SPORTS MEDICINE - FORT SCOTT Community College

Release To Treat and Consent Form

SPORTS MEDICINE - FORT SCOTT Community College

2108 SOUTH HORTON∙FORT SCOTT, KS 66701

Phone (620) 223-2700 ex.7050∙Fax (620) 223-4438

Fort Scott Community College suggests that all student athletes carry their own primary insurance coverage to minimize any costs which may be the responsibility of the student athlete. FSCC insurance benefits are not primary insurance coverage. Student athletes may be responsible for the payment of any costs of treatment that exceeds reasonable and customary charges.

Please check one: I DO I DO NOT - have primary insurance coverage

You should also be aware that the college-paid insurance on student athletes pays only for accidents which occur during a supervised game or practice and only as a secondary payor, meaning that your insurance pays first, and the college athletic insurance pays the reasonable and customary remainder of the claim total not paid by your insurance company after proper documentation. In the case of an illness or non-athletic related injury, any costs related to the treatment of you or your son or daughter will be your responsibility.

Release of Responsibility:

I understand that bills which may result from medical care deemed necessary for athletic injuries will be filed with my family or my primary policy first. Remaining balances will then be filed with the athletic accidental injury insurance purchased by the Fort Scott Community College Athletic Department. I also understand that it is my responsibility to forward all bills and insurance explanation of benefit (EOB) forms received by me to the Head Athletic Trainer at Fort Scott Community College. We acknowledge that Fort Scott Community College and the Athletics Department insurance are not responsible for care provided for pre-existing injuries, injuries incurred while not participating in intercollegiate athletics, or for medical treatment for conditions considered to be congenital or hereditary in nature.

I authorize that FSCC and its insurance agent pay the medical vendors direct for any bills incurred from accidents that are covered under the coverage purchased by the college. I am of majority age (18 years or older) and am granting authorization for emergency medical treatment of my own accord. I understand that I will be held responsible for all medical treatment costs associated when any non-game or non-practice related injuries may incur

Parental Permission/Realization of Possibility of Injury/Emergency Medical Treatment Authorization

(Student/Athlete’s under 18 years of age)

I/ or as parent or legal guardian of ______, I hereby give my consent for his/her practice and play in intercollegiate athletic events. I realize that if my child/dependent participates in athletics at Fort Scott Community College, he/she could suffer serious injury, including paralysis, to internal organs, muscular-skeletal system, bones, and even death. My signature below acknowledges this possibility.

I also grant permission for treatment deemed necessary for a condition arising during athletic participation, including medical or surgical treatment recommended by a medical doctor. I understand that every effort will be made to contact me prior to treatment.

I agree, if needed, to a medical exam and/or drug testing and I certify that the medical history contained herein is accurate to the best of my knowledge.

I authorize any medical personnel, insurance company, athletic director, physician, hospital, therapist, athletic trainer, assistant athletic trainer, dean of students, coaches, athletic secretary/office manager, or other persons who have attended, assisted, handled insurance claims, or examined the claimant to disclose any information with respect to any injury, policy coverage, medical history, injury history, therapy treatment, consultation, medical bills, prescriptions, treatment or rehabilitation, and copies of all medical records.

I have read and understand this authorization form and give my consent for emergency medical treatment for myself or my son or daughter should a medical emergency occur while I or my son or daughter is a student at Fort Scott Community College. I also understand that any costs related to this treatment will be my responsibility.

Both Signatures must be completed for athletes under 18 years old, only athlete’s signature for over 18 years old.

Signature of Student Athlete ______Date______

Signature of Parent/Guardian ______Date______

Name of Student Athlete: ______

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