Athlete Insurance Insurance Claim Filing Medical Addendum by liwenting

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									                             PENN STATE BEHREND ATHLETICS
                     STUDENT/PARENT INSURANCE INFORMATION FORM
PART I – STUDENT-ATHLETE’S INFORMATION
 NAME:                                                       SPORT(S):
 PSU STUDENT NUMBER:                                         BIRTH DATE:
 LOCAL PHONE #:                                              CELL PHONE NUMBER:
 HOME ADDRESS:                                               HOME PHONE NUMBER:
                                                             EMERGENCY CONTACT:
                                                                  PHONE NUMBER:


PART II – PRIMARY INSURANCE INFORMATION
   A.   Are you covered by a Medical Insurance plan?    Yes                    No
   B.   Are you covered by a Dental plan?               Yes                    No
   C.   Under whose name is the Primary Insurance Coverage listed?
   D.    Type of Insurance policy (check one):      HMO         PPO            UNRESTRICTED
   E.   Is Pre-Authorization required for services? Yes            No
         Primary Insurance Company Name:
        Primary Insurance Company Address:


        Primary Insurance Company Phone #:
        Agreement or Contract #:
        Policy #:                                                 Group #:
        Policy Effective/Expiration Date (if known):

PART III – PRIMARY CARE PHYSICIAN INFORMATION
   A. Name of Primary Care Physician:
   B. Phone Number of Primary Care Physician:
   C. Does your Primary Care Physician need to be contacted prior to medical referral to another
       physician(s) or to the Emergency Room?          YES                     NO

 Attach Insurance Card Copies Here




                                             PLEASE ENCLOSE A COPY OF
        BOTH SIDES OF YOUR INSURANCE CARD(S) AND YOUR PRESCRIPTION CARD(S) IN THE BOX ABOVE
   (This should include the policy holder’s name, policy number, claims address and customer service number.)

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       STUDENT/PARENT INSURANCE INFORMATION FORM (CONTINUED)
PART IV – PARENT/GUARDIAN CONTACT INFORMATION
       Father’s Name:                           Mother’s Name:
       Father’s Address:                        Mother’s Address:




       Father’s Phone #:                        Mother’s Phone #:
       Father’s E-Mail Address:                 Mother’s E-Mail Address:
       Father’s Employer:                       Mother’s Employer:
       Employer’s Address:                      Employer’s Address:




       Employer Phone #:                        Employer Phone #:
       Alternate Emergency Contact:
       Relationship to Athlete:
       Phone #:




        ***FAILURE TO COMPLETE THIS ENTIRE FORM
           WILL RESULT IN CLAIMS PROCESSING
                       DELAYS***




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 PROCEDURES FOR FILING AND MONITORING AN ATHLETIC INJURY CLAIM
Penn State University provides a “secondary” insurance policy for all student-athletes who participate in officially
sponsored intercollegiate athletics practices, games and travel. It is department policy that all student-athletes
have some form of primary insurance coverage in order to participate at Penn State Behrend College. Student-
athletes whose families do not have an insurance plan are encouraged to purchase an insurance package that
does not exclude NCAA intercollegiate athletic sports injuries. This primary insurance policy can be held by
either the parent/guardian or the student-athlete. In the event that the student-athlete sustains an injury that
requires medical attention outside the Athletic Training Room the following procedure will be initiated:

All providers of medical services will be requested to file a claim with the policyholder’s primary health insurance
company. All correspondence from the provider regarding these bills will be sent directly to the policyholder.

It is the policyholder’s responsibility to forward the following information to the address listed below within 60
days in order to ensure timely payment:

         All ORIGINAL, ITEMIZED bills listing all services rendered by that medical facility.
         Any and all Explanation of Benefits Statements (EOBs) from the primary insurance company for each
          original, itemized bill.

        Head Athletic Trainer
        Penn State Behrend College
        5103 Station Road
        Junker Center
        Erie, PA 16563-0400

Penn State University’s “secondary” insurance policy will only be applied after the student-athlete’s primary
insurance has been billed and the claim has been paid or a denial has been received.

Billing statements that simply indicate “Balance Due” are not sufficient. The statement must itemize the services
provided and charges in order to be accepted by the secondary insurance company and Penn State Behrend
College.

The University’s insurance carrier can make no payment until this process is fully completed.

The “secondary” insurance policy provided by Penn State University takes effect on the initial date of injury.
Coverage and payment of benefits for any injury cease at the end of 104 weeks from the date of initial injury.
No payment for services will be accepted with a date of service past the 104 week mark.


           ACKNOWLEDGEMENT OF INJURY CLAIMS FILING PROCEDURE
I, the undersigned, acknowledge and understand the correct procedure for filing an Athletic Injury
claim resulting from participation in intercollegiate athletics at Penn State Erie, The Behrend
College.

