FURMAN UNIVERSITY SPORTSMEDICINE CENTER - PDF

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IMPORTANT INSURANCE INFORMATION Dear Parents: Furman University provides an excess coverage policy for our intercollegiate athletes. Incurred medical charges are to be filed with your insurance first.
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IMPORTANT INSURANCE INFORMATION Dear Parents: Furman University provides an excess coverage policy for our intercollegiate athletes. Incurred medical charges are to be filed with your insurance first. After your insurance carrier acts on the claim, the Furman University Secondary Insurance Policy will pay the balance of the charges not covered by your insurance carrier. Regardless of your insurance situation, our program is designed to provide total payment on all injuries that occur as a result of participation in supervised athletic practices and competitions. It also covers travel to and from these events. The following guidelines must be followed for coverage: 1) The injury must occur in a supervised athletic practice or event. 2) The student-athlete must report the injury or condition to a member of the Sports Medicine staff within 30 days of the injury. 3) The medical referral must be authorized by a staff member of the Sports Medicine Dept. 4) All second opinions must be pre-approved by the Sports Medicine Dept. to qualify for coverage. 5) Injuries that occur outside the supervision of the Furman Athletic Department are not covered. 6) Inaccurate insurance information may result in a claim being denied. **If you do not have any health insurance on your student-athlete, we must have a written statement to that effect for our records. Page 2 In the event of an injury, the following steps are necessary in order for claims to be filed and paid in a timely manner: 1) The provider of service will file a claim on your behalf, with your insurance company, from the information provided on the Athletic Insurance Enrollment Form. 2) Once the provider receives an Explanation of Benefits (EOB) from your insurance carrier explaining payment, denial, or application to deductible they will then file with the Furman University Secondary Insurance Policy. 3) If you receive an (EOB) Explanation of Benefits or a statement from the provider, please forward it to our office as soon as possible. This will aid in expediting payment of the claim. In order for your student-athlete to receive coverage and be allowed to participate in the Intercollegiate Athletic Program the enclosed forms must be completed and returned to our office. If your insurance changes in any way during the year, please notify us immediately, so your studentathlete s records can be updated. If you have any questions regarding our athletic insurance program, please contact: Chris Paré, Athletic Insurance Coordinator Furman University Sportsmedicine Center Phone (864) Fax (864) Sincerely, Elaine Baker Elaine Baker, ATC, SCAT Director of Sports Medicine/ Associate Athletic Director ATHLETIC INSURANCE ENROLLMENT FORM FULL NAME OF STUDENT ATHLETE SPORT(S) Permission is hereby granted to FURMAN UNIVERSITY ATHLETIC DEPARTMENT to seek any needed medical or minor surgical treatment, x-ray examinations, physical therapy, and immunization for the above named student. In the event of serious illness, the need for major surgery, or significant accidental injury, I understand that an attempt will be made by the attending physician to contact me in the most expeditious manner possible. If said physician is unable to communicate with me, the treatment necessary for the best interest of the above named student may be given. I hereby authorize the Furman University Sportsmedicine Center to release my (student) information acquired in the course of my examination or treatment. I hereby authorize payment directly to the provider of medical treatment under my reimbursement of benefits included under my insurance policy. A copy of this authorization shall be deemed as effective and valid as the original and remain effective for one year from the date signed below. PARENT SIGNATURE RELATIONSHIP TO STUDENT STUDENT SIGNATURE DATE ATHLETE INFORMATION # - - Last Name First Name Middle Name Social Security Number / / ( ) Birth date Age Gender Student Cell Phone Permanent Street Address City State Zip Country ( ) ( ) ( ) Parent Home Number Parent Work Number Parent Address Parent Cell Phone EMERGENCY CONTACT ( ) ( ) ( ) Last Name First Name Home Phone Work Phone Cell Phone INSURANCE INFORMATION HMO PPO POS Primary Insurance Company Group # or Name Policy Number Type Other Street City State Zip Phone Employer Street City State Zip Phone Father Mother Self Other Relationship to Athlete Name of Insured Insured's Birth date Social Security Number HMO PPO POS Secondary Insurance Company Group # or Name Policy Number Type Other Street City State Zip Phone Employer Street City State Zip Phone Father Mother Self Other Relationship to Athlete Name of Insured Insured's Birth date Social Security Number Does your insurance company require a second opinion? Yes No Does your insurance company provide What is their toll-free telephone number? prescription coverage? Yes No IF YOUR INSURANCE COMPANY WILL NOT ALLOW YOUR STUDENT TO BE SEEN OUTSIDE OF THEIR NETWORK, THEN YOU NEED TO REQUEST A GUEST MEMBERSHIP (COVERAGE FOR A COLLEGE STUDENT). If you do not have ANY insurance, we need a written statement from you to accompany this form. Failure to complete and return this form will result in your son/daughter being withheld from ALL athletic activity. PLEASE NOTIFY THE SPORTSMEDICINE CENTER OF ANY CHANGE IN