Transcription
Policy and Procedures for New Student-Athletes (Revised May 2019)Parent(s), Guardian(s), Student-Athlete,Welcome to Bowling Green State University and participation in Intercollegiate Athletics. It is our goal toprovide our student-athletes with the best possible athletic health care. To achieve this, we will need yourassistance with a variety of matters. Each student-athlete will be required to complete the necessarypaperwork on file before being allowed to participate in any activity. We will also require a completedMedical Packet which includes: Demographics Sheet, Consent Form, Release Form, Nutritional DisclosureForm, Insurance information, Health History/Physical and Mental Health Screen. Please complete theseforms with appropriate signatures and dates. This information will be used by providers for billing and alsobe used to contact individuals in the event of an emergency. The completed Medical Packet can bebrought to campus and delivered in person OR may be mailed to: Daniel Fischer M.Ed., AT, AssistantAthletic Director for Sports Medicine, 1610 Stadium Drive, Sebo Athletic Center, Bowling Green OH 43403.In addition, each student-athlete will be evaluated by an approved member of the BGSU Medical Staffupon reporting to campus. This appointment will be scheduled by a member of the BGSU Athletic TrainingStaff.Bowling Green State University requires that all students submit valid and current Medical Insurance. It isalso required, by the BGSU Athletic Department, that all student-athletes submit current Medical InsuranceInformation for participation in BGSU Intercollegiate Athletics. If you do not have current medicalinsurance, you may get information about the BGSU Student Insurance by calling the Falcon HealthCenter at (419) 372-2271.In the event of an athletic injury, the athletic department has purchased an Excess Medical InsurancePolicy that will help cover medical expenses that are not covered by your personal medical insuranceprovider. Since the BGSU Athletic Department Insurance Policy is an excess policy, the student-athlete’sown primary insurance will be billed first and our policy will cover the expenses beyond the primary policyin accordance with the policy. Our policy will cover expenses for 104 weeks from the date of initialathletically related injury. After this 104-week period has ended, Bowling Green State University will not befinancially responsible for any expenses related to any injuries. As a result, it is imperative that all injuriesare reported to the appropriate athletic training personnel immediately. The Athletic Department will not befinancially responsible for any injury or illness that is not related to direct participation in BGSU athletics.Bowling Green State University’s Athletic Department assumes no financial or legal responsibility for: Unreported injuries including concussionsUnreported illness and medical conditionsCharges by a healthcare provider to which a student-athlete was not referred by a member of theSports Medicine Staff or team physician(s)Injuries or conditions not occurring during, or as a results of, participation in a scheduled,supervised practice and/or competition including self-inflicted injuriesWe have developed the following procedure to assist in processing bills that may occur as a result of anathletic injury:1) All medical bills incurred as a result of an athletic related injury will be billed to the student-athlete’sown primary insurance first.2) If we do not have complete or accurate insurance information, bills will be sent directly to you or to thestudent-athlete.
