OAKLAND UNIVERSITY INTERCOLLEGIATE ATHLETIC MEDICAL INSURANCE

Transcription

1 OAKLAND UNIVERSITY INTERCOLLEGIATE ATHLETIC MEDICAL INSURANCE We are extremely pleased to have your son/daughter as a student-athlete at Oakland University and hope that he/she will achieve academic, social, and athletic success. Each student-athlete is required to have a physical examination prior to any participation in any intercollegiate sport. The final decision on physical qualifications or reason for rejection is the responsibility of the team physician or athletic trainer. The team physician and/or athletic trainers also make the decision on when a student- athlete may return to competition after a previous injury. INJURIES-MEDICAL BILLS-INSURANCE COVERAGE-CLAIM PROCEDURE Injuries do occur and we attempt to provide our student athletes with the very best possible care. Medical bills are incurred when the athlete is treated, whether it is locally, during a road trip, or by a medical vendor in his/her home area. Report all injuries to the athletic trainer. A Certified Athletic Trainer will then refer you to the appropriate doctor if your case warrants further treatment or examination. Please remember that the Athletic Department will not assume responsibility for fees you incur with outside physicians, dentists, or healthcare facilities/providers unless the sports medicine personnel have referred you to such services. ONE FIRM STATEMENT: The NCAA does not permit us or any college or university to provide coverage or pay the bills incurred for expenses related to illnesses or conditions that are not sustained as a direct result of an accident in our intercollegiate sports program. INSURANCE COVERAGE: Oakland University provides a secondary athletic accident insurance for your son/daughter for accidents incurred while participating in the play or official practice of intercollegiate sports. It is the responsibility of every Oakland University student-athlete to have his/her own accident insurance. CLAIM PROCEDURE: All medical bills for your son/daughter incurred as the result of an injury in the intercollegiate sports program will be sent directly to your son/daughter or to your home address, unless the university has instructed the medical vendors otherwise. In some cases the Athletic Department may get a copy of the bill, but in no case will the Athletic Department be the primary place for the bill to be sent. A. Submit the bills incurred to your family insurance or employer group insurance plan first. They will do one of two things: a. Honor the claim and pay all or a portion of the bills incurred. b. Not honor the claim and send you a letter of denial. An example might be that your son/daughter is no longer part of your group policy after attaining the age of twenty-three. B. If there remains a balance after your family insurance, or employer group insurance plan has contributed towards the claim, send an explanation of benefits from the insurance company and a copy of the itemized bills incurred to the athletic department. If you receive a letter of denial from your family, employer group insurance or plan administrator, then send the letter of denial and a copy of the bills incurred to the Athletic Department. If you have no coverage, a letter from your employer with verification will be necessary. C. If the bills incurred are not paid by the family insurance, employer group insurance plan, the claim will be sent from the Athletic Department to our insurance carriers for processing. If they need any additional information, please cooperate with them and they will process the claim in the least possible amount of time. It is in your best interest to have the claim settled promptly since all bills incurred are in your name. OUMEDINSINFO 09 PLEASE KEEP THIS FORM FOR FUTURE REFERENCE

2 OAKLAND UNIVERSITY EMERGENCY INFORMATION Student Athlete Information Name of Athlete Sport Grizzly ID Number of Birth College Cell/College Phone Home Home Phone City State Zip Code Medical History Diabetes YES NO Epilepsy YES NO Heart Trouble YES NO Metal Pins YES NO Contacts/Glasses YES NO Blood Type Allergies: Medical History: Insurance Information Parent(s) Name of Birth Home Home/Cell Phone Work Phone Employer Medical Insurance Company Contract / Policy Number Insurance Phone Number In case of injury or serious illness, I hereby grant permission for Oakland University to secure medical services for the above named student athlete. Signature of Parent/Guardian ()

