Berry College Athletic Department

BCSMD 2013-2014 Form #1 BERRY COLLEGE ATHLETIC DEPARTMENT Medical Insurance Questionnaire Please print the following information legibly Athlete’s Full Name______Sport______Date______

Home Address______City State Zip

Date of Birth ______Athletic Year of Eligibility FR SO JR SR Student ID Number:______

Home Phone______Cell Phone______Berry P.O. Box______

Father’s Name______Employer’s Name______

Home Address______Employer’s Address______

______City State Zip City State Zip Home Phone______Employer’s Phone______

Father’s D.O.B.______

Mother’s Name______Employer’s Name______

Home Address______Employer’s Address______

______City State Zip City State Zip Home Phone______Employer’s Phone______

Mother’s D.O.B.______

Emergency Contact______Phone # ______Relationship:______

Primary Insurance Plan for Coverage of Athlete

Company or Plan______

Address______

Policy #______Group #______Deductible Amount______

Phone______Name of Insured______

Is the company or plan listed above an HMO, PPO, or POS?______Does your plan require you see a PCP?______

PCP (Primary Care Physician)______PCP phone______PCP location______

Policy restrictions______PCP Request: We suggest changing your Primary Care Physician (PCP) to a Rome physician. When an athlete requires a visit with his/her PCP, having the physician in Rome aids in facilitating the process specifically if the student athlete has an HMO. If interested in doing so, please contact 706-368-6335 or [email protected].

Policy Holder Signature Required I hereby authorize Berry College, Aetna, and Garner & Glover Company to inspect or secure copies of case history records, laboratory reports, diagnoses, x-rays, and other data covering this and/or previous confinements and/or disabilities. A photostat copy of this authorization shall be deemed as effective and valid as the original. BCSMD 2013-2014 Form #1 Policy Holder Signature______Student’s Signature______Date______