3) If you or the student-athlete receives any statements and/or bills, submit them to your own primaryinsurance for payment.a) The insurance company will send an Explanation of Benefits (EOB) directly to you explaining:i) The carrier has honored the claim and paid all or a portion of the bill.ii) Deny the claim entirely due to deductible balances, etc.iii) Deny the claim requesting additional information from the policyholder. BGSU’s excessinsurance policy will not pay on a claim if this is the reason for denial. BGSU will not beresponsible for missed payments/collection notices for this reason of denial.b) If there remains a balance, you must complete the following:i) Submit the EOB, itemized bill/statements, or other pertinent paperwork to the athletic trainingroom and it will be submitted to our excess insurance carrier.ii) Our insurance carrier is: AmeriBen P.O. Box 6947 Boise, ID 83707.iii) They may contact you for additional information that may be needed to process the claim.Please help them so that your claim may be processed as quickly as possible.c) Note: All itemized bills/statements/etc. must be submitted to AmeriBen within one year of the dateof service. AmeriBen will deny submissions after this time for timely filing. Bowling Green StateUniversity will not be responsible for a claim that has not been submitted due to lack of reportingthe necessary bills or EOB’s.4) Anytime the student-athlete’s insurance information changes, it is your responsibility to notify theSports Medicine Department immediately of these changes.a) Bowling Green State University will not be responsible for a claim that is not processed due to lackof proper, or accurate, primary insurance information.b) Bowling Green State University will not be responsible for a claim that has not been submitted dueto lack of reporting the necessary bills or EOB’s.5) All medical treatment, evaluation, testing, etc. must be authorized and referred by a BGSU sportsmedicine staff member.a) Authorizations and referrals will be made by completing appropriate paperwork prior to receivingany such services.b) If authorization and/or referral for medical services are not obtained, BGSU will not accept anyresponsibility for payment of services.c) If the injury occurs after hours, a member of the sports medicine staff must be notified bytelephone as soon as reasonably possible.d) If the condition is an emergency or other unusual circumstances exist not permitting priorcompletion of paperwork, sports medicine personnel must be notified as soon as reasonablypossible.6) All injuries requiring rehabilitation services will be coordinated through a BGSU Certified AthleticTrainer. If services are required at a different location, other than a BGSU Sport Medicine facility, thenprior approval for services MUST be obtained. If this procedure is not followed, all bills will be theresponsibility of the student-athlete Note: if these services are “out of network” – charges will be thestudent-athlete’s responsibility.7) BGSU sports medicine will not be liable for any medical expenses related to vision except forreplacement/repair of damaged eyeglasses, protective eye wear, or contact lenses or injury to the eyeas a result of direct participation in sport related team activities.8) BGSU sports medicine will not be liable for dental expenses unless resulting from participation in sportrelated team activitiesFailure to return this completed form will cause delays in your Pre-Season Physical Exam and MedicalClearance to participate in athletics at Bowling Green State University. Contact your Athletic Trainer if youhave questions Thank you in advance for your prompt attention to the enclosed material.
Respectfully,Daniel Fischer, M.Ed., ATAssistant Athletic Director for Sports Medicine/Insurance CoordinatorBowling Green State [email protected]
STUDENT ATHLETE’S NAME:SPORT:DATE OF BIRTH:BGSU ID#:CELL PHONE:FIRST AND LAST NAMES:HOMEHOME MAILING ADDRESS:HOME PHONE #CELL PHONE #EMERGENCYCONTACTDATE OF BIRTHRSF So RSSo Jr RSJr Sr RSSrBGSU EMAIL ADDRESS:MOTHER:(Or Guardian)Street:FATHER:(Or Guardian)Street:City/ State/ Zip:City/ State/ Zip:MOTHER:(Or Guardian)MOTHER:(Or Guardian)MOTHER:(Or Guardian)FATHER:(Or Guardian)FATHER:(Or Guardian)FATHER:(Or Guardian)CONTACT’S NAME:RELATIONSHIP:EMERGENCY CONTACT’S #:POLICY HOLDERNAME:INSURANCE INFOCircle One: FrPOLICYHOLDERDATE OF BIRTH:NAME OF INSURANCE COMPANYINSURANCEADDRESSINSURANCEPHONE NUMBER:POLICY NUMBER:GROUP NUMBER:RELATIONSHIP OFPOLICY HOLDERMEDICAID?(CIRCLE ONE)Rx GROUP:Rx BIN:YESNORx PCN:1.I hereby verify that I have submitted a front and back copy of my insurance card:2.Student-Athlete Signature (Required)Date (Required)(Parent signature required if S-A is under 18 years old)I hereby verify that I am currently covered under this insurance plan and will inform the Athletic Dept. of any changes:Student-Athlete Signature (Required)Date (Required)(Parent signature required if S-A is under 18 years old)3. I hereby verify that I have read and understand the sports medicine departments policy and procedures rules and regulations:Student-Athlete Signature (Required)(Parent signature required if S-A is under 18 years old)Date (Required)