INSURANCE COVERAGE PRE-CERTIFICATION FORM Athlete Name: Insurance Co: Insured Parent/Guardian: Sport: Phone: Contract Number Group Number Plan Number Policy Number PLEASE CONTACT YOUR INSURANCE COMPANY AND REQUEST ALL INFORMATION BELOW Referral or Pre-certification Required For: Doctor Visit Outpatient Surgery Inpatient Surgery MRI Physical Therapy Who should be contacted for referral/pre-certification? Insurance Company Primary Care Physician Name Primary Care Physician: Phone: Insurance Company Pre-certification Phone Number: Will your insurance company allow your student to be treated out of your network? Yes No What are your out of network benefits: What is your individual/family deductible: Date Insurance Company was contacted: FURMAN UNIVERSITY ATHLETIC DEPARTMENT RESERVES THE RIGHT TO REQUIRE MEDICAL SERVICES, DUE TO AN ATHLETIC INJURY, BE PERFORMED WITHIN YOUR HMO/PPO NETWORK. Parent Signature Date ***PLEASE NOTIFY THE SPORTSMEDICINE CENTER OF ANY CHANGES IN INSURANCE COVERAGE*** Please have your student-athlete complete the next two documents which are the HIPAA Standard Authorization forms. The first form gives their permission for media releases involving injury information as it pertains to athletic participation. The second form gives the student/ athlete s permission for us to keep you (the parent) and their sport coach informed of their injury and health status. Furman University Sportsmedicine Center Standard Authorization of Use and Disclosure of Protected Health Information Information to Be Used or Disclosed The information covered by this authorization includes: Disclosure of Protected Health Information regarding the individual s injury or health status as it relates to and affects athletic participation. Purposes of Disclosure Information listed above will be disclosed for the following purposes: To report the individual s injury or health status as it relates to their athletic participation in the form of media releases and the creation of Furman University Sports Information Media Guides. Persons Authorized to Use or Disclose Information Information listed above will be used or disclosed by: Clinical and Administrative Staff of Furman University Sportsmedicine Center. Persons to Whom Information May Be Disclosed Information described above may be disclosed to: Furman University Director of Sports Information Furman University Associate & Assistant Directors of Sports Information Expiration Date of Authorization This authorization is effective through 9/30/2017 unless revoked or terminated by the patient or patient s personal representative. Right to Terminate or Revoke Authorization You may revoke or terminate this authorization by submitting a written revocation to Furman University Sportsmedicine Center. You should contact the Privacy Official to terminate this authorization. Potential for Re-disclosure Information that is disclosed under this authorization may be disclosed again by the person or organization to which it is sent. It may not be possible to ensure your right to the protection of the privacy of this information once Furman University Sportsmedicine Center discloses it to another party. Rights of the Individual You may inspect or copy information used or disclosed under this authorization. You may refuse to sign this authorization. Signature Name of Student/Athlete (Print) Signature Date Furman University Sportsmedicine Center Standard Authorization of Use and Disclosure of Protected Health Information Information to Be Used or Disclosed The information covered by this authorization includes: Disclosure of Protected Health Information regarding the individual s injury or health status as it relates to and affects athletic participation. Purposes of Disclosure Information listed above will be disclosed for the following purposes: To determine the individual s status for athletic participation. To ensure the individual s health and safety during athletic participation. Persons Authorized to Use or Disclose Information Information listed above will be used or disclosed by: Clinical, Administrative and Billing Staff of Furman University Sportsmedicine Center. Persons to Whom Information May Be Disclosed Information described above may be disclosed to: Staff Coaches and Strength Coach of the sport in which the individual is a member. The parent or legal guardian of the signed individual. Expiration Date of Authorization This authorization is effective through 9/30/2017 unless revoked or terminated by the patient or patient s personal representative. Right to Terminate or Revoke Authorization You may revoke or terminate this authorization by submitting a written revocation to Furman University Sportsmedicine Center. You should contact the Privacy Official to terminate this authorization. Potential for Re-disclosure Information that is disclosed under this authorization may be disclosed again by the person or organization to which it is sent. It may not be possible to ensure your right to the protection of the privacy of this information once Furman University Sportsmedicine Center discloses it to another party. Rights of the Individual You may inspect or copy information used or disclosed under this authorization. You may refuse to sign this authorization. Effect of Refusing Authorization If you refuse to sign this authorization, Furman University Sportsmedicine Center with Furman University Athletic Department will be unable to approve your participation in the Intercollegiate Athletic Program sponsored by Furman University. Signature Name of Student/Athlete (Print) Signature Date
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