3 OAKLAND UNIVERSITY SPORTS MEDICINE MEDICAL HISTORY PLEASE PRINT DATE NAME DATE OF BIRTH Last First Middle CAMPUS ADDRESS PHONE HOME ADDRESS CITY STATE ZIP CODE SPORT G Number YEAR IN SCHOOL DO YOU HAVE A FAMILY PHYSICIAN? YES / NO IF SO, NAME CITY PHONE I. HOSPITALIZATION / SURGERY 1. Are you currently under medical supervision? Explain 2. Have you ever had surgery? Reason Reason Reason Reason 3. Have you ever been hospitalized for a reason other than surgery? Reason Reason 4. Have you ever been advised to have surgery not yet performed? If yes, why and when 5. I give permission to the Oakland University Sports Medicine Staff to receive my medical records. II. MEDICATION 1. Do you regularly use any prescription medication ( e.g., asthma, seizure, oral contraceptives)? If yes, List: 2. Do you regularly use any non-prescription medication (e.g., Advil, Sudafed ) 3. Do you regularly take nutritional supplements? If yes, describe: 4. Do you use narcotics, anabolic steroids or street drugs? If yes, describe: 5. Do you use tobacco products? If yes, describe: III. ALLERGIES

4 Aspirin Asthma Dust, Pollen Food (specify) Insect Stings (specify) Novocain Penicillin Sulfa Drugs TB Tine Test Tetanus Serum Other Drugs (specify) IV. IMMUNIZATIONS Flu Hepatitis B Measles Mumps Rubella TB Test Tetanus V. ILLNESSES (give date if within the past 3 years) Chicken Pox Diabetes Headaches (frequent or severe) Hepatitis Measles Mononucleosis Pneumonia Rheumatic Fever Scarlet Fever Stomach Disorder Tuberculosis Other (specify) VI. CARDIOVASCULAR SYSTEM 1. Have you ever fainted during exercise? 2. Have you ever had chest pains during or after exercise? 3. Have you ever been told that you might have high blood pressure? 4. Have you ever been told that you have a heart murmur? 5. Have you ever had a racing of your heart or skipped heartbeats? 6. Has anyone in your family died of heart problems or a sudden death from non traumatic causes before age 50? 7. Does anyone in your family have a history of Marfans Syndrome? Additional Information VII. HEAT PROBLEMS Have you ever had heat or muscle cramps? Have you ever been dizzy or faint in the heat? Have you ever been given I.V. fluids for heat problems? VIII. MUSCULOSKELETAL SYSTEM Have you ever injured any of the following that caused you to miss significant playing time (a week or more)? : Explain:

5 Y / N R / L Hip Y / N R / L Abdomen / Groin Y / N R / L Thigh Y / N R / L Knee Y / N R / L Shin / Calf Y / N R / L Ankle Y / N R / L Foot / Toes Y / N R / L Skull / Face / Nose Y / N R / L Teeth / Jaw Y / N R / L Neck Y / N R / L Back Y / N R / L Shoulder Y / N R / L Upper Arm Y / N R / L Elbow Y / N R / L Forearm Y / N R / L Wrist Y / N R / L Hand / Fingers IX. NEUROLOGIC SYSTEM 1. Have you ever had a head injury? If yes, date / explain 2. Have you ever been knocked out or unconscious? If yes, date / length of unconsciousness / explain / more than once 3. Have you ever had a seizure? If yes, date / explain 4. Have you ever had a stinger, burner or pinched nerve? If yes, date / explain X. OTHER MEDICAL CONDITIONS 1. Do you now or have you ever had: Anemia Calcium Deposit Eye Injury or Other Eye Problems Hearing Loss Hernia Severe Tooth or Gum Trouble Skin Problems (rashes, acne, boils) 2. Do you have loss or seriously impaired function of any paired organ? Ear Eye Kidney Ovary Testicle 3. Do you have? Contact Lenses Do you wear them during athletic competition Eyeglasses Do you wear them during athletic competition Corrective Brace or Support 4. Do you: Have any dental problems? Dead Teeth? Indicate Location Wear a dental appliance? Require a special mouth guard? 5. Pre-existing conditions:

