Please Fill out All Information Completely

Primary Insurance Information

PLEASE FILL OUT ALL INFORMATION COMPLETELY

Athlete Name Sport

Home Address

CityStateZip Code

D.O.B. Social Security #

Home Phone #______Cell Phone #

SHU ID#

Father's Name Social Security #

Employer Cell Phone

Employer Address D.O.B.

Mother's Name Social Security #

Employer Cell Phone

Employer Address D.O.B.

Please check type of insurance: HMO ____ PPO ____ MEDICAID ____ SHU____

Does your insurance require a referral from your primary physician? Yes____ No ____

Carrier Name

Issued to

Insurance Address

Phone ______Expiration Date

ID # Group #

Rx Bin# Rx PCN ______Rx Group #

Note to providers: Please bill the insurance company listed above FIRST. Seton Hall University’s insurance is SECONDARY.

Primary Insurance Card:

Please paste a clear copy of the front of insurance card. / Please paste a clear copy of the back of insurance card.

I have checked that the above insurance card covers prescription medication and I do not have a separate prescription card. Your insurance card will have “Rx Bin” number if it covers medication. Please Initial: ______

Insurance Information – Continued

Vision Insurance Plan

Name of Insurance Company

Address

Phone ( ) Expiration Date

ID # Group #

Dental Insurance Plan

Name of Insurance Company

Address

Phone ( ) Expiration Date

ID # Group #

Prescription Insurance Plan

Name of Insurance Company

Address

Phone ( ) Expiration Date

ID # Group #

BIN #

Secondary or Additional Insurance Cards:

Please paste a clear copy of the front of insurance card. / Please paste a clear copy of the back of insurance card.
Please paste a clear copy of the front of insurance card. / Please paste a clear copy of the back of insurance card.

Information

To Be Kept by Parent/Guardian

Outlined below is the athletic medical insurance policy instituted by Seton Hall University. It is in regard to an injury that is sustained during participation on one of our athletic teams. The NCAA does not permit Seton Hall or any college to provide coverage or pay bills for illness or conditions that are not the direct result of a sport related injury or that occurred previous to the athlete’s arrival at Seton Hall University.

It is the responsibility of the student-athlete to report to the Office of Sports Medicine within 24 hours of the injury in order to receive prompt medical care and to guarantee coverage. Please note that coverage and payment will not be guaranteed for any medical services obtained without the knowledge or pre-approval by the Office of Sports Medicine staff.

Below is a partial list of injuries covered by the Seton Hall Athletic Department.

Covered: Any injury occurring during a school supervised practice, game, conditioning session, weight lifting (team or individual), etc. where a coach, athletic trainer, and/or strength and conditioning coach is supervising.

Not Covered:Pre-existing injuries, illness, non-sport related injuries including dental and vision injuries, non-athletically related prescriptions, or doctor visits without the prior approval by a member of the Office of Sports Medicine, which includes all medical tests, surgeries, follow-ups that occur from this initial visit.

In compliance with New Jersey law, all students must have proof of health insurance coverage. The Seton Hall University Department of Athletics provides athletic accident coverage for athletic related injuries secondary to the student-athlete’s primary plan. Primary insurance coverage is provided by the student-athletes private/family plan. The procedures for the student-athletes private insurance policy must be followed in order for the athletic accident policy to go into effect. Secondary insurance will not cover any costs until the bills have first gone through the athlete’s primary insurance. Therefore, it is the responsibility of the student-athlete and parents/guardians to inform the Office of Sports Medicine of any changes in your insurance coverage during the course of the school year, as soon as the changes occur. You will be responsible for all financial charges if a student-athlete receives medical treatment and the insurance plan will not honor the charges because of an expired or changed insurance policy.

Insurance Filing Procedures:

All medical bills for your son/daughter that are a direct result of an athletic injury sustained while participating for Seton Hall athletics will be submitted directly to your primary insurance carrier.

If a balance remains after your primary insurance coverage, mail or fax the explanation of benefits (EOB) from the insurance company and a copy of the itemized bill (HCFA-1500 or UB92) to the address below c/o Sports Medicine.

If you receive a letter of denial with no payment from your primary insurance, mail or fax the letter of denial and a copy of the itemized bill (HCFA-1500 or UB92 form) to the address below c/o Office of Sports Medicine.

It is the responsibility of the parent and student-athlete to submit all required paperwork as soon as possible. All forms must be received within 12 months of the original date of service. If you have any further questions please do not hesitate to contact the Office of Sports Medicine at (973) 761-9738.

