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Paperwork for all returning student-athlletes. You also must complete and submit the physical form.
We are pleased to have you participating in athletics at Bryant University. We will strive to provide the greatest sports medicine care and coverage to enhance your intercollegiate athletic experience. However, it is imperative that you read carefully the following insurance information. We appreciate your cooperation in obtaining some vital information regarding your insurance carrier, so that we may assist you in quicker claims processing.
EVERY STUDENT AT BRYANT UNIVERSITY IS REQUIRED TO HAVE A PRIMARY INSURANCE POLICY IN EFFECT DURING THE ENTIRE ACADEMIC YEAR. BRYANT’S ONLY ATHLETIC INSURANCE COVERAGE IS AN EXCESS POLICY, AND OUR PROVIDER ONLY PAYS BENEFITS AS A SECONDARY CARRIER AFTER A CLAIM HAS BEEN PROCESSED (AND PAID) THROUGH YOUR PRIMARY INSURANCE CARRIER. IF YOUR SON/DAUGHTER DOES NOT HAVE HEALTH INSURANCE HE/SHE WILL BE REQUIRED TO PURCHASE THE STUDENT POLICY OR THEY WILL NOT BE ABLE TO PARTICIPATE IN INTERCOLLEGIATE ATHLETICS AT BRYANT UNIVERSITY.
1) If you have a pre-existing injury or condition that you are currently being treated by a doctor for (e.g. shoulder surgery, knee surgery, bulging/herniated discs) you MUST get a note from that doctor stating you are cleared to participate in athletics at Bryant University. Bryant’s secondary athletic policy does not pay for pre-existing conditions, please be aware of this in the event that your son/daughter may need clearance from our team physicians. 2) If your primary insurance carrier is an HMO or requires prior approval for services out of network our insurance company will NOT cover the bill if prior authorization is not obtained. Please obtain prior approval for your son/daughter to see our doctors by contacting your insurance company and informing them that your son/daughter is at college out of state and may be seeing doctors out of network. If the necessary prior approval or authorization is not obtained the remainder of the bills become your financial responsibility. 3) If your primary insurance company will not grant approval for your son/daughter to see doctors out of network while he/she is at Bryant University, it is strongly encouraged that you purchase the school’s student insurance policy (Koster Insurance Agency, Gary Fornari, 800-457-5599 x-232), which will allow for medical coverage for your son/daughter while he/she is here at Bryant University. Please note: Our team physicians are not providers of Aetna/US Healthcare, United Health Plans, Harvard Pilgrim, Oxford Health Plans, and Cigna. 4) If your primary insurance status changes at any time throughout the calendar year, (e.g. change in coverage or lapse in coverage) we ask that you notify us of the change within 30 days of the turnover or termination. Be advised that should your son/daughter’s coverage lapse and you fail to notify this department, any and all bills resulting from athletic participation will be forwarded to you and will be your financial responsibility. 5) 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 student-athlete’s follow up care. Please note it is Bryant University’s policy to not be held financially responsible for these second opinions. Also, any visits to a doctor, hospital, x-ray facility, etc., that the athletic training staff is not made aware of is not the financial responsibility of Bryant University. 6) In order for any payment to occur from our insurance company, the student-athlete must see a physician within 30 days of the injury date. If the student-athlete does not see a physician within this time period, our insurance company will not pay any of the bills and the financial responsibility is on the student-athlete and his or her parents/guardians. 2
7) Because of the new HIPAA-privacy act laws the athletic training staffs’ ability to make inquiries to insurance companies on student-athlete claims will be very limited. Please be advised that we may have to ask for your son/daughter’s involvement with any claims issues if necessary due to these privacy restrictions.
8) This is a reminder that our athletic insurance policy is a secondary injury or “accident” policy. The policy does not cover medical issues such as blood-work, lab-work, flu, cold, heart conditions, ob-gyn conditions, bronchitis, to just name a few examples. For these ailments, the student-athletes can always consult our campus Health Services in Hall 16 and reach them at 401.232.6220.
