Athletic Training
Athletic Training Athlete Information Demographics Name: __________________________________________
Sport: _____________________________
Age: _____ DOB: ___________ SSN: ___________________________
Student ID:__________________________
Local Information Address:
Cell Phone: ___________________________________________
_________________________________________ _________________________________________ E-Mail: _______________________________________________ _________________________________________
Home Information Address:
Home Phone: __________________________________________
________________________________________ ________________________________________ ________________________________________
Emergency Contact Information Primary: Parent/Guardian Name: ______________________________________ Relationship: _____________________________ Address: __________________________________________
Home Phone: ____________________________
_________________________________________________
Work Phone: ____________________________
E-Mail: ___________________________________________________ Cell Phone: ____________________
Secondary: Parent/Guardian Name: ______________________________________ Relationship: ____________________________ Address: __________________________________________
Home Phone: ___________________________
__________________________________________
Work Phone: ____________________________
E-Mail: __________________________________________________
Cell Phone: _____________________________
Athletic Training Pertinent Medical Information Do you have any allergies? If so, what are you allergic to?
Y
N .
Do you have asthma? If so, how is it controlled?
Y
N .
Have you ever been diagnosed with Diabetes? If so, how is it controlled?
Y
N .
Have you ever been diagnosed with Sickle Cell Trait? If so, how is it controlled?
Y
N .
Have you ever worn orthotics? If so, for what reason?
Y
N .
Have you ever had a concussion? If so, how many? . How many days do you think you were out of activity with each concussion? Please list the dates of each of your concussions:
Y
N .
. Please, list all medications and supplements that you take:
. Are there any other conditions that we should be aware of? .
Athletic Training
Medical Policy Statement This is to inform you of particular procedures that pertain to the health care of you/your son and/or daughter while they are participating in their respective sport(s) for Cardinal Stritch University. Please keep the information handy. Should you/your child be injured as a result of participating in athletics at Stritch, the following information will be useful and pertinent. 1. All student-athletes receive the same care whether they are male, female, scholarship athletes, non-scholarship athletes. 2. Per the Affordable Care Act, all domestic student-athletes are required to have medical insurance. Insurance information is to be submitted to the SWAT staff. 3. Stritch’s athletic insurance is designed as a secondary provider 4. Students must notify SWAT staff before outside/secondary medical opinion/procedure/doctors visit to be covered by Stritch’s athletic insurance
A. Explanation of Insurance Coverage i. The primary source of payment is the individual health insurance coverage of the athlete or of the athlete’s parents. YOUR INSURANCE WILL BE BILLED FIRST. We may occasionally ask you to check on or obtain referrals or authorization through your insurance prior to nonemergency injury treatment. It is the ATHLETE’S RESPONSIBILITY to obtain proper authorization and/or verify coverage with his/her insurance company. If your insurance company procedures are not followed, (i.e. authorization, obtain referral, etc) Stritch will be unable to assist with your claims. ii. If you follow all of your insurance company’s procedures and your insurance policy does not fully cover the charges, Stritch’s secondary insurance policy will pay the balance. It is the ATHLETE’S RESPONSIBILITY to send us the necessary paperwork from your insurance company to process the claim. The following items are needed to process the claim: 1. Explanation of Benefits or Denial 2. Itemized Bill iii. Stritch’s insurance coverage is a secondary insurance policy. This policy covers only sport-related injuries and/or illness as described in the medical referral policy.
iv. All insurance claims must be resolved within one calendar year of each specific injury. If this is not followed, the athlete and/or family may be responsible for any remaining bills. B. Physician Referrals/Consultations i. All student-athletes must be evaluated by a Stritch staff athletic trainer before referral to a physician will be made. A Stritch staff athletic trainer must authorize and properly refer all student-athletes for care administered by a physician or medical consultant (except in the event of a sport-related medical emergency). ii. If a student-athlete seeks medical care from a physician/medical consultant and/or receives any medical evaluation or treatment without prior notification, the student-athlete is responsible for obtaining any and all necessary documents for a proper insurance claim to be filed under Stritch’s athletic insurance policy. C. Medical Bills i. In the event that a student-athlete and/or parent(s)/guardian(s) should receive a bill/statement for medical care associated with an injury/illness that occurred as a direct result of participation in intercollegiate athletics at Cardinal Stritch University, the student-athlete must submit the bill/statement to his/her staff athletic trainer within 30 business days of receipt. **BILLS RECEIVED AFTER 30 BUSINESS DAYS MAY BE UNABLE TO BE FULLY PROCESSED AND MAY RESULT IN A BALANCE DUE TO THE STUDENT-ATHLETE ** Any questions concerning your child’s health care or insurance coverage can be directed to: Melissa Wenig, MS, ATC/LAT – Head Athletic Trainer Cardinal Stritch University (414)410-4129 [email protected]
PLEASE KEEP THIS MEDICAL POLICY INFORMATION PACKET FOR YOUR RECORDS.
