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BELLEVUE UNIVERSITY BRUINS Athletic Training

Read This First! Dear Athlete and 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, 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. 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 the procedures to follow after 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 provides 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 2010/11 academic year on any medical bills arising from the accident which caused injury while competing in athletics at Bellevue University. Payments 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-of-pocket 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 athletics 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

1000 Galvin Rd. Bellevue NE 68005 (402) 557-7057 www.bellevue.edu


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 $500.00 deductible if you receive services here without first gaining approval from your provider for payment. PROCEDURES FOLLOWING INJURY 1. Notify the Certified Athletic Trainer of any injury immediately. First Agency 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 if necessary. 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 Colleges’ secondary insurance plan on your behalf. Once this has been done, the claim will be sent to the Colleges’ 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. Be advised that after you receive this letter of confirmation from First Agency Insurance., you should correspond directly with them thereafter in order to expedite the process and payment of your claim. Claims representative at First Agency Ins. for Nebraska can be reached at 269-381-6630. 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 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. If there are any questions on this matter please call. (402) 557-7057. 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 you do not have a family physician, the team physicians are performing physical exams on July 29 and Sept. 1. 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. Please do not forget to complete the forms and enjoy the summer. Sincerely, Michael Livergood, MS, ATC, CSCS Head Athletic Trainer


First Agency, Inc. 5071 West H Avenue Kalamazoo, MI 49009-8501

RETURN FORM WHEN COMPLETE TO

PARENT/GUARDIAN/STUDENT INFORMATION FORM FORMFORM

Name of College/University

Attention This form is to be completed by the Parents, Guardians or Student

Address 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

Date of Birth

College Address

College Phone

(

)

Home Address

Home Phone

(

)

City

State

FATHER/GUARDIAN INFORMATION

Zip

MOTHER/GUARDIAN INFORMATION

Father's Name

Mother's Name

Social Security No.

Social Security No.

Address

Address

Employer

Employer

Address

Address

Telephone

(

)

Telephone

(

Medical Insurance Company or Plan

Medical Insurance Company or Plan

Address

Address

Policy Number

Policy Number

Telephone

(

)

Telephone

(

)

)

Is this plan an HMO or PPO?

Yes

No

Is this plan an HMO or PPO?

Yes

No

Is pre-authorization required to obtain treatment?

Yes

No

Is pre-authorization required to obtain treatment?

Yes

No

Is a second opinion required before surgery?

Yes

No

Is a second opinion required before surgery?

Yes

No

PLEASE COMPLETE AUTHORIZATION ON REVERSE SIDE OF THIS FORM


First Agency, Inc. 5071 West H Avenue Kalamazoo, MI 49009-8501

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 the 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. This Authorization is valid from the date signed for the duration of the claim.

Name of Claimant (please print)

Signature of Claimant (if claimant is 18 or older)

Name of Authorized Representative, or Next of Kin (please print)

Date

Signature of Authorized Representative of Next of Kin

Date

Relationship of Authorized Representative or Next of Kin to Claimant


BELLEVUE UNIVERSITY CONSENT FORM Print Name: __________________________________

HIPPA AUTHORIZATION TO RELEASE AND OBTAIN MEDICAL INFORMATION

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.

HIPPA was created to protect individual’s personal health information and increased patient access to personal records. This form authorizes 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.

(If you are under 19 years of age, your parents must also sign.)

B. Release of Information: Allows those listed to release information concerning your injuries to the media and/or other medical professionals. C. Assumption of Risk: Provides information to you concerning certain inherent risks involved in participating in intercollegiate athletics and that you are willing to assume responsibility for such risks.

____________________________

Signature:

____________________________

Signature may be that of athlete 19 years of age: If under 19, signature of parent or guardian is required.

