BELLEVUE UNIVERSITY ATHLETIC TRAINING
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READ THIS FIRST NOTE: No forms will be available at check-in Dear Athlete or Parent, Welcome to Bellevue University and Bruin athletics. Soon, you will be starting a new season at Bellevue University. This letter is to bring you up to date with the latest in the athletic training room. Drug testing may be performed this year. This is not to alarm you, but to reassure you and your parents we are interested in healthy athletes. The medical packet below should be completed before you receive your physicals. Please read these forms. These forms give a better understanding of previous illnesses or injuries you may have sustained in the past. This information also improves our ability to contact family members and communicate with insurance companies in the event of a serious injury. Do not forget, you must have health insurance in order to participate at Bellevue University.
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IMPORTANT ACCIDENT INSURANCE INFORMATION AND CLAIM FILING INFORMATION The following should be helpful in providing all responsible parties with the information necessary regarding the college’s secondary insurance plan and procedures following an injury.
The University requires that all athletes participating in intercollegiate sports be covered by a primary insurance plan before they are allowed to participate in such sports. Proof of such coverage will be required. In addition to your own primary insurance plan, Bellevue University also carries a secondary accident insurance policy which provides coverage to the University for student-athletes participating in intercollegiate sports. This policy secondary coverage only after the student-athlete has met their primary insurance policy deductible and has incurred $500 in additional out-of-pocket expenses per incident/accident effective during the 2012/2013 academic year on any medical bills arising from the accident which caused injury while competing in athletics at Bellevue University. Payments are made by the primary insurance carrier cannot be applied to the secondary insurance deductible of $500; this deductible consists of previously mentioned $500 in student-athlete out-ofpocket expenses after primary insurance policy deductible has been met. As an accidental insurance policy, it should be understood that the Bellevue University secondary insurance carrier determines whether an injury related to athletes is “accidental.” Pre-existing conditions are not covered; therefore, it is imperative that all injuries are immediately reported to the Head Athletic Trainer for accurate injury assessment, physician referral (if necessary) and appropriate documentation. Bellevue University also carries a catastrophic accident insurance policy for students participating in intercollegiate sports. The policy is only applicable after $25,000 of accident costs have been incurred as a result of an intercollegiate injury. If your primary insurance is with an out-of-state HMO health plan, I would strongly recommend that you purchase a temporary accident insurance policy (above). There is not an HMO provider close to the college campus. As a result, students with HMO coverage will generally be required by their insurance carrier to return home for any medical care and procedures beyond basic emergency services, even after receiving an initial assessment from the college’s medical team. I recommend that students with HMO’s check their policy on this issue and seriously consider purchasing a temporary accident insurance policy in order to receive local medical care and rehabilitation if deemed necessary. Please note that the colleges’ secondary insurance plan will not make payment in the absence of an HMO’s refusal to meet the $500 deductible if you receive services here without first gaining approval from your provider for payment.
PROCEDURE FOLLOWING INJURY
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1. Notify the Certified Athletic Trainer of any injury immediately. Mutual of Omaha Insurance will not be responsible for charges incurred by the athlete outside the medical network which has been established, if not first seen and approved by the Certified Athletic Trainer. 2. Be seen by the team physician (a medical doctor) on a per referral basis arranged by the Certified Athletic Trainer.
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3. Your primary insurance will be directly billed for all services deemed necessary by the team physician at the time the services are rendered. If the cost of these services exceeds the deductible required to satisfy the colleges’ secondary insurance, the certified athletic training staff will file a claim to the University’s secondary insurance plan on your behalf. Once this has been done, the claim will be sent to the University’s insurance company for processing. You will receive a letter of confirmation from First Agency Insurance regarding the status of your claim and any request for additional information. 4. Bellevue University’s athletic department utilizes the best physicians in the Omaha/Bellevue area to give our athletes excellent care without the delay of appointments or lines if they become sick or injured. As the forms enclosed are reviewed, you may notice that permission is granted for the athletic training department at Bellevue University to render care as needed for the health and well-being of its athletes. This is solely to provide the quickest and best possible care for you or your son or daughter. I hope this will help those that may have to deal with this issue. Physical and release forms must be completed and returned to my office before practice starts in August. If this is not accomplished you will not be allowed to participate in practices. If there are any questions on this matter please call (402) 557-7057 If you do not have a family physician, the team physicians are performing physical exams on July 30 and August 27 at 6 p.m. Physicals are on the main campus in the Gordon Lozier Athletic Center. No forms will be available at the check in. Please bring your completed forms. The cost will be $10. Please contact your coach for specific times for each team.