6 Do you know of or do you believe there is any health reason that should prevent you from participating in intercollegiate athletics? If yes, explain 6. Have you ever been screened for the sickle cell trait? Result: XI. FOR WOMEN ONLY of last menstrual period? of last gynecological exam / pap smear? My periods are now: (circle one) Regular (every days) Irregular (every 36 days or more) Absent (no periods for 3 months) 1. Do you have any gynecological problems (i.e. cramps, PMS, discharge, etc.) If yes, explain 2. Have you ever missed periods for 6 months or more? If yes, explain 3. Do any family members have a history of menstrual problems? If yes, explain ************************************************************************************* I certify that the answers to the preceding questions are correct and true. I understand that passing the physical exam does not necessarily mean that I am physically qualified to engage in intercollegiate athletics, but only that the examiner did not find a medical reason to disqualify me from participation. Student - Athlete s Signature It is understood that even though protective equipment is worn by the athlete, whenever needed, the possibility of an accident still remains. If in the judgment of any representative of Oakland University the above student-athlete should need immediate care and treatment as a result of any injury or sickness, I do hereby request, authorize, and grant permission to the attending physician, Oakland University Sports Medicine Staff, or other medical personnel to proceed with medical or minor surgical treatment, x-ray examination and immunizations. In the event of serious injury or illness, I understand that an attempt will be made by the appropriate medical personnel to contact my parents or legal guardian. If medical personnel are not able to communicate with the responsible party, the treatment necessary for my health may be provided. I do hereby agree to indemnify and save harmless the University and any Oakland University representative from any claim by any person whomsoever on account of such care and treatment of said athlete. Student - Athlete s Signature Parent / Guardian s Signature OUMEDHIS09

7 OAKLAND UNIVERSITY PHYSICAL EXAMINATION Examination NAME DATE OF BIRTH SEX M or F SPORT ATHLETIC SHOE SIZE MEN OR WOMEN HEIGHT WEIGHT BODY COMP PULSE BP / VISION R 20/ L 20/ CORRECTED Y N GLASSES CONTACTS MEDICAL: NORMAL ABNORMAL FINDINGS INITIALS APPEARANCE SKIN EYES (PUPILS: EQUAL / UNEQUAL) EARS / NOSE / THROAT LYMPH NODES DENTAL HEART (MURMUR / RHYTHM) LUNGS ABDOMEN (HERNIA, MASSES, TENDERNESS, SCARS ) GENITALIA: MALES ONLY (HERNIA, TESTICLES) MUSCULOSKELETAL: NECK BACK POSTURE SHOULDERS / ARMS ELBOW / FOREARM WRIST / HAND HIP / THIGH KNEE LOWER LEG / ANKLE FOOT / ARCHES FLEXIBILITY STRENGTH CLEARED RESTRICTIONS: NOT CLEARED FOR: REASON: RECOMMENDATIONS: NAME OF PHYSICIAN (PRINT / TYPE): ADDRESS: PHONE: SIGNATURE OF PHYSICIAN: PHYSEXAM09

8 Oakland University Sports Medicine Sickle Cell Trait Fact Sheet for Student-Athlete What is Sickle Cell Trait? Sickle Cell Trait is not a disease. Sickle Cell trait is the inheritance of one gene for sickle hemoglobin. Sickle cell trait will not turn into the disease. Sickle cell trait is a life long condition that will not change over time During intense exercise, red blood cells containing the sickle hemoglobin can change shape from round to quarter moon, or sickle. Sickled red cells may accumulate in the bloodstream during intense exercise, blocking normal blood flow to the tissues and muscles. During intense exercise, athletes with sickle cell trait have experienced significant physical distress, collapsed and even died. Heat, dehydration, altitude and asthma can increase the risk for and worsen complications associated with sickle cell trait, even when exercise is not intense Athletes with sickle cell trait should not be excluded from participation as precautions can be put into place Do You Know If You Have Sickle Cell Trait? People at high risk for having sickle cell trait are those whose ancestors come from Africa, South or Central America, India, Saudi Arabia, and Caribbean and Mediterranean countries. Sickle cell trait occurs in about 8 percent of the U.S. African American population, and between one in 2,000 to one in 10,000 in the Caucasian population Most U.S. states test at birth, but most athletes with sickle cell trait don t know that they have it. The NCAA recommends that athletics departments confirm the sickle cell trait status in all student athletes. Knowledge of sickle cell trait status can be a gateway to education and simple precautions that may prevent collapse among athletes with sickle cell trait, allowing you to thrive in your sport. How Can You Prevent a Collapse? Know your sickle cell status. Engage in a slow and gradual preseason conditioning regimen Build up your intensity slowly while training Set your own pace. Use adequate rest and recovery between repetitions, especially during gassers and intense station or mat drills. Avoid pushing with all out exertion longer than two to three minutes without a rest interval or a breather. If you experience symptoms such as muscle pain, abnormal weakness, undue fatigue or breathlessness, stop the activity immediately and notify your athletic trainer and/or coach. Stay well hydrated at all times, especially in hot and humid conditions.