Athletic Training
Medical/Insurance Policy Statement Acknowledgement I, ___________________________, have read and understand the stated Cardinal Stritch University procedures concerning health care and insurance coverage for injuries that may occur to myself/my son/my daughter while participating in intercollegiate athletics for Cardinal Stritch University.
________________________________________________ Student-Athlete’s Name (print)
________________________________________________ Student-Athlete’s signature
Date ____________
________________________________________________ Parent/guardian signature (if under 18 yrs old)
Date ____________
Athletic Training Acknowledgement of Assumption of Risk
I, _________________________________, hereby expressly and affirmatively state that I wish to participate in the sport(s) of ____________________ at Cardinal Stritch University. I realize that my participation in this activity involves risks of injury, including, but not limited to severe sprains, strains, fractures, head and neck injuries, and the possibility of paralysis or death. I also recognize that there are many other risks of injury or illness including serious disabling injuries which may arise due to my participation in this activity and that it is not possible to specifically list each individual injury/illness risk. However, knowing the material risks and appreciating, knowing and reasonably anticipating that other injuries and death are possibilities, I hereby assume all of the delineated risks of injury, all other possible risk of injury, and death which could occur by reason of my participation. I have had an opportunity to ask questions. Any questions I had have been asked and answered to my complete satisfaction. I understand the risks of my participation in this activity. Knowing and appreciating these risks, I voluntarily choose to participate, assuming all risks of injury or death due to my participation.
____________________________
Date _____________
Student-Athlete’s signature
_____________________ Parent/Guardian Signature (if under 18 yrs. of age)
Date _____________
Sport: _____________________________
Age: _____ DOB: ___________ SSN: ___________________________
Student ID:__________________________
Local Information Address:
Cell Phone: ___________________________________________
_________________________________________ _________________________________________ E-Mail: _______________________________________________ _________________________________________
Home Information Address:
Home Phone: __________________________________________
________________________________________ ________________________________________ ________________________________________
Emergency Contact Information Primary: Parent/Guardian Name: ______________________________________ Relationship: _____________________________ Address: __________________________________________
Home Phone: ____________________________
_________________________________________________
Work Phone: ____________________________
E-Mail: ___________________________________________________ Cell Phone: ____________________
Secondary: Parent/Guardian Name: ______________________________________ Relationship: ____________________________ Address: __________________________________________
Home Phone: ___________________________
__________________________________________
Work Phone: ____________________________
E-Mail: __________________________________________________
Cell Phone: _____________________________
Athletic Training Pertinent Medical Information Do you have any allergies? If so, what are you allergic to?
Y
N .
Do you have asthma? If so, how is it controlled?
Y
N .
Have you ever been diagnosed with Diabetes? If so, how is it controlled?
Y
N .
Have you ever been diagnosed with Sickle Cell Trait? If so, how is it controlled?
Y
N .
Have you ever worn orthotics? If so, for what reason?
Y
N .
Have you ever had a concussion? If so, how many? . How many days do you think you were out of activity with each concussion? Please list the dates of each of your concussions:
Y
N .
. Please, list all medications and supplements that you take:
. Are there any other conditions that we should be aware of? .