Student-Athlete Nutritional Supplement Disclosure FormStudent-Athlete Name:Sport:I am NOT now or do not intend to take any nutritional supplements.Student-Athlete ******I am taking or intend to take the following nutritional supplements.I acknowledge the risks to my health and the risk of losing my eligibility to participate I intercollegiate athletics if I takenutritional supplements and test positive for an NCAA banned substance that may be found in any substance that I maytake, regardless of the reason or purpose for taking such supplements.I acknowledge and understand that the labeling on these products can be misleading and inaccurate, and that salespersonnel are paid to sell these products and cannot accurately certify that these products contain no substances bannedby the NCAA or that may be detrimental to my health. Terms such as “healthy” or “naturally occurring” do notnecessarily mean safe to take or use, or that the NCAA or Bowling Green State University endorses or approves of itsusage.Before taking or using any supplement, I am responsible for taking appropriate steps to ensure that it does not containany substances banned by NCAA or that could be harmful. By making this disclosure, I am accepting the risks knownand inherent to taking these supplements. By listing these products and their ingredients below they will be reviewed bymy institution’s sports medicine staff for the purpose of determining whether they are medically safe to use and that theydo not contain substances banned by the NCAA. I understand that even with the review by my institution’s sportsmedicine staff the use of these substances can result in injury, including the possibility of death, and could result I apositive NCAA drug test. I should not take or use these products until their usage has been reviewed by myinstitution’s sports medicine staff, and even then, I use them at my own risk.Brand NameListed IngredientsBanned Substances (Yes or No)1.2.3.4.5.Student-Athlete SignatureDateI have reviewed this disclosure and educated the student-athlete about the possible risks and side effects of takingnutritional supplements.BGSU Sports Medicine Staff SignatureDate
Release, Consent to Treatment, and Indemnification AgreementStudent-Athlete Name:Sport:In consideration of being permitted to participate in intercollegiate athletics within the Department of Intercollegiate Athletics (“DIA”)at Bowling Green State University, and to use the DIA’s facilities and equipment, I understand and acknowledge that: Participation in sports requires an acceptance and assumption of risk of serious medical injury.Participation in intercollegiate athletics may expose me to hazards that may result in my illness, personal injury, or death. I understand andappreciate the nature of such hazards and risks.I am responsible for knowing the risks of injury associated with participation in, and adhering to rules and regulations applicable to my specifiedsport, including but not limited to those employed to minimize my risk of significant injury while participating in my sport.I must refrain from practice and competition during my medical treatment until I am discharged and given permission to resume activities by aBGSU team physician or BGSU sports medicine staff member.BGSU is not responsible for any previous or pre-existing medical condition(s) that I may have or injuries and illnesses that are not directly relatedto an official practice, contest, or conditioning session.I have read, fully understand and agree to be bound by the DIA’s medical policies and procedures. In the event of illness or injury, BGSU willonly be responsible for my care and treatment for one year after the date of such illness or injury and only if I follow the proper procedures Igaining medical treatment as outlined I the DIA’s medical policies and procedures.I am eighteen years of age or older, under no legal disability, and am fully competent to sign this agreement.RELEASEIn further consideration of being permitted to participate in intercollegiate athletics, I hereby accept all risks to my health and of myinjury or death that may result from such participation. I hereby release and discharged BGSU, its board of trustees, officers,employees, agents and representatives