9 Avoid using high caffeine energy drinks or supplements, or other stimulants, as they may contribute to dehydration Maintain proper asthma management Refrain from extreme exercise during acute illness, if feeling ill, or while experiencing a fever. Beware when adjusting to a change in altitude, e.g., a rise in altitude of as little as 2,000 feet. Modify your training and request that supplemental oxygen be available to you Seek prompt medical care when experiencing unusual physical distress For more information and resources, visit safety or speak with a member of the OU Sports Medicine staff.

10 OAKLAND UNIVERISTY SPORTS MEDICINE SICKLE CELL TRAIT WAIVER FORM Sickle Cell Trait Testing The NCAA mandates that all NCAA student-athletes have knowledge of their sickle cell trait status before the student-athlete participates in any intercollegiate athletics event, including strength and conditioning sessions, practices, competitions, etc. The NCAA and Oakland University strongly recommend that EVERY student-athlete be tested for sickle cell trait. The Oakland University Department of Intercollegiate Athletics offers sickle cell trait screening in the form a blood test to all student-athletes as part of the pre-participation physical examination process. I understand that I am under NO obligation to be tested for sickle cell trait and that my refusal to be tested for sickle cell trait will NOT be held against me and will NOT negatively impact my practice or playing time at Oakland University. Notwithstanding the above, if I refuse sickle cell trait testing and if Oakland University believes, in its reasonable judgment, that I may be at risk or exhibit symptoms of sickle cell trait, Oakland University MAY require testing in order to ensure my safety and may withhold me from practice and/or competition until I agree to sickle cell trait testing. Testing for Sickle Cell trait will be conducted at a specified lab and results will be reported to the Oakland University Director of Sports Medicine. I have had the opportunity to read the Oakland University Sport Medicine Fact Sheet on Sickle Cell Trait. In addition, I have been given the opportunity to ask questions concerning the sickle cell trait and testing. Furthermore, I was able to discuss the risks associated with participating in intercollegiate athletics. Any questions or concerns that I may have had have been addressed to my satisfaction. I understand the risks involved if I choose NOT to be tested for sickle cell trait, and I knowingly assume such risks. SICKLE CELL TRAIT TESTING WAIVER I, understand and acknowledge that the NCAA Student-Athlete Name and the Oakland University Department of Intercollegiate Athletics mandate that all student-athletes have knowledge of their sickle cell trait status. Additionally, I have read and fully understand the aforementioned facts about sickle cell trait and sickle cell trait testing. Recognizing that my true physical condition is dependent upon an accurate medical history and a full disclosure of any symptoms, complaints, prior injuries, ailments, and/or disabilities experienced. I hereby affirm that I have fully disclosed in writing any prior medical history and/or knowledge of sickle cell trait status to Oakland University Sports Medicine staff. I do not wish to undergo sickle cell trait testing as part of my pre-participation physical examination and I voluntarily agree to release, discharge, indemnify and hold harmless the State of Michigan, the University, its officers, employees and agents from any and all costs, liabilities, expenses, claims, demands, or causes of action on account of any loss or personal injury that might result from my non-compliance with the mandate of the NCAA and the Oakland University Department of Intercollegiate Athletics. 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. Student-Athlete Signature Sport Grizz ID # Parent/Guardian Signature (If under 18years of age) Parent/Guardian Print Name Witness

