STUDENT-ATHLETE INSURANCE INFORMATION FORM NAME: Last
Soc. Sec. #: MM/DD/YY
Does this student-athlete have medical insurance coverage? If "NO": Please skip "Insurance" section below and complete "Policy Holder" section. YES NO Is this insurance plan part of a Health Maintenance Organization (HMO)? I.D. #: Insurance Co. Name: Policy #: Address: Group #: City: State: Zip: Plan #: Phone #: BIN #: YES
INSURANCE
Birth Date:
Sport:
DATE:
Middle
First
NO
PCP Name: PCP Phone #:
PCN #: Effective Date of Policy:
POLICY HOLDER
MM/DD/YY
NAME: Address: City: Phone (H):
Last
Middle
First
Birth Date:
State: Zip: Phone (C):
Relationship to Athlete:
Soc. Sec. #: MM/DD/YY
Policy Holder's Employer:
I hereby authorize Western Kentucky University Athletic Department to file a claim for the athletic injury sustained by my son or daughter under the previously listed group medical policy and I agree and consent that any amounts payable under this policy be paid to the medical provider. I hereby authorize Western Kentucky University to inspect and/or secure copies of case history records, laboratory reports, diagnosis, x-rays, and any other data covering this and/or confinements and/or disabilities. A photo static copy of this authorization shall be deemed effective and valid as the original. ***PLEASE attach or enclose A COPY OF BOTH FRONT AND BACK OF YOUR MEDICAL INSURANCE CARD and PRESCRIPTION MEDICATION CARDS (IF YOU HAVE ONE)FOR OUR RECORDS*** I/We agree that all information provided in this document is accurate and complete to the best of my/our knowledge. I/We understand any incorrect or undisclosed information could result in possible overpayments for which I/we will be responsible for reimbursing in full upon request.
**If no medical insurance coverage in place for the student-athlete, please sign Affidavit of No Medical Insurance below: AFFIDAVIT OF NO MEDICAL INSURANCE I, the undersigned, state that I have no medical health insurance under which the above named student-athlete is covered. Parent / Guardian__________________________________