9) Finally, our secondary excess athletic policy oftentimes pays only a portion of the bill for orthotic shoe inserts. Many insurance companies do not cover orthotics at all. Please be aware that even if your son/daughter needs to get orthotics and your insurance company denies the entire amount our company may still only pay a portion of that amount, leaving the remainder your financial responsibility.
We are pleased to say that we are still working with the orthopedic doctors of Orthopedic Group, Inc. This is our fourth year working with this team. They have accommodated us graciously with the insurance needs of our student athletes and have created a reduced rate for student-athletes with insurance that will not pay for services rendered by them. This would apply to student-athletes with out of network HMOs and subscribers to insurance plans that the physicians’ office does not take. If you have any questions on this the athletic training staff would be more than happy to answer them for you. You can still check out our docs online at ogi-docs.com. For your records, their information is as follows:
Orthopedic Group, Inc. Dr. Michael Feldman Dr. Jonathan Gastel 588 Pawtucket Avenue Pawtucket, RI 02860 401.722.2400 ext 3307 (Deb) Fax 401.728.3920
We strive to provide the best services possible for the student-athletes at Bryant University, but parental responsibilities in such matters as these are vital and cannot be neglected.
Because of the HIPAA privacy act law our claim process has changed slightly; for your records here is our secondary insurance information:
Diversified Group Administrators PO Box 6540 Harrisburg, PA 17112 Attn: Jerrie, Claims Handler Claims assistance 800.427.9308, extension 3026
We thank you very much for your time and careful attention to these matters. Please feel free to call with any questions: John Ruppert, Associate Athletic Director, (401)232-6737; or Patrick O’Sullivan, L/ATC, Head Athletic Trainer, (401)232-6073.
Thank you again, we look forward to working with your son or daughter in the fall. 3
THIS FORM MUST BE COMPLETED, SIGNED AND RETURNED TO THE ATHLETIC TRAINING DEPARTMENT PRIOR TO YOUR PARTICIPATION ON A BRYANT UNIVERSITY INTERCOLLEGIATE ATHLETIC TEAM FOR THE 2007-2008 ACADEMIC YEAR.
I have read the document regarding athletic injury coverage, and I understand the policies and procedures regarding payment of medical bills. I also understand the risks of participating in intercollegiate athletics, especially contact sports, and I am of my own free will, applying to participate in
(Name of Sport(s))
Bryant University does not bar student participation in intercollegiate athletics solely by reason of handicap. The university reserves the right, however, to exclude or restrict a student’s participation where there exists a substantial risk of significant injury and/or aggravation of a pre-existing medical condition.
In consideration for Bryant University allowing me to participate in intercollegiate athletics: 1. I assign the benefits of my personal insurance to the appropriate providers of my medical care and agree to the terms set forth by the previous insurance letter and all of the terms set forth by that of the secondary insurance policy carried by Bryant University Athletics. 2. I agree to furnish ACCURATE, COMPLETE and CURRENT insurance information to the Athletic Training department. 3. I accept complete responsibility for my present physical condition, including any special disabilities, whether or not disclosed to Bryant University. 4. I will not hold Bryant University or anyone acting on its behalf liable for injuries that I may incur as a consequence of my participation in intercollegiate activities. 5. I understand that “non-athletic related injuries” (i.e., injuries outside of my sport, injuries occurring on personal time, injuries suffered during other non-varsity sporting events, etc.) will not be covered under the school’s secondary insurance and will be the sole responsibility of the athlete and their primary insurance.
Student-athlete Signature: ______Date: ______
6. I have read the enclosed materials regarding athletic injury insurance coverage, and I understand the policies and procedures regarding the responsibility to provide insurance and the payment of medical bills.
Parent’s/Guardian’s Signature: ______Date: ______Student-athlete signature if over 18 and parent/guardian unavailable: ______Date:______4
Suggestion Regarding Insurance
Out of state insurance coverage can often cause problems when having to be seen by a doctor while away at school. It is suggested that you call your primary insurance company to try to get a written authorization to see our doctors. It is strongly recommended that you purchase the student insurance if you cannot get prior approval from your primary health insurance.
By signing below you acknowledge that you have read and understand the above statement.
