Intercollegiate Athletics Pre-Participation Packet

Transcription

1 Intercollegiate Athletics Pre-Participation Packet The sports medicine staff is comprised of athletic trainers who are members of the National Athletic Trainers, certified by the Board of Certification, and licensed by the State of Rhode Island. The primary staff is supplemented by work study student workers, designated team physicians, and a host of medical consultants and sub-specialists. The certified athletic training staff is responsible for the daily operation of the department, and work under the direction of the team physicians, and consultants. The team physicians work jointly to set medical policy, and attend to all injuries and illnesses. The medical staff determines the athlete s participation status, and makes all decisions on when athletes are permitted to return to competition. Consulting medical specialists assist when their particular field of expertise is required to supplement the diagnosis and treatment process. These consultants are used on a referral basis. Prior to participating in any practice or competition, including try-outs, the following Pre-Participation Packet needs to be completed and reviewed by the athletic training staff. Please use the following guide to assist your completion of this packet: Pgs. 2-8 Page 9 Page 10 Page 11 Pgs Pgs Athletic Medical Questionnaire. Please read and answer as completely and honestly as possible. Explain any Yes responses (i.e.: dates of significant injuries and/or surgeries). HIPAA Release Authorization. Please read, sign and date allowing the medical staff to communicate your condition with each other in addition to relevant RIC personnel (coaches, etc.). Assumption of Risk & Release to Treat Form. Please read, sign and date acknowledging your role and RIC s role in creating safe environment as well as giving RIC medical staff permission to treat you (parent/guardian signature required if under 18). Agreement to Disclose Injuries and Illnesses. Please read, sign and date attesting to the fact that you agree to openly and honestly disclose symptoms of injuries and/or illnesses. This allows us to provide the best care possible for you. Sickle Cell Screen Guideline and Waiver. Please read and either submit proof of a prior sickle cell trait test, arrange to be tested and provide RIC with results, or sign waiver on page 14. Insurance Page: Please read insurance policy on page 15 and complete ALL requested information on page 16. YOU MUST INCLUDE A COPY OF THE FRONT & BACK OF ALL INSURANCE CARDS! In the event of an injury claim related to your participation in athletics, this form is used to assist the claim process. If you ARE currently taking medication to treat ADHD, please review the information outlining the required medical exception documentation for both NCAA and Rhode Island College. Follow the NCAA Medical Exception Documentation link on our website and present a copy of this page to your treating physician to assist your completion. Please return required documentation with this packet or send directly to the Rhode Island College Athletic Training Department. If you are NOT taking medication to treat ADHD, you may disregard this. PLEASE NOTE: Although you may be asked to fill out information multiple times on many pages, we ask that you fill out all forms in their entirety as many of these pages are separated and shared with different entities, i.e. Insurance claims agent. This helps to protect the information you provide to us by allowing us to share only that information which a specific party requires. 1

2 ATHLETIC MEDICAL QUESTIONNAIRE I. BIOGRAPHICAL DATA Office Use Only o Physical clearance o Insurance/Card o Medical questionnaire o HIPPA/Release to tx o Inj. Disclosure Form o Sickle Cell Trait Initials 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: 2

3 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) 3

4 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 4

5 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 below 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 6. Do You Have A History of Migraine Headaches? NO How Often? Front of Head Back of Head All Over Your Head YES Please Describe Medications Taken for Migraines? 7. Have You Had Headaches For More Than Three (3) Months? YES NO 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? 5. Have you ever had any of the following: No Yes 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 5

6 g. Painful shoulder secondary to activity? No Yes 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: YES NO Have you ever had any injury or illness other than those already noted? YES NO Do you have any ongoing or chronic illnesses? YES NO Have you ever been hospitalized overnight? YES NO Have you ever been told by a physician to restrict your sports activity or not to participate in a sport? YES NO Are you currently under a physician s care for any medical conditions? YES NO Have you ever been under the care of a psychiatrist and/or psychologist? YES NO Have you consulted and/or been under the care of a chiropractor, podiatrist and/or other such practitioner in the past five (5) years? YES NO Have you ever had a rash or hives develop during and/or after exercise? YES NO Do you cough, wheeze, or have trouble breathing during or after exercise / practice? YES NO Have you ever been told that you have kidney disease? YES NO Have you had a viral infection (i.e. mononucleosis, myocarditis, etc.) within the past six (6) months? YES NO Have you ever had seizures, convulsions, and/or epilepsy? YES NO Have you ever had gall bladder disease and/or a urinary problem? YES NO Do you have ringing in your ears or trouble hearing? YES NO Do you have frequent ear infections or nosebleeds? YES NO Have you ever had an abnormal chest x-ray and/or pneumonia? 6

7 YES NO Do you require any special equipment (braces, neck rolls, dental, orthotics, hearing aids, etc.) YES NO Have you ever had the chickenpox? If yes, when? YES NO Have you had a tetanus booster within the past five (5) years? If yes, when? YES NO Have you ever received the Hepatitis B (HBV) Vaccination series (all 3 shots)? If yes, when? YES NO Do you smoke cigarettes, use smokeless tobacco, or use tobacco in any form? YES NO Do you use alcohol? If yes, how often? YES NO Have you ever used / tried marijuana, cocaine, or any other illicit street drugs? YES NO Do you have any questions regarding drugs, tobacco, or alcohol? YES NO Do you take or have you taken Ergogenic Aids/Supplements? YES NO Do you feel stressed out? If yes, do you feel as though you get the necessary support to deal with your stress? YES NO Have you had a weight change (loss or gain) of greater than 10 pounds in the past year? YES NO Are you a vegetarian? If yes, what type? YES NO Do you regularly lose weight to participate in your sport? YES NO Do you want to weigh more or less than you presently do? YES NO Have you ever felt forced to limit your food intake due to concerns about your weight and/or body size? YES NO Have you had a history of anorexia, bulimia (forced vomiting), and/or any other eating disorders? YES NO Have you had any hypoglycemic episodes (low blood sugar) within the last twelve (12) months? YES NO 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 7

