Rhode Island College Student-Athletes, Parents or Guardians. FROM: Athletic Training/Sports Medicine Department. Athletic Insurance Information

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1 TO: Rhode Island College Student-Athletes, Parents or Guardians FROM: Athletic Training/Sports Medicine Department RE: Athletic Insurance Information We are pleased to have you/your son/daughter participating in athletics at Rhode Island College, and would appreciate your cooperation in obtaining some vital information regarding insurance. This will help to ensure the best medical coverage possible, and assist in quick claims procedures. This information will become a part of your permanent file; therefore it is imperative that the enclosed form be filled out in its entirety, and promptly returned to the following address: Athletic Training Office The Murray Center Rhode Island College 600 Mt. Pleasant Avenue Providence, RI Currently, our insurance coverage is an excess policy. Simply stated, this means that Rhode Island College s athletic insurance provider pays allowable benefits (up to the usual & customary allowance) only after the claim is processed through a primary insurance carrier retained by the parents, guardian, or the studentathlete themselves. This policy is similar to most other college and university athletic departments. STUDENT-ATHLETES MUST HAVE CURRENT PRIMARY INSURANCE IN ORDER TO BE A MEMBER OF A RHODE ISLAND COLLEGE ATHLETIC TEAM. Injuries occurring from participation in club sports, intramurals, recreation or any other activity outside the realm of intercollegiate athletics ARE NOT covered under this policy. Also, injuries sustained in the preparation of a sport that occur prior to the sport s official institutional start date are not considered to be athletically related. Likewise, any injuries occurring after the conclusion of a sport s official NCAA season are not covered. In addition, should your primary insurance coverage status change anytime throughout the calendar year, we ask that you inform us of the change thirty (30) days prior to turnover or termination. Be advised that should your insurance coverage lapse, all bills incurred from athletic participation will become your responsibility. The athletic department will not be liable for these types of expenses should this lapse occur. It is the student-athlete s responsibility to verify his/her insurance coverage. It is important to note that this policy is separate from that obtained through Rhode Island College. This policy is utilized for athletic related injuries only, whereas the Rhode Island College policy does not cover intercollegiate athletic injuries.

2 Should an athletic related injury occur, the student-athlete must notify a staff athletic trainer prior to seeking outside medical attention. Emergencies are an obvious exception. The student-athlete must report to the athletic training room to complete an insurance claim form and to receive pertinent secondary insurance information to be submitted to the medical provider at the time of service. It is the student-athlete s responsibility to ensure that the claim has been sent to their primary insurance carrier. After you submit the claim to the primary carrier, if there is a remaining balance, you must submit the provider bill and explanation of benefits statement (EOB) or denial notice, which you should receive in the mail from your primary insurance carrier, to the following address: Ms. Janet Karaica Summit America Insurance Services 2180 South 1200 East, Suite 520 Salt Lake City UT Fax We respect your right to seek a second opinion; however, we ask that this be done in consultation with the athletic training staff so proper lines of communication can be established to help facilitate the athlete s follow up care. Also, it is important to note that it is Rhode Island College s policy not to be held financially responsible for these second opinions. Likewise, the athletic department will not pay for any unauthorized visits to the doctor, hospital, x-ray facility, etc. We strive to provide the best services possible for the student-athletes at Rhode Island College, but your responsibilities in matters such as this are vital and cannot be neglected. We thank you for your time and careful attention to this matter. Please feel free to call us with any questions (401) Please retain this letter for your records and future reference.