Send Claims to: Seton Hall University – Office of Sports Medicine

400 South Orange Avenue

South Orange, NJ 07079

Fax #: (973) 275-2995

Please keep this sheet for reference in the event the student athlete is injured while at Seton Hall University, return the duplicate on the next page signed by a parent/guardian.

Athletic Injury Insurance Information

Signed by Parent/Guardian and returned to Office of Sports Medicine

Below is a partial list of injuries covered by the Seton Hall Athletic Department.

Insurance Filing Procedures:

If a balance remains after your primary insurance coverage, mail or fax the explanation of benefits (EOB) from the insurance company and a copy of the itemized bill (HCFA-1500 or UB92) to the address below c/o Sports Medicine.

If you receive a letter of denial with no payment from your primary insurance, mail or fax the letter of denial and a copy of the itemized bill (HCFA-1500 or UB92 form) to the address below c/o Office of Sports Medicine.

Send Claims to: Seton Hall University – Office of Sports Medicine

400 South Orange Avenue

South Orange, NJ 07079

Fax #: (973) 275-2995

Please read the above page carefully. If you have any questions please contact the Office of Sports Medicine. This sheet is also available on the Sports Medicine page located on shupirates.com. Please sign this paper and return to the Office of Seton Hall Sports Medicine. Student Athlete’s will not be cleared for participation until this form is signed and returned.

I, ______, parent/guardian of ______am aware of the insurance protocol for medical expenses at Seton Hall University. We agree that all insurance information in the above pages is true and complete to the best of our knowledge.

Student-Athlete Signature Date

Parent/Guardian Signature ______Date

**Must be signed by parent/guardian**

Assumptionof Risk/Liability Waiver

Consentof Medical Care & Treatment

Please read completely and carefully, and sign below:

The undersigned hereby certifies that the answers to the Sports Medicine health history questionnaire and physical examination are correct, true, and honest.

We understand that having passed the pre-participation medical/physical examination does not necessarily mean that the student-athlete is physically qualified to engage in athletics, but only that the examiner did not find a medical reason to disqualify them.

The Team Physician and members of the Seton Hall University Office of Sports Medicine have overriding say concerning athletic participation status and medical exclusion.

We understand and accept the risks of injury, the possibilities of permanent disability, and death inherent to the relevant sport. By signing below the student-athlete pledges to do their best to reduce these risks by keeping in the best physical condition and following the advice of the team physician, attending physician, certified athletic trainer (ATC), and coaching staff concerning the prevention, treatment, and rehabilitation of athletic injuries.

A concussion is a “complex patho-physiological process affecting the brain, induced traumatic biomechanical forces” and is characterized by a rapid onset of cognitive impairment. Although a concussion most commonly occurs after a direct blow to the head, it can occur after a blow elsewhere that is transmitted to the head. Athletes that are not fully recovered from an initial concussion are significantly vulnerable for recurrent, cumulative, and even catastrophic consequences of a second concussive injury. By signing below the student-athlete is acknowledging an understanding of the risk associated with concussion, has read the Seton Hall University Concussion Management Policy and pledges to report all head trauma to an ATC.

We grant permission to the Sports Medicine Staff to hospitalize and/or secure treatment for me for any athletic injury. If the student-athlete is under the age of 18, the undersigned parent/guardian grants permission to the Sports Medicine Staff to hospitalize and secure treatment for my son/daughter for any athletic injury.

I give permission for Certified Athletic Trainers (within the Athletic Department), the Seton Hall University Student Health Services Staff, and all consulting physicians, permission to exchange, written or orally, any information concerning any injuries or illness which effects my ability to participate in physical activities throughout the time in which I am an official student athlete at Seton Hall University. Any change in this status must be made in writing by the student athlete and rendered to all parties concerned.

We, the undersigned, have read and understand the Medical Policy statement and agree to follow its policies and procedures. We also hereby release Seton Hall University, its agents and employees, from any liability caused by, or arising out of the athletic participation in the University’s athletic program, unless solely caused by the negligence of the University, its agents, or employees.

______

Athlete’s Name (Print) Parent’s Name (Print)**

______

Athlete’s Signature Parent’s Signature**

______

Date Date

**Parent’s signature required if student-athlete is under 18 years of age.

TREATMENT CONSENT FORM FOR MINORS

**If you are not under 18 at the time you fill out this packet, you may disregard this page**

NAMESPORT

SOCIAL SECURITY # SCHOOL ID #

DATE OF BIRTH

HOME PHONE ( )

Person to be notified in case of emergency, illness, or injury:

NAME

PHONE ( )

FAMILY PHYSICIAN

PHONE ( )

CONSENT:

In case of routine health examinations, diagnostic procedures, treatment of illnesses, and/or injuries, permission is hereby granted to treat the student-athlete named above by the Team Physician, referred physicians, Office of Sports Medicine Staff, and other emergency facilities as indicated. Upon verbal notification and approval, permission is granted for the Team Physician or other specialized physicians to perform warranted surgical procedures at designated emergency facilities.