Policy Holder Signature __________________________________________ Date ______________________
(MUST BE SIGNED BY THE OWNER OF THE HEALTH INSURANCE POLICY, NOT BY THE STUDENT-ATHLETE OR SPOUSE, UNLESS THEY ARE THE OWNER.)



       (NOTE: THIS CAN BE A LENGTHY PROCESS, PLEASE BE PATIENT!!!)
Please direct any questions or concerns regarding this process, or the filing of medical bills to a
member of the Sports Medicine Staff at 814-898-6340 or 814-898-7227.



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                    Penn State Behrend College Sports Medicine Services
                         STUDENT ATHLETE PERSONAL INFORMATION
N a me :                                               Date:
Sport:                                                 Class: SOPH       JR      SR      5th

Student-Athlete Home Address




Student-Athlete Home Phone Number


Student-Athlete Local/School Address




Student-Athlete Campus or Cell Phone Number


Student-Athlete E-Mail Address


Student-Athlete PSU Student Number


Student-Athlete Birth Date:

Last Known Tetanus Shot:

Student-Athlete Emergency Contact:
Relationship to Student-Athlete:

Are you allergic to any medications?             YES                NO
           If yes, what medications:



Are you allergic to:         LATEX        BEE STINGS     PEANUT Products      Other Foods?
           Other allergies not already listed:

Have you ever been tested for sickle cell trait? YES           NO

Do you know, or have you been told you are a carrier for sickle cell gene?
       Y ES     NO

Have you ever been Impact tested for concussion baselines prior to this year?
       Y ES     NO       If so, when and how many times.

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               STUDENT-ATHLETE MEDICAL HEALTH HISTORY ADDENDUM
Please answer all questions completely and thoroughly. If a question does not pertain to you, please respond
with N/A. Failure to disclose or falsification of medical information may invalidate your insurance coverage,
cancel your eligibility to participate in intercollegiate athletics according to the NCAA Rules and releases Penn
State Erie, The Behrend College from financial responsibility for undisclosed conditions. Any existing problems
must be discussed with the team physician at the time of physical examination.

I. BEHAVIORAL HISTORY
  A. Do you smoke?                        YES        NO
  B. Do you drink alcohol?                YES        NO
  C. Do you take any drugs?               YES        NO

        If yes, what drugs do you take?



  D. Do you take any supplements or vitamins?             YES         NO

        If yes, what supplements do you take?


II. PERSONAL HEALTH HISTORY
        A. Have you sustained any injuries, either athletically related or non-athletically related since your last
           pre-participation physical here at Penn State Erie, The Behrend College?

                YES          NO

        If yes, please list the injury, date of injury and outcome of the injury below.
        Injury:                                               Date of Injury:
        Injury Outcome:



        Injury:                                               Date of Injury:
        Injury Outcome:



        Injury:                                               Date of Injury:
        Injury Outcome:


  B. Have you had any surgeries since your last pre-participation physical here at Penn State Behrend?
        Yes       No
        If yes, please describe the surgeries.



  C. Have you been admitted to the hospital for any reason since your last pre-participation physical here at
        Penn State Behrend?       Yes       No


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If yes, please explain why you were hospitalized.




III. FAMILY HISTORY
   A. Has any member of your family died of heart problems or of sudden death since your last pre-
        participation physical here at Penn State Behrend?
         Yes            No
     If yes, please explain




I hereby certify that the above stated responses are true and accurate. I understand that failure to disclose or
falsification of information may disqualify me from participation in intercollegiate athletics and releases Penn
State Erie, The Behrend College from medical, legal and financial responsibility for such conditions. I hereby give
my full consent to be examined by members of the Penn State Erie, The Behrend College Sports Medicine Staff
and submit to any medical tests deemed necessary, done at my own expense, to determine my fitness to
participate in intercollegiate athletics.


___________________________________________________                         _________________________________
                   Student-Athlete Signature                                              Date


___________________________________________________                         _________________________________
(Parent/Guardian Signature (If student-athlete is under 18 years of age)                  Date




               PENN STATE ERIE, THE BEHREND COLLEGE SPORTS MEDICINE SERVICES
                              CONSENT FOR MEDICAL TREATMENT
         By providing this medical information, I hereby give my consent to receive medical treatment
         for injuries/illnesses incurred by me as a result of participation in intercollegiate athletic
         activities as a student-athlete at Penn State Erie, The Behrend College. I understand that
         treatment will only be carried out by members of the Penn State Erie, The Behrend College
         Sports Medicine Staff or designated outside agencies. I also understand that the medical
         decisions regarding my participation status are solely those of the Penn State Erie, The Behrend
         College Sports Medicine Staff based on all medical information available and agree to abide by
         any decision made, understanding that said decision is made in the best interest of my overall
         health and well-being.

         __________________________________________                        ____________          _____________
                       Student-Athlete Signature                               Age                      Date


         __________________________________________________________                              __________________
                       Parent/Guardian Signature                                                        Date
               (If student-athlete is under 18 years of age)




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