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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