3 Student-Athlete s Name: (FIRST) (LAST) (MIDDLE) SPORT: STUDENT IDENTIFICATION #: LOCAL ADDRESS: City, State, Zip HOME ADDRESS: City, State, Zip DATE OF BIRTH: LOCAL PHONE #: HOME PHONE #: FATHER/GUARDIAN: ADDRESS: (IF DIFFERENT) HOME PHONE #: WORK PHONE #: MOTHER/GUARDIAN: ADDRESS: (IF DIFFERENT) HOME PHONE #: WORK PHONE #: PRIMARY INSURANCE: INSURANCE CO.: POLICY #: INS. ADDRESS: City, State, Zip INSURANCE PHONE #: SUBSCRIBER S NAME: SECONDARY INSURANCE: INSURANCE CO.: POLICY #: INS. ADDRESS: City, State, Zip INSURANCE PHONE #: SUBSCRIBER S NAME: PLEASE INDICATE IF THIS POLICY IS A HEALTH MAINTENANCE ORGANIZATION (HMO) NO YES PLEASE CHECK HERE IF YOUR ONLY INSURANCE COVERAGE IS THROUGH RHODE ISLAND COLLEGE (University Health Plans/Consolidated Health). *BY SIGNING BELOW, YOU CONFIRM THAT YOU HAVE READ AND UNDERSTAND THE ENCLOSED POLICY AND GIVE RHODE ISLAND COLLEGE S INSURANCE PROVIDER THE RIGHT TO PROCESS ALL ATHLETIC RELATED BILLS AFTER PRIMARY COVERAGE HAS BEEN MET. YOUR SIGNATURE ALSO AUTHORIZES THE RELEASE OF INFORMATION FROM YOUR PRIMARY AND SECONDARY MEDICAL INSURANCE CARRIER TO THE RIC ATHLETIC DEPARTMENT. THE INFORMATION WILL BE UTILIZED TO PROPERLY DETERMINE THE COORDINATION OF BENEFITS BETWEEN THE TWO CARRIERS AS APPLICABLE. Parent/Guardian Signature Date: (IF ATHLETE IS UNDER 18) Student-Athlete Signature Date: Please include a photocopy of the front AND back of your insurance card

4 Office Use Only o Physical clearance o Insurance/Card o Medical questionnaire o HIPPA/Release to tx o Inj. Disclosure Form ATHLETIC MEDICAL QUESTIONNAIRE I. BIOGRAPHICAL DATA Name: Last First Middle Date Home Address: Student ID # City, State, Zip Local/Dorm Address: DOB: (If Different from above) Local Phone: ( ) Date Entered Rhode Island College: Sport(s): Cell Phone: ( ) Parent s/guardian s Information Mother: Address: Home Phone: ( ) Work Address Work Phone: ( ) Father: Address: Home Phone: ( ) Work Address Work Phone: ( ) Person to notify in case of emergency: (IF OTHER THAN PARENT/GUARDIAN) Phone: Relationship:

5 II. VISION INFORMATION III. DENTAL INFORMATION Do you wear eyeglasses? Yes No Do you have any special dental needs? Yes No For reading only? Yes No If yes, explain: For driving only? Yes No Do you have false teeth or bridges? Yes No For sports only? Yes No Do you have braces or retainers? Yes No All of the time? Yes No Have you had any wisdom teeth removed? Yes No Do you wear contact lenses? Yes No Do you wear prescription sport goggles? Yes No IV. GENERAL MEDICAL HISTORY PLEASE EXPLAIN ANY YES ANSWERS. 1. Have you ever been tested for, diagnosed with, or treated for any of the following conditions: a. Asthma? No Yes If yes, do you require an inhaler for athletic activities? b. Diabetes? No Yes If yes, Do you daily monitor your blood sugar level? No Yes How many times per day? What is your average level? c. Epilepsy? No Yes d. Hepatitis? No Yes e. Mononucleosis? No Yes f. Migraines? No Yes g. Frequent Headaches? No Yes h. Ear Problems? No Yes i. Ulcer? No Yes j. Appendicitis? No Yes k. Hemorrhoids? No Yes l. Kidney Problems? No Yes m. Gout? No Yes n. Liver Problems? No Yes o. Eating Disorders? No Yes p. Rheumatic Fever? No Yes q. ADD/ADHD No Yes (If yes, please submit NCAA medical exception paperwork)