Student Athlete Signature: ______
Parent Signature (if under 18): ______5
Bryant University Athletics Insurance/Emergency Information
Name: ______DOB: ______Social Security #: ______Sport: ______
Local Address/Box#: ______Local Phone#/School# ______
Home Address: ______Home Phone# ______Cell Phone # ______
Father/Guardian: ______Social Security#: ______Address (if different): ______Daytime Phone: ______Nighttime Phone: ______
Mother/Guardian: ______Social Security#: ______Address (if different): ______Daytime Phone: ______Nighttime Phone: ______
**Please check here if your son/daughter has no insurance coverage through you, your family, or his/herself: ______
If the student-athlete has health insurance coverage, PLEASE SUBMIT A COPY OF THE FRONT AND THE BACK OF THE INSURANCE CARD, as well as completing the following information as applicable: Primary Insurance: Ins. Co. ______Effective: ______Claims Address: ______Policy#______Group #______Insurance Customer Service Phone# ______Subscriber’s name: ______Subscriber’s SS# ______PCP info: ______Name Address Phone Number
Does your son/daughter have a Secondary Insurance Policy? _____yes _____no If yes, please provide information and attach a copy of the card: ______Is pre-authorization required for surgery? ____yes _____no Is a referral required from your PCP before visiting with a specialist? ___yes ___no Is prior approval required before your son/daughter sees a specialist and/or any physician out of state and/or network? If yes, please explain: ______***By signing below, you confirm that you have read, met the criteria for and that you understand the enclosed Bryant University athletic insurance policy.
Parent Signature (IF UNDER 18):______Date: ______Student-Athlete Signature: ______Date: ______For Athletic Trainers Use: Known Allergies: ______
Known Medications: ______6
Other Conditions: ______SHARED RESPONSIBILITY FOR SPORT SAFETY & ASSUMPTION OF RISK
NAME: ______Date: ______
LOCAL ADDRESS/BOX#: ______Local Phone: ______Cell Phone: ______HOME ADDRESS: ______Home Phone: ______
SPORT: ______S.S. # ______DOB: ______
Participation in sport requires an acceptance of risk of injury. The realm of that risk can include catastrophic injury and/or death. 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 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 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.
REALEASE TO TREAT By signing within, I hereby authorize the Athletic Training Staff, Team Physicians and medical consultants of Bryant University to provide any and all care as deemed necessary for any specific injury or condition. However, if there are specific parameters due to religious beliefs, etc., that do not allow certain treatments to be carried out, please specify below or send in information (i.e., blood transfusion, do not resuscitate, etc.).
Please Print Full Name______
Signature of Student Athlete: ______Date: ______
Parent Signature (if under 18): ______Date: ______
Special requests: ______7
BRYANT UNIVERSITY INTERCOLLEGIATE ATHLETICS PERSONAL INFORMATION CONSENT FORM
The release and/or use of certain (otherwise protected) information contained in the educational, financial, or medical records of student-athletes is often necessary for the conduct of day-to-day athletic business for the pursuit of the mission and goals of the Bryant University intercollegiate athletic program.
I agree to allow the Bryant University Athletic Training staff to disclose and discuss medical records with my parents and/or legal guardians and coaches.
I agree to allow members of the Bryant University faculty to disclose my academic progress for the purposes of monitoring my academic progress in regards to NCAA eligibility regulations.
I agree to allow the Bryant University athletic department designee to monitor my full or part-time status (12 credits).
I agree to allow a member of the Bryant University athletic staff to submit my name, photograph, academic GPA, etc.; in regards to academic awards or athletic achievements – Academic All-American, Scholar athlete.
I agree to allow the Bryant University Sports Information Director to release basic information to media outlets concerning participation status in areas such as: medical, eligibility, and disciplinary (College/ Team rules). Examples: Bob will not play in today’s game due to disciplinary actions regarding team rules. Bob will not participate in today’s game due to a knee injury.
I am accountable for all University, NCAA, Conference, and athletic department policies as stated in the Bryant University Student-Athlete Handbook distributed at all compliance meetings and available in the athletic office.
The privacy and dignity of the student-athlete is paramount. Bryant University’s intercollegiate athletic department, to the full extent possible under State and Federal Law will protect every student-athlete.