Athletic Training
Medical Policy Statement This is to inform you of particular procedures that pertain to the health care of you/your son and/or daughter while they are participating in their respective sport(s) for Cardinal Stritch University. Please keep the information handy. Should you/your child be injured as a result of participating in athletics at Stritch, the following information will be useful and pertinent. 1. All student-athletes receive the same care whether they are male, female, scholarship athletes, non-scholarship athletes. 2. Per the Affordable Care Act, all domestic student-athletes are required to have medical insurance. Insurance information is to be submitted to the SWAT staff. 3. Stritch’s athletic insurance is designed as a secondary provider 4. Students must notify SWAT staff before outside/secondary medical opinion/procedure/doctors visit to be covered by Stritch’s athletic insurance
A. Explanation of Insurance Coverage i. The primary source of payment is the individual health insurance coverage of the athlete or of the athlete’s parents. YOUR INSURANCE WILL BE BILLED FIRST. We may occasionally ask you to check on or obtain referrals or authorization through your insurance prior to nonemergency injury treatment. It is the ATHLETE’S RESPONSIBILITY to obtain proper authorization and/or verify coverage with his/her insurance company. If your insurance company procedures are not followed, (i.e. authorization, obtain referral, etc) Stritch will be unable to assist with your claims. ii. If you follow all of your insurance company’s procedures and your insurance policy does not fully cover the charges, Stritch’s secondary insurance policy will pay the balance. It is the ATHLETE’S RESPONSIBILITY to send us the necessary paperwork from your insurance company to process the claim. The following items are needed to process the claim: 1. Explanation of Benefits or Denial 2. Itemized Bill iii. Stritch’s insurance coverage is a secondary insurance policy. This policy covers only sport-related injuries and/or illness as described in the medical referral policy.
iv. All insurance claims must be resolved within one calendar year of each specific injury. If this is not followed, the athlete and/or family may be responsible for any remaining bills. B. Physician Referrals/Consultations i. All student-athletes must be evaluated by a Stritch staff athletic trainer before referral to a physician will be made. A Stritch staff athletic trainer must authorize and properly refer all student-athletes for care administered by a physician or medical consultant (except in the event of a sport-related medical emergency). ii. If a student-athlete seeks medical care from a physician/medical consultant and/or receives any medical evaluation or treatment without prior notification, the student-athlete is responsible for obtaining any and all necessary documents for a proper insurance claim to be filed under Stritch’s athletic insurance policy. C. Medical Bills i. In the event that a student-athlete and/or parent(s)/guardian(s) should receive a bill/statement for medical care associated with an injury/illness that occurred as a direct result of participation in intercollegiate athletics at Cardinal Stritch University, the student-athlete must submit the bill/statement to his/her staff athletic trainer within 30 business days of receipt. **BILLS RECEIVED AFTER 30 BUSINESS DAYS MAY BE UNABLE TO BE FULLY PROCESSED AND MAY RESULT IN A BALANCE DUE TO THE STUDENT-ATHLETE ** Any questions concerning your child’s health care or insurance coverage can be directed to: Melissa Wenig, MS, ATC/LAT – Head Athletic Trainer Cardinal Stritch University (414)410-4129 [email protected]
PLEASE KEEP THIS MEDICAL POLICY INFORMATION PACKET FOR YOUR RECORDS.
Athletic Training
Medical/Insurance Policy Statement Acknowledgement I, ___________________________, have read and understand the stated Cardinal Stritch University procedures concerning health care and insurance coverage for injuries that may occur to myself/my son/my daughter while participating in intercollegiate athletics for Cardinal Stritch University.
________________________________________________ Student-Athlete’s Name (print)
________________________________________________ Student-Athlete’s signature
Date ____________
________________________________________________ Parent/guardian signature (if under 18 yrs old)
Date ____________
Athletic Training Acknowledgement of Assumption of Risk
I, _________________________________, hereby expressly and affirmatively state that I wish to participate in the sport(s) of ____________________ at Cardinal Stritch University. I realize that my participation in this activity involves risks of injury, including, but not limited to severe sprains, strains, fractures, head and neck injuries, and the possibility of paralysis or death. I also recognize that there are many other risks of injury or illness including serious disabling injuries which may arise due to my participation in this activity and that it is not possible to specifically list each individual injury/illness risk. However, knowing the material risks and appreciating, knowing and reasonably anticipating that other injuries and death are possibilities, I hereby assume all of the delineated risks of injury, all other possible risk of injury, and death which could occur by reason of my participation. I have had an opportunity to ask questions. Any questions I had have been asked and answered to my complete satisfaction. I understand the risks of my participation in this activity. Knowing and appreciating these risks, I voluntarily choose to participate, assuming all risks of injury or death due to my participation.
____________________________
Date _____________
Student-Athlete’s signature
_____________________ Parent/Guardian Signature (if under 18 yrs. of age)
Date _____________