6 IV. GENERAL MEDICAL HISTORY (Cont.): 2. Do you have allergies to: a. Food? b. Medications? c. Other? 3. Do you take medication(s) regularly? No Yes If yes, please list 4. Have you ever had a hernia? No Yes If yes, please explain and list date(s) 5. Have you ever had an organ removed surgically or one that was absent at birth? (i.e. kidney, testicle, ovary) No Yes If yes, please list 6. Have you ever vomited blood or passed blood in the stool or urine? No Yes If yes, please explain 7. If female, do you experience any problems with your menstrual cycle? No Yes If yes, please explain a. Have you had menstrual periods within the past 12 months? No Yes If yes, how many? When was your most recent menstrual period? b. How much time do you usually have from the start of one period to the start of another? c. What was the longest time between menstrual periods within the past year? 8. Are you presently being treated by a doctor? No Yes If yes, please explain 9. Do you have any general health condition(s) not covered in this section? No Yes If yes, please explain V. CARDIAC HISTORY PLEASE EXPLAIN ANY YES ANSWERS 1. Have you ever been tested for, diagnosed with, or treated for Marfan s Syndrome? No Yes 2. Do you have any heart disease or heart murmur? No Yes 3. Do you presently have or have you ever had anemia? No Yes 4. Have you ever been diagnosed as having high blood pressure? No Yes 5. Do you have Hemophilia? No Yes 6. Have you ever been treated by a doctor for a heart or blood condition? No Yes 7. Do/did either of your grandparents ever have: PLEASE INDICATE WHICH GRANDPARENT a. Heart Disease? No Yes b. High Blood Pressure? No Yes c. Diabetes? No Yes d. Stroke? No Yes 8. Has any blood relative died suddenly before the age of 50 other than due to trauma? No Yes

7 VI. HEAD INJURIES / CONCUSSION: 1. Have you ever suffered a Head Injury / Concussion (no matter how minor)? NO YES List Date(s) / Time Missed (e.g. practices or games) Please Describe 2. Have you ever been evaluated by a doctor for a Head Injury / Concussion? NO YES Please Describe Were any diagnostic tests performed? NO YES (check all that apply) X-ray MRI CT-Scan Neuropsychological Testing Other 3. Have you ever been hospitalized, knocked out, become unconscious, and/or lost your memory due to a Head Injury / Concussion? NO YES Please Describe 4. Have you ever been advised not to participate in athletic activities due to a Head Injury / Concussion? NO YES Please Describe 5. Do you suffer from headaches? NO YES (check all that apply) When? Every Day 1-2 Times/Week 1-2 Times/Month Where Are Your Headaches Located? Left Side of Head Right Side of Head Front of Head Back of Head All Over Your Head 6. Do You Have A History of Migraine Headaches? NO YES Please Describe How Often? Medications Taken for Migraines? 7. Have You Had Headaches For More Than Three (3) Months? NO YES Please Explain VII. ORTHOPEDIC HISTORY PLEASE EXPLAIN ANY YES ANSWERS 1. Have you ever had any of the following neck problems: a. Burners or pinched nerve? No Yes b. Sprain? No Yes c. Fracture/Dislocations? No Yes d. Surgical Fusion? No Yes e. Other? (i.e. disc disease/injury) No Yes 2. Do you have frequent mid-back pain? No Yes 3. Do you have frequent low-back pain? No Yes 4. Have you ever had a low-back problem that caused a burning sensation, numbness, or weakness down either/both legs? No Yes 5. Have you ever had any of the following: a. Bone/Tissue infection? No Yes b. Fractures? No Yes c. Cysts, Tumors, Bone Deformities? No Yes d. Cortisone Shot? No Yes e. Separated/Dislocated joint? No Yes f. Water on the knee or other joint? No Yes g. Painful shoulder secondary to activity? No Yes

