<p> BCSMD 2013-2014 Form #1 BERRY COLLEGE ATHLETIC DEPARTMENT Medical Insurance Questionnaire Please print the following information legibly Athlete’s Full Name______Sport______Date______</p><p>Home Address______City State Zip</p><p>Date of Birth ______Athletic Year of Eligibility FR SO JR SR Student ID Number:______</p><p>Home Phone______Cell Phone______Berry P.O. Box______</p><p>Father’s Name______Employer’s Name______</p><p>Home Address______Employer’s Address______</p><p>______City State Zip City State Zip Home Phone______Employer’s Phone______</p><p>Father’s D.O.B.______</p><p>Mother’s Name______Employer’s Name______</p><p>Home Address______Employer’s Address______</p><p>______City State Zip City State Zip Home Phone______Employer’s Phone______</p><p>Mother’s D.O.B.______</p><p>Emergency Contact______Phone # ______Relationship:______</p><p>Primary Insurance Plan for Coverage of Athlete</p><p>Company or Plan______</p><p>Address______</p><p>Policy #______Group #______Deductible Amount______</p><p>Phone______Name of Insured______</p><p>Is the company or plan listed above an HMO, PPO, or POS?______Does your plan require you see a PCP?______</p><p>PCP (Primary Care Physician)______PCP phone______PCP location______</p><p>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].</p><p>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______</p>