11 First Agency, Inc West H Avenue Kalamazoo, MI PARENT/ GUARDIAN/STUDENT INFORMATION FORM RETURN FORM WHEN COMPLETE TO Name of College/University Attention This form is to be completed by the Parents, Guardians or Student. City State Zip Note: Complete all blanks on this form. Failure to complete all blanks will result in claims processing delays. If information is not applicable, indicate the reason it is not (e.g., deceased, divorced, unknown). Name of Athlete Sport Social Security No. or Passport No. of Birth Please note that the Injured Person s Social Security Number MUST be provided as required by the Center for Medicare Services pursuant to Section 111 of the Medicare, Medicaid and SCHIP Extension Act of College College Phone ( ) Home Home Phone ( ) City State Zip FATHER /GUARDIAN INFORMATION MOTHER /GUARDIAN INFORMATION Father s Name Social Security No. of Birth Mother s Name Social Security No. of Birth Employer Employer Telephone ( ) Telephone ( ) Medical Insurance Company or Plan Medical Insurance Company or Plan Policy Number Telephone ( ) Policy Number Telephone ( ) Is this plan an HMO or PPO? Yes No Is pre-authorization required to obtain treatment? Yes No Is a second opinion required before surgery? Yes No Is this plan an HMO or PPO? Yes No Is pre-authorization required to obtain treatment? Yes No Is a second opinion required before surgery? Yes No PLEASE COMPLETE AUTHORIZATION ON REVERSE SIDE OF THIS FORM Berkley OS /10

12 First Agency, Inc West H Avenue Kalamazoo, MI AUTHORIZATION - To Permit Use and Disclosure of Health Information This Authorization was prepared by First Agency, Inc. for purposes of obtaining information necessary to process a claim for benefits. Upon presentation of the original or a photocopy of this signed Authorization, I authorize, without restriction (except psychotherapy notes), any licensed physician, medical professional, hospital or other medical-care institution, insurance support organization, pharmacy, governmental agency, insurance company, group policyholder, employer or benefit plan administrator to provide First Agency, Inc. or an agent, attorney, consumer reporting agency or independent administrator, acting on its behalf, all information concerning advice, care or treatment provided the patient, employee or deceased named below, including all information relating to, mental illness, use of drugs or use of alcohol. This Authorization also includes information provided to our health division for underwriting or claim servicing and information provided to any affiliated insurance company on previous applications. If this Authorization is for someone other than myself, that individual has given me authority to act on his/her behalf as explained below. I understand that I have the right to revoke this Authorization, in writing, at any time by sending written notification to my agent or to us at the above address. I understand that a revocation will not be effective to the extent we have relied on the use or disclosure of the protected health information or if my Authorization was obtained as a condition to determine my eligibility for benefits. Revocation requests must be sent in writing to the attention of the Claims Supervisor. I understand that First Agency, Inc. may condition payment of a claim upon my signing this authorization, if the disclosure of information is necessary to determine the level or validity of the claim payment. I also understand, once information is disclosed to us pursuant to this Authorization, the information will remain protected by First Agency, Inc. in accordance with federal or state law. I understand that I, or my authorized representative, is entitled to receive a copy of this authorization upon request This Authorization is valid from the date signed for the duration of the claim. Name of Claimant (please print) Name of Authorized Representative, or Next of Kin (please print) Signature of Claimant (if claimant is 18 or older) Signature of Authorized Representative or Next of Kin Relationship of Authorized Representative or Next of Kin to Claimant

13 OAKLAND UNIVERSITY SPORTS MEDICINE INFORMATION RELEASE AUTHORIZATION I,, give consent for my medical records to be released to any Oakland University Team Physician involved in the care of my illness or injury; or to a physician appointed by the Oakland University Sports Medicine Staff. Athlete s Signature / / I also give consent for the Oakland University Sports Medicine Staff to release the following information to the sports information department, media or a scout / representative of any professional or amateur athletic organization seeking information (for employment purposes). - Body part affected by injury or illness - Nature of the injury (sprain, fracture, etc. ) -Status of the athlete for same day and future competition Athlete s Signature / / THIS RELEASE REMAINS VALID UNTIL REVOKED IN WRITING BY THE ABOVE SIGNED OU INFOREL09