Michael Livergood, MS, ATC, CSCS Head Athletic Trainer
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Sincerely,
BELLEVUE UNIVERSITY ATHLETIC TRAINING PRE-PARTICIPATION EXAMINATION & MEDICAL HISTORY
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** Athlete will be unable to participate in Bellevue University athletics until the complete physical and medical questionnaire is completed and signed by the athlete and physician **
Date: Name (Last, First, M.I.): Birthdate: SSN: Sport: Marital Status: High School Attended: Current Address: Parent’s Address: Family Physician:
Age: Sex: Grade:
Phone: Phone:
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PHYSICAL EXAMINATION AND EVALUATION Measurements and Vital Signs 1. Height (inches) 2. Weight (lbs) 3. Blood Pressure Clinical Evaluation 4. Ears 5. Eyes 6. Nose 7. Mouth & Throat 8. Abdomen & Viscera 9. Heart 10. Lung & Chest 11. Genitalia
Normal Normal Normal Normal Normal Normal Normal Normal
Abnormal Abnormal Abnormal Abnormal Abnormal Abnormal Abnormal Abnormal
Ortheopedic Evaluation 12. Neck 13. Upper Extremities 14. Low Back 15. Lower Extremities 16. Knee 17. Ankle
Normal Normal Normal Normal Normal Normal
Abnormal Abnormal Abnormal Abnormal Abnormal Abnormal
ACCEPTED
REJECTED
Abnormalities (describe in detail)
Examination Results (Circle One) Reason for Rejection
Physicians Signature:
Date:
Athletic Trainer’s Signature:
Date:
PERSONAL HISTORY
4 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
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12. 13. 14. 15. 16. 17. 18. 19.
FIRST NAME
20. 21. 22. 23. 24.
LAST NAME
25. 26.
Are you allergic to any medications? Medications: Do you take medications on a regular basis? a. Medications: Do you have epilepsy, or ever suffered a seizure a. Approximate date of last episode Have you been treated for diabetes? a. Medications: Has a physician ever told you that you are anemic? Have you ever had high blood pressure? a. Medications: Have you had any of the following diseases (circle below)? a. Heart Kidney Lung Liver Do you have asthma? a. Medications: Have you ever had a hernia? Has it been repaired? a. Date of surgery: Have you ever had a concussion or head injury? a. Date and severity: Have you ever been “knocked out” unconscious? a. Date and how long: Have you ever stayed in a hospital overnight because of a head injury? a. Date and length: Have you ever had a neck injury involved bones, nerves or discs that disabled you for over 3 days? a. Strains, Sprains, Fractures, Loss of Feeling, Numbness, Pain Do you wear any of the following dental applications (circle below)? a. List: Have you ever had a broken bone or fracture in the past five years? a. List bone and side: Have you ever had a shoulder injury? a. Date and type: Have you ever injured your back? Do you presently have back pain? a. If yes, how frequently: Have you injured your knee in the past five years? a. Type of injury and side: Did it require medical attention and/or surgery? a. Date and type: Have you had a severe ankle sprain? a. Date, Type and side: Have you had ankle surgery? a. Date and type: Do you have a metal implant in your body (pin, screw, plate, etc.)? a. List and location: Do you have any other medical conditions or problems which may affect your performance? a. List: Do you have a history of sickle cell anemia? Have you had any surgeries not listed above? a. List:
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NO NO
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YES YES
NO NO
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HISTORY OF IMMUNIZATIONS (Date of last booster) TETANUS: _________INFLUENZA: _________MMR: _________MENIGITIS: _________HEPATITIS:_________ Signature:
Date:
The above signed, herewith, certifies that the answers to these questions are correct and true. I understand Bellevue University cannot be held responsible for any previous medical condition(s) that he/she might have. I understand that this physical is for no other purpose than to clear me for athletic participation at Bellevue University. I understand it is not a physical illness which may develop in the future.