8 VII. ORTHOPEDIC HISTORY (Cont.) 6. Have you ever had: a. Bone, Joint, or Ligament Surgery? No Yes b. Metal Screws, Plates, or Staples inserted? No Yes c. Surgery advised but not done? No Yes d. Arthrogram (dye study)? No Yes e. Arthroscope? No Yes f. Magnetic Resonance Imaging (MRI) No Yes g. Bone Scan, Bone Density Study, Tomogram? No Yes h. Computerized Axial Tomography (CAT Scan) No Yes 7. Do you suffer frequent/severe Joint sprains/strains? No Yes 8. Do you wear or have you been advised to wear orthotics in your shoes? No Yes 9. Do you regularly wear any brace, tape, or other appliance for protection or to correct an orthopedic problem? No Yes 10. Please list any problems you have had examined by an orthopedic physician. 11. Please list any orthopedic problems/conditions you have that are not covered in this section: 12. Have you ever been advised to not participate in athletics because of a head, neck or other orthopedic problem? No Yes VIII. HEALTH HABITS: {All questions are strictly CONFIDENTIAL & will not be shared with parents or coaches!} NO YES Have you ever had any injury or illness other than those already noted? NO YES Do you have any ongoing or chronic illnesses? NO YES Have you ever been hospitalized overnight? NO YES Have you ever been told by a physician to restrict your sports activity or not to participate in a sport? NO YES Are you currently under a physician s care for any medical conditions? NO YES Have you ever been under the care of a psychiatrist and/or psychologist? NO YES Have you consulted and/or been under the care of a chiropractor, podiatrist and/or other such practitioner in the past five (5) years? NO YES Have you ever had a rash or hives develop during and/or after exercise? NO YES Do you cough, wheeze, or have trouble breathing during or after exercise / practice? NO YES Have you ever been told that you have kidney disease? NO YES Have you had a viral infection (i.e. mononucleosis, myocarditis, etc.) within the past six (6) months? NO YES Have you ever had seizures, convulsions, and/or epilepsy? NO YES Have you ever had gall bladder disease and/or a urinary problem? NO YES Do you have ringing in your ears or trouble hearing? NO YES Do you have frequent ear infections or nosebleeds? NO YES Have you ever had an abnormal chest x-ray and/or pneumonia? NO YES Do you require any special equipment (braces, neck rolls, dental, orthotics, hearing aids, etc.) NO YES Have you ever had the chickenpox? If yes, when?

9 NO YES Have you had a tetanus booster within the past five (5) years? If yes, when? NO YES Have you ever received the Hepatitis B (HBV) Vaccination series (all 3 shots)? If yes, when? NO YES Do you smoke cigarettes, use smokeless tobacco, or use tobacco in any form? NO YES Do you use alcohol? If yes, how often? NO YES Have you ever used / tried marijuana, cocaine, or any other illicit street drugs? NO YES Do you have any questions regarding drugs, tobacco, or alcohol? NO YES Do you take or have you taken Ergogenic Aids/Supplements? NO YES Do you feel stressed out? If yes, do you feel as though you get the necessary support to deal with your stress? NO YES Have you had a weight change (loss or gain) of greater than 10 pounds in the past year? NO YES Are you a vegetarian? If yes, what type? NO YES Do you regularly lose weight to participate in your sport? NO YES Do you want to weigh more or less than you presently do? NO YES Have you ever felt forced to limit your food intake due to concerns about your weight and/or body size? NO YES Have you had a history of anorexia, bulimia (forced vomiting), and/or any other eating disorders? NO YES Have you had any hypoglycemic episodes (low blood sugar) within the last twelve (12) months? NO YES Would you like to meet with a dietitian to discuss your nutritional needs or eating habits? If you have answered YES to any of the above, please explain: IX. HEAT-RELATED PROBLEMS: 1. Have you ever suffered from a heat related injury? NO YES (Check all that apply): Heat Cramps-Date(s)? Heat Syncope (Fainting)-Date(s)? Heat Exhaustion-Date(s)? Heat Stroke-Date(s)? 2. Have you ever received intravenous fluids (IV) for a heat-related problem? NO YES Date(s)? 3. Have you ever been hospitalized for a heat-related problem? NO YES Date(s)? 4. Have you ever been advised not to participate in athletic activities due to a Heat-related Injury? NO YES Please Describe

10 X. DERMATOLOGIC: 1. Do you have any skin problems that we should be aware of (e.g. itching, rashes, acne, warts, eczema, fungus, etc.)? NO YES Please Describe/Date 2. Have you ever been under the care of a dermatologist for any condition? NO YES Please Describe 3. Have you ever been advised not to participate in athletic activities due to a skin condition? NO YES Please Describe AFFIRMATION OF MEDICAL HISTORY: Please describe below any further injury/illness information, which is knowledgeable to you and not included on this form. Have you ever been advised to not participate in athletics because of a physical, medical, or mental problem? No Yes If you have a private physician, please give his/her name, address, and date of last physical exam. ALL OF THE ABOVE HAS BEEN ANSWERED TRUTHFULLY AND TO THE BEST OF MY KNOWLEDGE. I GRANT PERMISSION TO RHODE ISLAND COLLEGE HEALTH SERVICES TO RELEASE INFORMATION TO THE SPORTS MEDICINE STAFF REGARDING MY HEALTH AS IT PERTAINS TO MY PARTICIPATION IN THE INTERCOLLEGIATE ATHLETIC PROGRAM AT THE COLLEGE. STUDENT-ATHLETE SIGNATURE DATE Office Use Only Reviewed By: Reviewer s Signature Date Reviewer s Printed Name

