance policy will only cover accidental injuries which occur
   while participating in a scheduled practice, tryout or event. The policy states that “an
   accident means a sudden, unexpected and unintended event which in identifiable and results
   in an injury to an insured person participating in a covered event.” Accident does not include
   a loss contributed to by disease or sickness. Pre-existing conditions will not be included.
   Student-athletes are responsible for all other injuries and illnesses. Please provide
   documentation, that all pre-existing injuries are either under the care of a physician,
   have been resolved, or that the student-athlete has been cleared for competition in
   intercollegiate athletics by a physician, to the Certified Athletic Training Staff.

10. Coverage is provided under the Athletic Accident Insurance Plan for injuries or conditions:
    A) caused solely by the student-athlete’s participation in a covered event (i.e. practice, game,
    match, etc.) and B) that are not the result of a specific accident, provided that such injury or
    condition first manifests itself while the insured person is covered under the policy. This
    benefit will include misuse injuries, overuse injuries, strains, tendonitis, stress fracture, heat
    stroke, and other similar conditions. Aggravation or reoccurrence of injuries shall be
    included, provided the student-athlete was cleared by a physician for full participation,
    without limitations, in the year and for the sport for which the aggravation or reoccurrence is
    being claimed. All injuries due to the same or related causes are considered one injury.

11. The athletic accident benefit is $25,000. This benefit is provided by the institution to all
    eligible student-athletes for the nine month academic year. The Athletic Accident
    Insurance Plan will pay/cover expenses incurred within 104 weeks (2 years) after the
    date of the accident up to a maximum of $25,000. This benefit includes coverage for
    treatment of injury to natural teeth.

12. Hospital room and board are included, up to the semi-private room rate.

13. When more that one surgical procedure is performed at the same time, but in different
    areas, with a different surgical incision, the highest payment will be for the surgery
    which costs the most. The Athletic Accident Insurance Plan will pay a maximum of
    50% for the second surgical procedure and 25% for the third surgical procedure.

14. Expenses incurred on an outpatient basis for physiotherapy due to an accident are limited to
    $300, unless specifically ordered by an orthopedic surgeon. Physiotherapy includes heat
    treatment, or diathermy, ultrasonic microtherm, manipulation, adjustment, massage therapy
    and acupuncture.

15. Initial medical treatment must be incurred within 90 days from the date of accident/injury.

16. The Athletic Accident Insurance Plan provides coverage for athletic related conditions, as
    described above, up to a maximum of $5,000 per athletic related condition.

17. The athletic accident benefit is increased to $75,000 under another plan (not through Markel
    Insurance) for NCAA participating institutions.

18. To be eligible for reimbursement, a claim form must be submitted within 180 days from the
    date of injury.
19. The Athletic Accident Insurance Plan does not cover, nor provide benefits for:
       a. Expenses for treatment to the teeth, except for treatment resulting from injury to
          natural teeth.
       b. Injury due to participation in a riot.
       c. Routine physical examinations, preventative care, elective surgery and elective
          treatment, or services solely to improve appearance.
       d. Expense for knee orthopedic devices, unless prescribed for use during post-surgical
          physical therapy.

20. Benefits payable under the Athletic Accident Insurance Plan will be reduced by 50% for
    surgical benefits if the insured student-athlete has no coverage under an HMO, PPO, or
    similar arrangement and the insured student-athlete does not use the facilities of the HMO,
    PPO, or similar arrangement for the provision of benefits.

21. Benefits payable under the Athletic Accident Insurance Plan will be reduced by 50% for
    outpatient benefits if the insured student-athlete doe not attempt to obtain an out-of-network
    authorization or a referral from their managed care provider to get treatment.

22. The Certified Athletic Training Staff and the Student Insurance Coordinator will assist the
    student-athlete in obtaining the proper referrals, but ultimately if a reduction of benefits
    occurs, the financial responsibility shall fall upon the student-athlete, parents or guardians.

23. The Athletic Accident Insurance Plan is a secondary policy to work in conjunction with the
    student-athlete’s primary (personal) insurance. Once both policies have paid on a bill, the
    student-athlete should bring remaining bills to the office of the head certified athletic
    trainer for consideration of payment.

24. **Athletes can only receive the necessary paperwork needed to file a sport related
    injury claim from the certified athletic trainers. Athletes must be seen and evaluated
    by the certified athletic trainers prior to being issued the Athletic Accident Insurance
    Plan paperwork. Any bills received by the athlete or athlete’s parents/guardians, that
    are part of a sport related injury claim, need to be brought to the certified athletic
    trainers so that they may be turned in for processing by the Athletic Accident Insurance
    Plan. We cannot facilitate the payment of bills if we do not know about them.**

25. The 50% reduction in benefits will not apply to emergency treatment required within 24
    hours after an accident which occurred outside the geographic area serviced by the HMO,
    PPO, or similar arrangement.
                           Filing Insurance Claims Procedures
              **A claim form must be submitted within 180 days from the date of injury**

        Methodist University recognizes its obligation to its intercollegiate student-athletes to provide a
program of insurance that would be both cost effective and would assist in alleviation the financial
burden of residual medical charges resulting from an accidental injury during official team practice or
competition. The Athletic Accident Insurance Plan is designed to cover eligible expenses not fully paid
by the parent/guardian/student-athlete’s insurance carrier. As our coverage is in EXCESS of any other
medical insurance the student-athlete may have, a student-athlete must submit all expenses incurred
to their insurance plan(s) first. The following procedures must be followed to insure accurate and
prompt filling of claims.

       1. The student-athlete must report any injuries to their certified athletic trainer within 24-28
          hours following the accident or injury.
       2. File all charges with your primary insurance carrier first. If you are insured by an HMO/PPO
          you must obtain pre-authorization for all services rendered or benefits will be reduced by
          50%. The Certified Athletic Training Staff and the Student Insurance Coordinator will assist
          the student-athlete in obtaining the pre-authorization from the student-athlete’s HMO/PPO.
          Ultimately, the responsibility falls with the student-athlete and the student-athlete’s
          parents/guardians. Failure to obtain the pre-authorization from the HMO/PPO will
          result in the student-athlete’s parents/guardians being financially responsible for
          expenses incurred.
       3. If the primary insurance (the student-athlete’s private insurance) does not pay the entire bill:
               a. Secure a claim form and instructions from the Certified Athletic Training Staff or the
                   Student Insurance Coordinator
               b. Fill in the necessary information; have the attending physician and supervising
                   certified athletic trainer complete their portion of the form.
               c. Attach all itemized medical and hospital bills (to receive an itemized bill may take a
                   special request on the part of the student-athlete or the parents/guardians)
               d. Mail them to the Claims Administrator at:
                       Summit America Insurance Services, LC
                       7400 College Blvd., Suite 120
                       Overland Park, KS 66210
                       Phone: 1-800-926-3441
                       Fax: 913-327-7520
                       Email: EIIA@summitamerica-ins.com

				
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