from any liability to me, my personal representatives, heirs, next of kin, and assigns, from anyand all claims, causes of action, damages, and costs for any and all illness or injury to myself, including death that may result from oroccur during my participation, or loss of or damage to my property, to the full extent allowed by law.CONSENT TO TREATMENTIn further consideration of being permitted to participate in intercollegiate athletics, I hereby authorize and consent to such diagnostic,medical and/or surgical treatment as may be considered necessary or appropriate under the circumstances for the treatment of anyillness or injury arising from or sustained by me while engaged in activities related to intercollegiate athletics. The attendingphysician(s), athletic trainers(s), appropriate staff, and BGSU and its officers, agents, and employees shall not be responsible in any wayfor ay consequences from said diagnostic, medical and/or surgical treatment and are hereby released from any and all claims of causesthat may arise, grow out of, or be incident to such diagnosis and treatment, to the full extent allowed by law.INDEMNITYIn further consideration of being permitted to participate in intercollegiate athletics, I further agree to indemnify and hold harmless theBGSU and its board of trustees, officers, employees, agents and representatives from liability for the injury or death of any person(s)and damage to property that may result from my negligent or intentional act or omission while participating in my sport.I HAVE CAREFULLY READ THIS AGREEMENT AND UNDERSTAND IT TO BE A RELEASE OF ALL CLAIMSAND CAUSES OF ACTION FOR INJURY OR DEATH OR DAMAGE TO MY PROPERTY THAT OCCURS WHILEPARTICIPATING I INTERCOLLEGIATE ATHLETICS, AND THAT IT OBLIGATES ME TO INDEMNIFY THEPARTIES NAMED FOR ANY LIABILITY FOR INJURY TO OR DEATH OF ANY PERSON AND DAMAGE TOPROPERTY CAUSED BY MY NEGLIGENT OR INTENTIONAL ACT OR OMISSION. THIS AUTHORIZATIONEXPIRES SIX (6) YEARS FROM THE DATE IT IS SIGNED, UNLESS REVOKED EARLIER IN WRITING.Student-Athlete SignatureDateParent/Legal Guardian of Student-Athlete(If student-athlete is under 18 years of age)DateSignature of WitnessDate
Authorization for the Release of Medical InformationInitialAuthorization for the release of medical information to AthleticTraining Students and other BGSU Sports Medicine Staff membersInitialAuthorization for the release of medical information to BGSUCoaches and other BGSU athletic department staffInitialAuthorization for the release of medical information to ProfessionalTeams and RepresentativesInitialAuthorization for the release of medical information to parentsand/or guardiansInitialAuthorization for the release of medical information to BGSU SportsInformation Staff and other MediaInitialAuthorization for the release of Drug Testing Results to parent(s),legal guardian(s), and/or bothThis authorizes the athletic trainers, team physicians and athletics staff, including coaches representing Bowling Green State University,to release information concerning my medical status, medical conditions, injuries, prognosis, diagnosis and related personallyidentifiable health information to groups mentioned above. This information includes injuries or illnesses relevant to past, present orfuture participation in athletics at Bowling Green State University.The reason for this disclosure is to all such individuals participating in the delivery of athletic training services to assist and participatein the providing of healthcare to me while I am a student-athlete. I understand that the entities that receive this information are nothealthcare providers or health plans covered by federal privacy regulations, and that the information described above may be redisclosed publicly and that the information will no longer be protected by those regulations.I understand that this information will be shared via mediums including but not limited to: verbal communication, phone calls, textmessages, email messages.I understand that Bowling Green State University will not receive compensation for its use/disclosure of the information. I understandthat I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment. I may inspect orcopy any information used/disclosed under this authorization.I understand that I may revoke this authorization in writing at any time by notifying the Director of Sports Medicine, but if I do, it willnot have any effect on actions the University took in reliance on this authorization prior to receiving the revocation. Thisauthorization expires one year from the date it is signed, unless revoked earlier in writing.Printed Name of Student-AthleteSportBGSU Student ID numberStudent-Athlete SignatureDateSignature of Parent/Legal Guardian(if student-athlete is under 18 years of age)Date