11 HIPPA Release Authorization While various interpretations exist regarding covered entities as related to privacy matters, the following represents a release authorization for the sharing of medical information. By signing below I understand the following conditions: A. The authorization covers information about injury and illness that might occur during the course of the academic year. B. The authorization is valid for one year only and will conclude at the end of the academic year unless the specific situation remains unresolved. C. The authorization covers only those directly involved with my athletic participation including primary care physicians, team physicians, consulting physicians, emergency room physicians, athletic trainers, physical therapists, coaches, strength & conditioning staff and any others directly involved with issues affecting my general fitness to participate in intercollegiate athletics. The above information will be given to only those either directly involved in the care and treatment of any specific condition, to those responsible for rehabilitation or athletic-related fitness or conditioning programs or to those responsible for decisions regarding actual participation in practice or game situations. Any athlete has the right to revoke this authorization and by doing so cannot and will not be denied any required medical care. Participation in intercollegiate athletics is contingent upon the completion of this authorization; therefore, choosing to revoke this authorization is a choice not to play. By signing below, I attest that I have read the above statement, understand its intent, and grant release authority as outlined within. Name: Sport: Signature: Date:

12 ASSUMPTION OF RISK & RELEASE TO TREAT NAME: LOCAL ADDRESS: DATE: PHONE: HOME ADDRESS PHONE: SPORT Student ID.# Participation in sport requires an acceptance of risk of injury. The realm of that risk can include catastrophic injury and/or death. Student-athletes rightfully assume that those who are responsible for the conduct of sport have taken reasonable precautions to minimize such risk, and that their peers participation in sport will not intentionally inflict injury upon them. By choosing to participate in sport, the student-athlete acknowledges the above, and accepts risks as an inherent part of their chosen sport. Periodic analysis of injury patterns lead to refinements in the rules and other safety decisions. 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. RELEASE TO TREAT By signing below, I hereby authorize the Athletic Training Staff, Team Physicians and Medical consultants of Rhode Island College to provide any and all care as deemed necessary for any specific injury or condition. Please Print Full Name: Signature Date: Parent/Guardian Signature Date: (Necessary if Athlete is under 18 years of age)

13 AGREEMENT TO DISCLOSE INJURIES OR ILLNESSES In consideration of my being permitted to participate in the intercollegiate athletic program(s) at Rhode Island College, I agree to fully disclose to the Rhode Island College Sports Medicine staff, health services staff, team physicians, and/or medical consultants engaged by them, any and all signs and symptoms of injury and/or illness, including concussions/mild traumatic brain injury about which I become aware. I understand that any disclosed information will be utilized for the purpose of safeguarding my health as it pertains to my participation in intercollegiate athletics at Rhode Island College. I also understand that any disclosed information will be treated as confidential health care information and will only be shared with those directly involved in decisions related to my participation in Rhode Island College athletics. I also verify that I have been given information or told how to electronically access information pertaining to the signs/symptoms, prevention, and care of concussions/mild traumatic brain injury, including a copy of the Rhode Island College athletics concussion protocol, which is also available in the athletic training room for my reference. Name (please print) Sport Signature Date