Date

Signature of Parent/Guardian

Date

Signature Student-Athlete

Release of Medical Information

Date

Student-Athlete’s Name

Sport/Team

Temporary Address

Permanent Address

Cell PhoneHome Phone

I hereby authorize the following physicians, sports medicine staff and other health care personnel representing Seton Hall University and the Seton Hall University Department of Athletics to obtain information regarding my protected health information and any related information regarding any injury or illness during my training for and participation in intercollegiate athletics. This protected health information may concern my medical status, medical condition, injuries, prognosis, diagnosis, athletic participation status, and related personally identifiable health information.

I agree that my parent(s)/guardian(s) will be involved in or notified of my treatment only if I give permission, OR if the following is concerned that my life may be in danger.

Member NameAffiliation/Position

Dr. Anthony FestaOrthopedic physician

Dr. Anthony ScilliaOrthopedic physician

Dr. Vincent McInerneyOrthopedic physician

Dr. Michael KellyPhysician

Anthony TestaDirector of Sports Medicine

Dawn PuringtonAssistant Athletic Trainer

Theodore Cowling Assistant Athletic Trainer

Catherine LassAssistant Athletic Trainer

Julia TomaroAssistant Athletic Trainer

______(Athlete’s Name) Date ______

______(Athlete Signature) Date ______

______(Parent’s Signature if under 18)Date ______

Student-Athlete Authorization/Consentfor Disclosure of Protected Health Information

I hereby authorize the physicians, athletic trainers, sports medicine staff and other health care personnel representing Seton Hall University and the Seton Hall University Department of Athletics to release information regarding my protected health information and any related information regarding any injury or illness during my training for and participation in intercollegiate athletics. This protected health information may concern my medical status, medical condition, injuries, prognosis, diagnosis, athletic participation status, and related personally identifiable health information. This protected health information may be released to other health care providers, parents/guardians, hospitals and/or medical clinics and laboratories, athletic coaches, strength and conditioning coaches, medical insurance coordinators, insurance carriers, medical supply vendors and/or service companies, academic counselors, athletic and/or university administrators, chaplains and/or clergy members, Athletic Trainer Tracking System Software, sports information staff and members of the media.

I understand that my authorization/consent for the disclosure of my protected health information is a condition for participation as an intercollegiate student-athlete for Seton Hall University. I understand that my protected health information is protected by federal regulations under either the Health Information Portability and Accountability Act (HIPAA) or the Family Educational Rights and Privacy Act of 1974 (Buckley Amendment) and may not be disclosed without either my authorization under HIPAA or my consent under the Buckley Amendment. I understand that once information is disclosed per my authorization/consent, the information is subject to redisclosure and may no longer be protected by HIPAA and/or the Buckley Amendment.

I understand that I may revoke this authorization/consent at any time by notifying in writing the Director of Sports Medicine, but if I do, it will not have any effect on the actions Seton Hall University or the Seton Hall University Department of Athletics took in reliance on this authorization/consent prior to receiving the revocation. I also understand that revocation of this authorization/consent may affect my athletic eligibility. This authorization/consent expires six (6) years from the date it is signed.

Name of Student-AthleteSignature of Student-AthleteDate

Social Security NumberDate of Birth

Signature of Parent/Legal Guardian of Student-Athlete (if under 18 years of age)Date

Concussion Information Sheet

What is a concussion?

A concussion is an injury to the brain caused by a direct or indirect blow to the head or caused by the head striking something else such as the ground. A concussion typically causes the rapid onset of short lived impairment of brain function that resolves spontaneously with time. However, occasionally there can be a more significant problem, and it is important that the symptoms from every concussion be monitored by your athletic trainers and team physicians. Concussions usually do not cause structural damage to the brain. A concussion can occur whether or not a person is “knocked out.” When you suffer a concussion, you may have problems with concentration and memory, notice an inability to focus, feel fatigued, have a headache or feel nauseated. Bright lights and loud noises may bother you. You may feel irritable, be more emotional or have other symptoms. It may be difficult to study, attend class, or use the computer.