Initial Athletic Health History Form&Pre-Participation Physical ExamName:Sport:Class:FroshHome Address:Campus Address:Cell Phone:Emergency Contact:Physician’s Name/Address/Phone #:SophDate of Birth:JR SR5th YRMEDICAL HISTORY1. Has a doctor ever denied or restricted your participation in sportsfor any reason?2. Were you born without or have you suffered the loss of a lung,kidney, eye, testicle, ovary, or any other organ?3. Has a doctor ever told you that you have : (Circle, if yes)High Blood PressureHeart MurmurHeart ProblemHigh CholesterolHeart Infection4. Have you ever passed out or nearly passed out during exercise?5. Have you ever passed out or nearly passed out after exercise?6. Have you ever had discomfort, pain, or pressure in your chestduring exercise?7. Does your heart race or skip beats during exercise?8. Do you tire more quickly than your teammates?9. Has a doctor ever treated you for asthma or seasonal allergies?10. Do you cough, wheeze, or have difficulty breathing during or afterexercise?11. When exercising in the heat, have you had severe musclecramping?12. Have you ever become ill from exercising in the heat?13. Have you ever been told you have Sickle Cell Anemia or Trait?DO YOU HAVE OR HAVE YOU EVER 9.30.31.32.33.34.Pneumonia?Mononucleosis?Rheumatic Fever or Scarlet Fever?Diabetes?Epilepsy/ Convulsions/ Seizures?Any bleeding problems or Anemia?An immune system disease?Kidney Disease?A hernia?A stomach disorder or appendicitis?Recurrent headaches?Abdominal pain or nausea?Been hospitalized?Any surgeries?A stress fracture?A screw, pin or plate surgically implanted into your body?Are you taking ANY prescription or over-the-counter medicines?Are you taking ANY supplements, vitamins or herbs?An allergic reaction to medication, food or insects?Is any doctor presently treating you for any disorder?An MRI, MR-Arthrogram, X-ray, CT scan or Bone Scan?35.36.37.38.Do you currently have any problems with your Hearing?Have you experienced an ear ache in the last 12 months?Do you feel that your hearing is good?Do you wear any corrective hearing devices?HEARING HISTORYSex:MFBGSU ID:Home Phone:Emergency Phone:YVISION HISTORYN Y Y N N 39. Do you wear glasses or contact lenses?40. Have you experienced any eye infections in the past 12 months?41. Do you feel that your vision is good?DENTAL HISTORY42. Do you have any chipped, loose or missing teeth?43. Do you wear any dental appliances? (i.e. Retainer, spacers )44. Are you currently experiencing any dental problems?FAMILY HISTORY45.46.47.48.49.50.51.52.53.Family history of Heart conditions?Family history of High blood pressure?Family history of Sickle cell anemia or trait?Family history of Dying during or following exercise?Family history of Death prior to the age of 50?Family history of Asthma?Family history of Marfan’s syndrome?Family history of Eating disorders?Family history of Depression?54.55.56.57.At what age was your first menstrual period?Age:When did your last menstrual period begin?Date:What was the longest time between periods in the last year?Have you even been on birth control pills or injections?FEMALES ONLY SECTIONGENERAL QUESTIONSYN Y N Y N Y N Y N58. Have you been wearing any type of brace, support, or other special padding for participation in athletic activities?59. Have you had an illness or injury in the last 12 months that has not been listed previously?60. Have you used in the past or are you currently using any type of performance enhancing substances or drugs?61. Are you currently taking medication for Attention-Deficit Hyperactive Disorder?62. Do you know of any health reason why you should not participate in the BGSU athletic programs at this time?63. Have you ever been prescribed an inhaler or currently use one? EXPLAIN ALL “YES” ANSWERS TO THE ABOVE QUESTIONS IN THIS SPACEREFERRING TO THE QUESTIONS BY THEIR NUMBER:##########
HAVE YOU HAD AN INJURY .80.81.HEAD (concussion- ‘knocked out’, surgery, hospitalization, other)FACE (fracture, eye, ear, nose, surgery, other)NECK (strain, fracture, stingers, burners, surgery, other)SHOULDER (dislocation, strain, sprain, rotator cuff injury, tendonitis, surgery, other)ARM/ELBOW (sprain, strain, tendonitis, fracture, dislocation, surgery, other)WRIST/THUMB/HAND (sprain, strain, tendonitis, fracture, dislocation, surgery, other)FINGERS (sprain, facture, surgery, other)CHEST (pain, lungs, heart, surgery, other)ABDOMEN (kidney, spleen, appendix, liver, surgery, other)GENITALIA (groin, testicle, ovary, warts, surgery, other)BACK (strain, sprain, fracture, chronic pain, disc, surgery, other)HIP/THIGH (strain, fracture, surgery, other)KNEE (sprain, cartilage, bursitis, tendonitis, patella, surgery, other)LOWER