PLEASE ATTACH A COPY OF THE FRONT AND BACK OF YOUR INSURANCE CARD by tamir13

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									                                         LOUISIANA TECH UNIVERSITY SPORTS MEDICINE
                                                      HEALTH INSURANCE INFORMATION / AUTHORIZATION 2008- 09
Athlete’s Name (Last, First MI)                                                                               SS No.                                            Date of Birth_________________
Age                      Sex          Male           Female         Sport                                                                       Academic Year (circle)       1    2     3   4    5
Permanent Address                                                                                      City                                     State                  Zip:__________________
Home Phone                                                                                           Cell_______________________________________________________________
Medications currently taking?
Allergies/Asthma?

               FATHER’S / GUARDIAN’S INFORMATION                                                                  MOTHER’S / GUARDIAN’S INFORMATION
 Name                                                                                               Name
 SS No. ______________________________ DOB _________________ ____                                   SS No. ______________________________ DOB _________________ ____
 Home Address                                                                                       Home Address


 Home Phone _____________________________________________________                                   Home Phone _____________________________________________________
 Employer                                                                                           Employer
 Employer Address                                                                                   Employer Address
 Work Phone ______________________________________________________                                  Work Phone ______________________________________________________
 Insurance Company                                                                                  Insurance Company
 Address                                                                                            Address
 Policy / ID #                                                                                      Policy / ID #
 Group #                                                                                            Group #
 Insurance Company Phone #                                                                          Insurance Company Phone #
 Type of Insurance-                                                                                 Type of Insurance-
      HMO          PPO          Indemnity          Other                                                  HMO          PPO          Indemnity           Other
 Primary Care Physician                                                                             Primary Care Physician
 Physician Phone #                                                                                  Physician Phone #
 Is preauthorization necessary for medical/diagnostic services?                Yes        No        Is preauthorization necessary for medical/diagnostic services?                Yes           No
 Phone #                                                                                            Phone #
 Is your son / daughter covered under this policy?                            Yes         No        Is your son / daughter covered under this policy?                            Yes            No
 Any Additional Insurance Policies? (i.e. vision, dental)                     Yes         No        Any Additional Insurance Policies? (i.e. vision, dental)                     Yes            No
 If Yes, please provide appropriate information____________________________                         If Yes, please provide appropriate information____________________________
 ________________________________________________________________                                   ________________________________________________________________

HMOs: If a student-athlete’s primary insurance is an HMO, the LA Tech (“LA Tech”) Sports Medicine Department strongly recommends the policy holder change the primary care physician (PCP) to
a LA Tech Team Physician or local physician. This will allow the student-athlete to have a network of physicians in the Ruston area, as well as better access to care.
PLEASE READ CAREFULLY!
 I hereby acknowledge that I have read and understand the LA Tech Athletic Department’s Insurance Policy regarding athletic injuries.
 •    I am aware that preexisting injuries/conditions or aggravation of them through athletic activity are not a covered benefit.
 •    I hereby authorize LA Tech and their insurance coordinator to secure & inspect copies of case history records, lab reports, diagnoses, x-rays, & any other data pertaining to the injury/illness I
      am receiving care for or previous confinements of disabilities relevant to the care of the injury/illness.
 •    I agree to supply any & all information requested by my primary insurance, the LA Tech Department of Intercollegiate Athletics & their insurance coordinator in a timely manner.
 •    I hereby authorize the LA Tech Sports Medicine Department and/or my coach to hospitalize & secure treatment for me for any athletic injury/illness.
 •    A photocopy of this authorization shall be deemed as effective & valid as the original.
 •    Furthermore, I understand that it is the responsibility of the parents/guardians and student-athlete to inform LA Tech and its Athletic Training Staff of any change in the above health insurance
      information. In addition, I agree to notify the LA Tech Sports Medicine Department immediately upon any change. If I fail to do so, I fully understand that I may be solely responsible for any &
      all charges incurred for treatment of an injury and/or illness as failure to report the existence of new primary insurance coverage information may result in denial of insurance claims by LA
      Tech.
 •    I hereby certify that I have read & understand the above statements, that any & all questions have been answered to my satisfaction, & that the answers provided are true, complete, & correct
      to the best of my knowledge.
 •    I hereby authorize LA Tech to provide and procure necessary information to/from healthcare providers and/or my insurance carrier so that a health insurance claim can be filed on behalf of
      myself and my eligible dependent son/daughter.
 •    MUST BE SIGNED BY ATHLETE AND POLICYHOLDER.


  Policy Holder’s Signature                                                                                                        Date

  Student-Athlete’s Signature                                                                                                      Date




PLEASE ATTACH A COPY OF THE FRONT AND BACK OF YOUR INSURANCE CARD
                                                                                                                                                          Updated 7/24/2008 3:15:01 PM

								
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