14 For Freshman and Transfer Student-Athletes Only Sickle Cell Screen Guideline and Waiver Dear Parents and RIC Incoming Student-Athletes, Recently, The NCAA Division III delegates adopted new legislation to mandate testing for Sickle Cell Trait for all new incoming student-athletes for the academic year. Therefore, prior to participation in any varsity athletic activities (including try-outs, camps, pre-season conditioning, practices, or competitions), new athletes must either 1) show proof of prior testing for sickle cell trait, 2) get tested for sickle cell trait if a prior test is not available, or 3) sign a waiver releasing Rhode Island College of liability if they decline to be tested. New student-athletes need to do one of the following: 1. Provide RIC with documentation showing your sickle cell trait status. Many states test routinely at birth. Contact your health care provider to request a copy of your results. Additionally, some results are available through the New England Newborn Screening Program for the following states: MA, ME, NH, RI, and VT. Visit for further contact information for each state. Or 2. If no report is available, you can request to have the blood test done by your Primary Care Provider and results sent to RIC Health Services. Alternatively, you can make an appointment at RIC Health Services for the testing to be done on campus ($12 lab fee may apply). If you need to be tested, make arrangements as soon as possible to avoid delay in obtaining your results. Or 3. Sign a waiver releasing Rhode Island College, its officers, employees, and agents from any and all costs, liability, expense claims, demands or causes of action on account of any loss or personal injury that might result from your refusal to be tested. Submit the completed and signed waiver to RIC Health Services. Please note: It is preferred that all athletes know their status to help ensure their health during participation in athletics. Prior to signing the waiver, we advise all athletes to consult with their Primary Care Provider and parent or guardian. Please return a copy of your lab report or a signed waiver to: Rhode Island College Health Services Browne Hall 600 Mount Pleasant Ave Providence, RI P: (401) F: (401) For more information on Sickle Cell Trait Go to and follow the Health & Safety tab followed by the Sickle Cell Trait link on the right Athletes that are positive for the sickle cell trait will have reasonable precautions to manage the condition while participating in their sport such as the following; be allowed to slowly build up the intensity and duration of their training, longer rest periods for recovery, modified performance tests and altering their participation status during periods of heat stress, dehydration, asthma or illness.

15 Rhode Island College Sickle Cell Trait Waiver Form About Sickle Cell Trait: Sickle cell trait is an inherited condition of the oxygen-carrying protein, hemoglobin, in the red blood cells. Sickle cell trait is a common condition (over 3 million Americans.) Although sickle cell trait is most predominant in African-Americans and those of Mediterranean, Middle Eastern, Indian, Caribbean, and South/Central American ancestry, persons of all races and ancestry may test positive for sickle cell trait. Sickle cell trait is usually benign, but during intense, sustained exercise, hypoxia (lack of oxygen) in the muscles may cause sickling of red blood cells. The cells change from their normal disc shape to a crescent or sickle shape. They can then accumulate in the bloodstream and block blood vessels, leading to collapse from the breakdown of muscles starved of blood. Sickle Cell Trait Testing: The NCAA recommends that all athletes have knowledge of their sickle cell trait status. All new student-athletes for the fall of 2013 are required to show proof of prior sickle cell testing, be tested for sickle cell trait, or sign a waiver before participating in any athletic events; including conditioning, try-outs, camps, practices, or competitions. Sickle Cell Trait Testing Waiver I,, understand and acknowledge that the NCAA recommends that all athletes have knowledge of their sickle cell status. Additionally, I have read and fully understand the aforementioned facts and the Department of Athletics policy about sickle cell trait and sickle cell trait testing, and I acknowledge that Rhode Island College has suggested that I consult with my Primary Care Provider and parent or guardian prior to signing this waiver. I hereby affirm that I have fully disclosed in writing any prior medical history and/or knowledge of sickle cell trait status Rhode Island College s Athletic Department and Health Services personnel. I do not wish to undergo sickle cell trait testing and I understand that by refusing to undergo this testing, I assume all risks associated with such refusal and, in consideration for being granted the opportunity to participate in intercollegiate athletics at Rhode Island College without agreeing to be tested for the sickle cell trait, I (for myself, my heirs, my executors, my administrators and assigns) voluntarily agree to release, discharge, indemnify, and hold harmless the Rhode Island Board of Education, Rhode Island College, their officers, members, employees, agents, and their successors and assigns (collectively, the Releasees )from any and all liability, actions, causes of action, debts, costs, claims, demands, damages or expenses, including attorneys fees, arising from any loss or personal injury, including death, related in any way to my participation in intercollegiate athletics at the College without being tested. I understand that the signing of this waiver means that, among other things, I am giving up the right to sue the Releasees for any such losses, damages, injury or costs that I may incur. I have read and signed this document with full knowledge of its significance. I further state that I am at least 18 years of age and competent to sign this waiver. Athlete s Signature Athlete s Print Name Date Parent/Guardian s Signature Parent/Guardian s Print Name Date (if under 18 years of age) Witness Signature Date