8 injury? NO YES Please Describe XI. 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 XII. 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 8

9 HIPAA 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: 9

10 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) 10

11 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 11

12 Rhode Island College Sickle Cell Screen Guideline, Information, and Waiver Dear Parents and RIC Incoming Student-Athletes, Recently, The NCAA Division III delegates adopted legislation to mandate testing for Sickle Cell Trait for all new incoming student-athletes for and now ALL 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. All student-athletes need to have one of the following options in their medical file for 2014: 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 for approximately $12. If you need to be tested, make arrangements as soon as possible to avoid delay in obtaining your results and delaying your clearance for participation in athletics. 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: The signing of the waiver is not recommended. 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 Read the Sickle Cell Trait Educational Information sheet Please return a copy of your lab report to: OR Return a copy of your waiver to: Rhode Island College Health Services Sports Medicine Browne Hall Murray Center 600 Mount Pleasant Ave 600 Mount Pleasant Ave Providence, RI Providence, RI P: (401) P: (401) F: (401) F: (401)

13 Sickle Cell Trait Educational Information What is Sickle Cell Trait? Sickle cell trait is an inherited condition of the oxygen-carrying protein, hemoglobin, in the red blood cells. 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 red blood cells change from the normal disc shape to a crescent or sickle shape. These cells can then accumulate in the bloodstream and block the blood vessels, leading to collapse from the rapid breakdown of muscles starved of blood. This is more likely to occur with timed runs, intense exertion of any type for 2-3 continuous minutes without a rest period, intense drills and other spurts of exercise after prolonged conditioning exercises, and other extreme conditioning sessions. Common signs and symptoms of a sickle cell emergency include: increased pain and weakness in the working muscles (especially the legs, buttocks, lower back); cramping type muscle pain; soft, flaccid muscle tone; and/or sudden onset of symptoms without early warning signs. For more information on Sickle Cell Trait Go to and click on Sickle Cell Trait link. For athletes positive for the sickle cell trait, the following reasonable precautions will be taken in order to appropriately manage the condition: The athlete will slowly build up the intensity and duration of their training. This will also include longer periods for rest and recovery. The athlete will participate in pre-season conditioning programs in order to prepare for the rigors of the competitive season. The athlete may have modified performance tests, such as mile runs, serial sprints, etc. The athlete will stop all activity and seek medical evaluation with the onset of symptoms, such as muscle cramping, pain, swelling, weakness, tenderness, undue fatigue, or shortness of breath. The athlete will be given the opportunity to set their own pace during conditioning drills. The athlete s participation may be altered during periods of heat stress, dehydration, asthma, illness, or activity in high altitudes. 13

14 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 student-athletes by 2014 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. 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 voluntarily agree to release, discharge, indemnify, and hold harmless the State of Rhode Island, the College, its officers, employees, agents, and their successors and assigns from any and all costs, claims, damages or expenses, including attorneys fees, arising from any loss or personal injury that might result from my refusal to be tested. 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 14

15 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 following form be filled out in its entirety. 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 student-athlete 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. Also most illnesses are deemed to be non-athletic related and are therefore not covered under this policy. 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. IF AN ATHLETIC INURY OCCURS: If the injury occurs when a Rhode Island College athletic trainer is not present, 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.** 15

16 Student-Athlete s Name RHODE ISLAND COLLEGE SPORTS MEDICINE DEPARTMENT Health Insurance Information / Authorization (PLEASE TYPE OR PRINT IN BLACK INK!) Sex Male Female Date of Birth Sport Home Address Student Identification No. City State Zip Phone # Medications currently taking? Allergies/Asthma? Name Home Address FATHER S / GUARDIAN S INFORMATION Name Home Address MOTHER S / GUARDIAN S INFORMATION Home Phone Work Phone Cell Phone Home Phone Work Phone Cell Phone Primary Insurance Insurance Company Policy / ID # Group # Insurance Company Phone # Subscriber s Name Type of Insurance: Secondary Insurance (if applicable) Insurance Company Policy / ID # Group # Insurance Company Phone # Subscriber s Name Type of Insurance: HMO PPO HMO PPO Other Other Please Check Here If Your ONLY Insurance is Through Rhode Island College (University health plans/consolidated Health) PLEASE READ CAREFULLY! I hereby authorize RIC, the hospitals, & physicians connected with or provided, to furnish information to insurance carriers concerning any illness, injury, & treatments & I hereby assign to the party all payments for medical services rendered to the student-athlete. I agree to supply any & all information requested by my primary insurance, RIC and/or their excess insurance company in a timely manner. I hereby authorize the RIC Sports Medicine Department and/or my coach to secure treatment for me for any athletic injury/illness. (must be cosigned by parent/guardian if student-athlete is under 18 years of age) A photostatic copy of this authorization shall be deemed as effective & valid as the original. I agree to notify the RIC Sports Medicine Department immediately upon any change in the above health insurance information. If I fail to do so, I fully understand that I will be responsible for any & all charges incurred. I hereby certify that I have read & understand the above statements, and enclosed policy, and that any & all questions have been answered to my satisfaction. I also certify that the answers I have provided are true, complete, & correct to the best of my knowledge. Student-Athlete s Signature Date Parent/Guardian s Signature (If student-athlete is under 18 years of age) Date 16