______(Student – athlete signature) (Date)
(Participating on the team (s)) (Academic year)
______(Parent/Guardian signature if student-athlete under 18) (Date) 8
Bryant University Returning Student-Athlete Update Form
Name:______Sport(s):______
School year 2007-2008 Anticipated Graduation Year:______
This form must be completed and returned before the student-athlete will be permitted to practice or play. Per NCAA recommendations, this is an annual health status review since you received a medical evaluation upon your entrance to Bryant University. Upon completion of returning student-athlete update, if further medical evaluation is necessary, the Athletic Training staff will refer to the appropriate party at that time.
PLEASE ANSWER THE FOLLOWING QUESTIONS (FRONT AND BACK), BEING AS TRUTHFUL AS POSSIBLE AS WE ARE HERE TO HELP AND PROTECT YOUR HEALTH AND WELL-BEING.
1. Have you been hospitalized or had a major illness since your most recent medical evaluation or Athletic Training update? YES NO If yes, please explain:______
2. Are you CURRENTLY ill in any way? YES NO If yes, please explain: ______
3. Have you had a major injury (including concussion) since your most recent medical evaluation or update? YES NO If yes, please explain: ______
4. Are you currently injured in any way? YES NO If yes, please explain: ______
5. Have you experience any “passing out”, “blacking out”, or syncope since your last medical evaluation or update? YES NO
6. Have you been diagnosed with a cardiac problem or high blood pressure since your last update? YES NO
7. Are you taking any medications on a regular basis? YES NO If yes, list medication(s) and reason(s):______
8. Are you currently taking any medications for an injury or illness? YES NO If yes, please list and give reason(s): ______
9. Do you have asthma? YES NO If yes, please bring an extra inhaler for the Athletic Training staff to hold for you.
10. Do you have diabetes? YES NO If yes, please specify your care and regimen for your condition below: 9
______**Please speak with the Athletic Training staff upon your return to school. 11. Do you have any drug allergies? YES NO If yes, please list: ______
12. Do you have any food or insect allergies? YES NO If yes, please list: ______
13. Do you have any allergies that require the use of an epi-pen? YES NO If yes, please explain: ______***Please bring an extra epi-pen to school with you for the Athletic Training staff to hold.
14. Do you have any other health concerns or issues that were not covered in the above questions? YES NO If yes, please explain: ______
The undersigned:
A. Understands that he/she must refrain from practice and/or play while ill or injured, whether or not receiving medical treatment. However, during medical treatment, student- athletes must wait to be cleared by a physician, therapist, or an Athletic Trainer.
B. Understands that the Athletic Trainer reserves the right to hold out a student-athlete if the Athletic Trainer feels it is in the student-athlete’s best interest to seek out further medical evaluation.
C. Understands the risks of participating in intercollegiate athletics here at Bryant University.
D. Certifies that the student-athlete answered the above questions truthfully and did not withhold any information form the Athletic Training staff.
Student-athlete signature:______Date: ______
Full Participation ______Cleared but needs Medical referral ______
NOT CLEARED ______Cleared but needs Orthopedic referral ______
Reason for NOT CLEARING: ______
Referral to: ______
Signature of Reviewing Certified Athletic Trainer: ______10
BRYANT UNIVERSITY PHYSICAL EXAMINATION FORM ALL STUDENT-ATHLETES
NAME: ______DATE OF BIRTH: ______
HEIGHT: ______WEIGHT: ______BP: ______PULSE: ______
CHECK BELOW IF NORMAL:
SKIN ______ HERNIA (CHECK) ______ HEAD______ EYES ______
LYMPH NODES ______ THYROID ______
HEART ______ NEUROLOGIC ______
LUNGS ______ EARS ______
ABDOMEN ______ NOSE______
GENITALIA______ THROAT ______
PHYSICIANS SUMMARY: I hereby declare that (name of athlete) ______is medically cleared to participate in intercollegiate athletics at Bryant University.
Fit to participate: YES NO Further evaluation needed: YES NO 11
COMMENTS: ______
Examining Physician: ______Phone Number: ______
Physician Signature: ______Date: ______