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 physicians, to render me any preventive, first aid, rehabilitative or emergency treatment that they deem reasonably necessary to my health and wellbeing. Also, when necessary for executing such case, I grant permission for hospitalization at an accredited hospital. Date:

____________________________

SSN#:

____________________________

Signature:

____________________________

Signature may be that of athlete 19 years of age: If under 19, signature of parent or guardian is required. Parent/ Guardian

Date:

____________________________ I hereby grant permission on behalf of my minor son or daughter or my ward.

Parent/ Guardian

____________________________

SSN#:

____________________________

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 permanent injuries or death. 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. Date:

____________________________

Signature:

__________________________

BELLEVUE UNIVERSITY - 1000 Galvin Rd. South - Bellevue, NE 68005


BELLEVUE UNIVERSITY SPORTS MEDICINE PRE-PARTICIPATION EXAMINATION & MEDICAL HISTORY DATE: NAME:

AGE: LAST

FIRST

SSN:

BIRTDATE:

/

SEX:

(M)

(F)

M.I.

GRADE

SPORT:

MARITAL STATUS:

/

FR

(circle one):

SO

JR

SR

HIGH SCHOOL ATTENDED:

ATHLETE ADDRESS: PARENT'S ADDRESS: PARENT'S PHONE:

(

)

FAMILY PHYSICIAN:

PHONE: (

)

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

ORTHEOPEDIC EVALUATION 12. Neck 13. Upper Extremities 14. Low Back 15. Lower Extremities 16. Knee 17. Ankle ABNORMALITIES

Normal

Abnormal

EXAMINATION RESULTS Accepted: Rejected: Reason for Rejection:

(describe in detail)

PHYSICIANS SIGNATURE

ATHLETIC TRAINER'S SIGNATURE


PERSONAL HISTORY (PLEASE FILL OUT THIS FORM BEFORE DOCTORS’ EXAMINATION) YES YES

NO NO

1. 2.

YES

NO

3.

YES

NO

4.

YES

NO

5.

YES

NO

6.

YES

NO

7.

YES

NO

8.

YES

NO

9.

YES

NO

10.

YES

NO

11.

YES

NO

12.

YES

NO

13.

YES

NO

14.

YES

NO

15.

YES

NO

16.

Are you allergic to any medications? List: Do you take any medication(s) on a regular basis? List: Do you have epilepsy, or ever suffered a seizure? Date of last seizure (approx.) Have you been treated for diabetes? Medication(s): Has a physician ever told you that you are anemic? Have you ever had high blood pressure? Medication(s): Have you had any of the following diseases? (circle) HEART LUNG KIDNEY LIVER Do you have asthma? Medication(s): Have you ever had a hernia? Has it been repaired? Date: Have you ever been “knocked out” unconscious? Date: How Long: Have you ever had a concussion or head injury? Date(s): Severity: Have you ever stayed in the hospital overnight because of a head injury? Date: Have you ever had a neck injury involving bones, nerves, or discs that disabled you for over 3 days? (strains, fractures, loss of feeling, numb, pain) Do you wear any of the following dental appliances? (Circle) PERMANENT BRIDGE PERMANENT CROWN/JACKET FULL PLATE BRACES RETAINER Have you ever had a broken bone or fracture in the past five years? Bone and Side: Have you ever had a shoulder injury?

YES

NO

17.

YES YES

NO NO

18. 19.

YES

NO

20.

YES

NO

21.

YES

NO

22.

YES

NO

23.

YES

NO

24.

YES

NO

25.

YES

NO

26.

Date and Type: Have you ever had a shoulder surgery? Date and Type: Have you ever injured your back? Do you presently have back pain? (circle when) SELDOM OCCASIONALLY FREQUENTLY WITH EXERCISE AFTER HEAVY LIFTING Have you injured your knee in the past five years? Structure and Side: Did it require medical attention and/or surgery? Date and Type: Have you had a severe ankle sprain? LEFT RIGHT Date and Type: Have you had ankle surgery? Date: Do you have a metal implant in your body? (pin, screw, plate, etc.) List and Where: Do you have any other medical conditions or problems which may affect your performance? List: Have you had any surgeries not listed above? List:

HISTORY OF IMMUNIZATION - (DATE OF LAST BOOSTER) TETANUS: MENIGITIS: INFLUENZA: HEPATITIS: MMR: The undersigned, 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.

SIGNATURE

DATE

*** Athlete will be unable to participate in Bellevue University athletics until this form is completed and signed by the athlete and physician.

/BU_AT_medicalPacket2010  

http://bubruins.com/documents/2010/6/29/BU_AT_medicalPacket2010.pdf?id=18

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