LEG (sprain, strain, fracture, tendonitis, shins, surgery, other)ANKLE (sprain, strain, fracture, tendonitis, surgery, other)FOOT (sprain, fracture, strain, tendonitis, surgery, other)TOES (sprain, fracture, surgery, other)OTHERS:YesNo RTRTRTRTRTRTRTRTRTRTRTRTRTDateCurrent PLAIN ALL “YES” ANSWERS TO THE ABOVE QUESTIONS (#64-81):######DIET HISTORYDO YOU HAVE or HAVE YOU EVER HAD:82.83.84.85.86.87.88.89.Anorexia, Bulimia, or any other eating disorders?Do you want to weigh more or less than you do right now?Have you ever induced vomiting to control your weight?Have you ever used laxatives, diuretics or diet pills for weight loss?Are you currently taking any vitamins, minerals, or supplements?Are there any food groups you choose not to eat (meat, dairy, etc.)?What is your ideal weight?What Foods, including supplements, have you eaten in the last 24 hours?YesNo Weight: DateExplainLBSBreakfast:Lunch:Dinner:SnacksTHE UNDERSIGNED ATHLETE:1. Understands that he/she must refrain from practices or play while ill or injured, whether or not receiving medical treatment, and during medical treatment until he/sheis discharged from treatment or is given permission by a Bowling Green State University Team Physician to restart participation despite continuing treatment.2. Understands that having passed the physical examination does not mean that he/she is physically qualified to engage in athletics, but only that the evaluator did notfind a medical reason to disqualify him/her at the time of the said evaluation.3. Certifies that the answers to the above questions are correct and true to the best of his/her knowledge.ATHLETE’s SIGNATURE:DATE:PARENT’s SIGNATURE:DATE:(required if athlete is under 18 years of age)I have reviewed this history with the student-athlete, documented all yes answers, and requested all necessary medical records.BGSU MEDICAL STAFF SIGNATURE:DATE:
Physical ExaminationName:Height:Vision: L 20/Pulse:MEDICALWeight:R 20/ Corrected Y N% Body Fat (optional):Glasses Y N Contacts Y N Pupils: EqualBP:Left arm/Right Arm(PRN BP Recheck or position) Left arm/Right ArmNORMALComments regarding Abnormal Findings ymph NodesHeartPulsesLungsAbdomenGenitilia (males based examination onlySTATUS Cleared Cleared after completing evaluation/rehabilitation for: Not Cleared for:Recommendations:Name of examiner (Print/type):Address of examiner:Signature of examiner:Reason:Date:Phone:Modified from the form approved by the American Academy of Family Physicians, American Academy of Pediatrics, American Medical Society for SportsMedicine, American Orthopedic Society for Sports Medicine and American Osteopathic Academy of Sport Medicine.February 2010
Informed Consent for Sickle Cell Trait Screening I consent to have a sample of blood drawn in order to determine if I have SickleCell Anemia Trait. I understand the results will be made available to BGSU Sports Medicine Personnel,BGSU Coaches, as well as BGSU Health Center Staff. I understand the results will not determine eligibility nor influence depth chartdecisions.Print NameSign NameDate I Refuse the Above Available Testing due to prior knowledge of testing resultsand I will provide Bowling Green State University with the necessarydocumentation of my testing results.Print NameSign NameDate
Informed Acknowledgement of Non-AthleticallyRelated Physician Appointment I understand that scheduling an appointment with my certified athletic trainer to beseen by a physician (General Practitioner or Orthopedic) for a non-athleticallyrelated illness or injury is a courtesy extended to student-athletes. I understand that my attendance at this appointment does not release me from anyand all costs associated to, or generated from, the appointment itself or anysubsequent costs such as, but not limited to, insurance co-pay, lab fees, radiology,etc. I understand an athletically related injury is considered to be an injury sustainedduring organized intercollegiate activities. On-campus intramurals, recreational sportleagues, etc are considered non-athletically related and need to be reported to mycertified athletic trainer. By signing below I acknowledge and accept the responsibility of payment for nonathletically related injury and illness.Student-Athlete SignatureDateParent/Legal Guardian of Student-Athlete(If student-athlete is under 18 years of age)DateSignature of WitnessDate
Policy that will help cover medical expenses that are not covered by your personal medical insurance provider. Since the BGSU Athletic Department Insurance Policy is an excess policy, the student-athlete’s own primary insurance will be billed first and our policy will cover the expenses beyond the primary policy in accordance with the policy.