PARENT/GUARDIAN/STUDENT INSURANCE INFORMATION FORM
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ATHLETE INFORMATION Name of Athlete: Social Security No., or Passport No. Current Address: City: Phone (Mobile): Email Address:
FATHER/GUARDIAN INFORMATION
MOTHER/GUARDIAN INFORMATION Mother’s Name: Social Security No.: Address: Employer: Telephone (Home): Telephone (Mobile): Telephone (Work): Medical Insurance Company or Plan: Address: Policy Number: Telephone: Is this plan an HMO or PPO? Is pre-authorization required to obtain treatment? Is a second opinion required before surgery? Additional Information:
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Father’s Name: Social Security No.: Address: Employer: Telephone (Home): Telephone (Mobile): Telephone (Work): Medical Insurance Company or Plan: Address: Policy Number: Telephone: Is this plan an HMO or PPO? Is pre-authorization required to obtain treatment? Is a second opinion required before surgery? Additional Information:
Sport: Date of Birth: State:
Zip:
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BELLEVUE UNIVERSITY CONSENT FORM Signature may be that of athlete 18 years of age. If under 18, signature of parent or guardian is required. Printed Name: (If you are under 18 years of age, your parents must also sign) The basic content of each is: A. Medical Consent: Allows Bellevue University athletic trainer and physicians to treat any injury or illness incurred by you while at Bellevue University. B. Release of Information: Allows those listed to release information concerning your injuries to media and/or other medical professionals. C. Assumption of Risk: Provides information to your concerning inherent risks involved in participating in intercollegiate athletics and that you are willing to assume responsibility for each risk.
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MEDICAL CONSENT I hereby grant permission to Bellevue University team physicians and /or their consulting physician’s to render me, any treatment or medical or surgical care that they deem reasonably necessary to my health and well being. I also hereby authorize the athletic trainers at Bellevue University who are under the direction and guidance of Bellevue University team physician, to render me any preventive, first aid, rehabilitative or emergency treatment that they deem reasonably necessary to my health and well-being. Signature:
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Date:
Parent/Guardian: (I hereby grant permission on behalf of my minor son or daughter or my ward.)
HIPPA AUTHORIZATION TO RELEASE AND OBTAIN MEDICAL INFORMATION HIPPA was created to protect individual’s personal health information and increased patient access to personal records. This form authorized the release of medical information to the Bellevue University certified athletic trainer, team physicians and athletic coaches; furthermore, to provide necessary medical information to Bellevue University Sports Information Department and media outlets concerning illness or injury relative to my participation in athletics at Bellevue University. This document is active for one year after date of signature. Signature:
SSN#:
Date:
Parent/Guardian: (I hereby grant permission on behalf of my minor son or daughter or my ward.)
ASSUMPTION OF RISK & SPORTS SAFETY The responsibility of sport safety must be shared. This group includes administrators, coaches, physicians, athletic trainer and student-athletes. I, the undersigned, am aware that there is a certain risk of injury involved in my participation in intercollegiate athletics at Bellevue University. I understand that my signature does not relieve the University of its responsibilities to me. This document is intended to make me aware of my responsibility on preventing potential injuries, complying with the treatment plan of the BU athletic medical staff, and that there is a risk of injury. I understand that this includes the risk of spinal cord and brain injury that may result in paralysis and the possibility of other prominent injuries or death. Signature:
Date:
I have read the above shared responsibility statement. I acknowledge the fact that these risks exist and I am willing to assume responsibility for such risks while participating at Bellevue University.