To: Bryant University Student Athletes



Paperwork for all incoming freshman and transfer athletes. You also must complete and submit the physical form and orthopedic evaluation 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.

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-. 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.

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:__________

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): ______________________________

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: _____________________________________________________________________________

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: _______________________________________________________________

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)

Bryant University Athletic Department Health Questionnaire

I. Biographical Data Date: _______________

Name: _____________________________________

LAST FIRST MIDDLE S.S. # ___________________________

Home Address: _____________________________________ DOB: ___________________________

__________________________________________ Home phone: _________________

Local Address/Box#: ___________________________ Sport(s): ____________________

_________________________________________ Date Entered College: ____________

Parent/Guardian Information:

Mother’s Full Name: _______________________________ Home Phone: ______________________

Home Address: ___________________________________ Work Phone: ______________________

________________________________________________ Cell Phone: ________________________

E-mail: __________________________

Father’s Full Name: _______________________________ Home Phone: ______________________

Home Address: __________________________________ Work Phone: ______________________

_______________________________________________ Cell Phone: _______________________

E-mail: ___________________________

Person to notify in case of emergency: ______________________________________________

Phone# ______________________________________________

Relationship: ______________________________________________

II. Vision Information III. Dental Information_______________

Do you wear eyeglasses? YES NO Do you have any special dental needs? YES NO

For reading only? YES NO If yes, explain: ______________________________

For driving only? YES NO Do you have false teeth or bridges? YES NO

For sports only? YES NO Do you have braces or retainers? YES NO

All the time? YES NO Have you had any wisdom teeth removed? YES NO

Do you wear contact lenses? YES NO If yes, when were they removed and how many?

Prescription sport goggles? YES NO __________________________________________

History of blurred vision

(not corrected by glasses) YES NO

Blindness (either eye) YES NO

Cataracts YES NO

Glaucoma YES NO

IV. General Medical History___________________________________________

1. Have you ever been tested for, diagnosed with, or treated for any of the following conditions?

Asthma? YES NO Irritable Bowel (IBS)? YES NO

Diabetes? YES NO Amenorrhea? YES NO

Epilepsy? YES NO Eating Disorders? YES NO

Hepatitis? YES NO Liver Problems? YES NO

Mononucleosis? YES NO Recurrent Nose Bleeds? YES NO

Migraines? YES NO Pain/Pressure in Chest? YES NO

Frequent headaches? YES NO Tuberculosis? YES NO

Ear Problems? YES NO Heat Related Illness? YES NO

Ulcer? YES NO Hypoglycemia? YES NO

Appendicitis? YES NO Acid Reflux? YES NO

Hemorrhoids? YES NO Rheumatic Fever? YES NO

Kidney Problems? YES NO Anemia? YES NO

Gout? YES NO Difficulty Sleeping? YES NO

Thyroid Problems? YES NO Emotional Illness? YES NO

Depression/Anxiety? YES NO Poor Blood Clotting? YES NO

Skin Disease? YES NO MRSA? YES NO

Chronic UTI’s? YES NO Colitis? YES NO

Phlebitis? YES NO Restless Leg Syndrome? YES NO

2. Do you have allergies to:

a. Food? _______________________________________________________________________

b. Medications? _________________________________________________________________

c. Other? _______________________________________________________________________

3. Please list any medications you are taking on a daily basis (prescription, nonprescription, birth control, etc.) __________________________________________________________________________________

______________________________________________________________________________________

4. Have you ever had a hernia? YES NO

5. Have you ever had an organ removed surgically or one that was absent at birth? YES NO

6. Have you ever vomited blood or passed blood in the stool or urine? YES NO

7. If FEMALE, do you experience any problems with your menstrual cycle? YES NO

8. Are you presently being treated by a doctor? YES NO

Please explain any of the YES answers: ______________________________________________________

________________________________________________________________________________________________________________________________________________

V. CARDIAC HISTORY________________________________________________

***PLEASE EXPLAIN ALL YES ANSWERES***

1. Have you ever been tested for, diagnosed with, or treated for Marfan’s Syndrome? YES NO

2. Have you ever been tested for, diagnosed with, or treated for Sickle Cell Anemia? YES NO

3. Do you have any heart disease or heart murmurs? YES NO

4. Do you presently have or have you ever had anemia? YES NO

5. Have you ever been diagnosed with high blood pressure? YES NO

6. Do you have hemophilia? YES NO

7. Have you ever been treated by a doctor for a heart or blood condition? YES NO

8. Have you ever experienced “blacking out”, “passing out”, or syncope? YES NO

Please explain any YES answers: ___________________________________________________________

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

9. Has any parent, grandparent, or sibling had (please state who was diagnosed to the left):

Heart Disease? YES NO __________________________________________________

High Blood Pressure? YES NO __________________________________________________

Diabetes? YES NO __________________________________________________

Stroke? YES NO __________________________________________________

Cancer? YES NO __________________________________________________

Kidney Disease? YES NO ___________________________________________________

10. Has anyone in your immediate family died suddenly of unknown cause before that age of 50? _____________________________________________________________________________________

VI. ORTHOPEDIC HISTORY ______________________________________________

*** PLEASE EXPLAIN ALL YES ANSWERS

1. Have you ever had a concussion or loss of consciousness? YES NO

2. If yes to #1, was overnight hospitalization ever required? YES NO

3. Do you have frequent mid-back pain? YES NO

4. Do you have frequent low-back pain? YES NO

5. Have you ever had a low-back problem that caused a burning sensation, numbness, or weakness down one or both legs? YES NO

6. Have you ever had any of the following neck problems:

“Burner”, “Stinger”, or pinched nerve? YES NO Sprain? YES NO

Fractures or Dislocations? YES NO Surgical Fusion? YES NO

7. Have you ever had any of the following:

Bone/Tissue Infection? YES NO Fractures? YES NO

Cysts, Tumors, Bone Deformities? YES NO Cortisone Shot? YES NO Separated/Dislocated joint? YES NO “Water on the knee” or other joint? YES NO

Painful shoulder secondary to activity? YES NO

8. Have you ever had:

Bone, Joint, or Ligament surgery? YES NO Metal screws, Plates or Staples inserted? YES NO

Surgery ADVISED but not done? YES NO Arthrogram (dye study)? YES NO

Arthroscopy? YES NO Magnetic Resonance Imaging (MRI)? YES NO

Bone Scan or Bone Density study? YES NO CAT Scan? YES NO

9. Do you suffer from frequent/severe ankle/knee sprains? YES NO

10. Do you wear or have you been advised to wear orthotics in your shoes? YES NO

11. Do you wear any brace, tape or other appliance for an orthopedic problem or as protection? YES NO

13. Please list any orthopedic problems/conditions you have that are not covered in this section. _________

______________________________________________________________________________________

14. Have you ever been advised to NOT PARTICIPATE in athletics because of head, neck, or other orthopedic problems? YES NO _________________________________________________________

15. Have you ever been advised to NOT PARTICIPATE in athletics because of a physical, medical, or mental problem? YES NO ___________________________________________________________

16. Do you have any physical, medical, or mental conditions not covered in this questionnaire? YES NO

17. If you have a private physician, please give his/her name, address and date of last physical exam.

______________________________________________________________________________________

______________________________________________________________________________________

XI. All of the above has been answered truthfully and to the best of my knowledge. I grant permission to the Bryant University Health Services to release information to the Sports Medicine Staff regarding my health as it pertains to my participation in the intercollegiate athletic program at the University.

___________________________________________________ ___________________

SIGNATURE DATE

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