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AVE MARIA UNIVERSITY Athletic Training – Sports Medicine Insurance Policies and Procedures

Ave Maria University Athletic Insurance Policy and Procedures:

The NAIA provides a Catastrophic Injury Insurance Policy thru Mutual of Omaha which covers student-athletes who are catastrophically injured while participating in covered intercollegiate athletic activities. This policy has a high deductible of $25,000.00 and is meant to supplement other insurance coverage that may reach their limits because of the catastrophic level of injury.

Ave Maria University’s Insurance Policy Description

Ave Maria University has purchased a basic accident insurance policy through United States Fire Insurance Company to cover student athletes during their participation in NAIA recognized sporting activities to help cover any gaps that may arise between a primary insurance policy (required for participation), and the Catastrophic Insurance Policy provided by the NAIA. As this is an excess policy, it only covers medical costs associated with an athletic injury that are not covered by any other valid and collectible insurance. The maximum benefits for AMU’s policy are set at $25,000.00 at which time the NAIA’s Catastrophic Insurance Policy would begin to pick up. This policy does cover most standard care for athletic injuries, but non-traditional, experimental, elective or highly specialized treatments/braces may not be covered. It is important to check with our Athletic Training staff before receiving any of these types of treatments. This policy does not provide coverage for general medical conditions/ illnesses/sickness. This policy becomes null and void if the student athlete does not adhere to Ave Maria University Policies for utilizing the secondary athletic insurance policy. These policies are listed below.

Ave Maria University Policies for utilizing Ave Maria’s Secondary Athletic Insurance

We would like to make you aware of our regulations with regard to insurance coverage that must be in place in order for the student athlete to participate in our athletic programs. We want to make sure both the student athlete and the parent or guardian are aware of the potential out of pocket expenses in the case of an injury while participating in intercollegiate athletic sanctioned activities such as practice, conditioning, and games. Injuries must occur in a NAIA sanctioned event to be covered by the school’s policy. In other words any voluntary activities such as extra weight lifting sessions, pick-up games, etc. will not be covered under this policy.

1. Each student athlete must have primary insurance coverage for athletic accident/injuries in order to participate in any Ave Maria University Athletic Program.

a. This coverage must extend beyond emergency care. b. This insurance may be as a dependent under a parent/guardian or a personal insurance policy. In

the case where the student athlete is not currently eligible for coverage under a policy there are many sources available to obtain a compliant insurance policy. AMU athletic trainers or administrators can suggest a few acceptable insurance plans to purchase. Please contact the Athletic Training staff for assistance in the case you are unable to comply with the policy of Ave Maria University.

i. If a student athlete’s insurance coverage lapses for any reason during the academic year the student athlete will be held responsible for any bills incurred during the time frame that they were uninsured.

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ii. If a student athlete’s insurance does not provide coverage for athletic injuries, the student athlete will be held responsible for bills incurred. This will also result in the student athlete being unable to participate in their respective sport until they have purchased the acceptable coverage and presented proof to the training staff.

c. All student athletes must provide the school with either a card showing the policy in force in which the student athlete is covered or a front and back copy of the card to be kept on file by the athletic training staff.

i. If an athlete’s insurance coverage changes during the school year, the athletic training staff must be provided with a new card immediately.

ii. If this transition causes the athlete to be uninsured and the athlete continues to participate and sustains an injury, any bills incurred as a result of that injury will be the full financial responsibility of the student athlete.

d. Student athletes should be knowledgeable about their insurance procedures and restrictions including but not limited to co-pays required at time of service, pre-certifications, referrals needed for specialists, etc.

i. Co-pays must be paid by the student athlete at the time of the appointment. ii. Ave Maria University will not be held responsible if the guidelines of the student

athlete’s insurance are not followed. iii. If an athlete’s primary insurance company denies a claim because proper

procedures were not followed the student athlete may be held responsible. 2. Student athletes must notify the athletic trainer of any and all injuries.

a. Any medical bills incurred as a result of an injury that has not been reported to the Athletic Training Staff will not be covered.

i. If an injury occurs during a practice in which an Athletic Trainer is not present that requires emergency care, the coach will notify the athletic trainer and the student athlete will follow up with the athletic trainer when they are able to.

ii. Treatment for the injury must begin within 90 days of onset of the injury with benefits lasting up to 104 weeks after the injury

1. No treatments will be covered after the 104 week period 3. Student athletes should make every effort to notify athletic training staff of any and all medical care they

seek outside of the athletic training facility. a. Athletes will be given a letter to take with them to providers with Ave Maria’s insurance policy

information on it. b. Athletes with medical appointments over school breaks in which they don’t have access to the

provider letter should contact the athletic training staff and we will send the letter on your behalf. 4. Student athletes should submit any bills that have not been processed through the school’s insurance

policy with an Explanation of Benefits from student athlete’s primary insurance company as quickly as possible to the Head Athletic Trainer.

a. Bills submitted must be itemized bills in order for Athletic Training Department to be able to bill the insurance company. Itemized bills can be requested from the medical provider.

b. Student athlete may be required to call provider to give them permission to speak to Athletic Trainer.

c. Ave Maria University is not responsible for dealings with the athlete’s primary insurance claims. We are happy to offer advice to aid students in dealings with their primary insurance company, but ultimately this responsibility will fall on the student athlete and/or parents/guardians.

5. The Ave Maria University Athletic Secondary insurance policy will not cover the primary insurance deductible. However, the Ave Maria secondary insurance policy will cover primary co-insurance amounts with restrictions as per-provider.

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Tips for ensuring lowest possible out of pocket cost and least amount of hassle when dealing with medical bills incurred as a result of athletic injuries

1. Know what is covered so that you know when to have medical bills submitted to Ave Maria Athletics

Secondary Insurance 2. Know your primary insurance policy procedures and report any restrictions to the athletic training staff

BEFORE you sustain an injury a. If you do not know your insurance restrictions CALL YOUR PARENTS TO FIND OUT

3. If your insurance company has in and out of network benefits, call your company prior to moving to campus to try and set up a temporary network of providers near Ave Maria University for medical care while in Ave Maria.

a. This may require student athlete to submit documentation each semester showing full-time enrollment

b. If your insurance company will not set up benefits in and around the Ave Maria/Naples, FL area, then your child is essentially uninsured and additional coverage should be purchased, otherwise you run the risk of high out of pocket cost.

4. Report all injuries to the Ave Maria University Athletic Training Staff 5. Inform Athletic Training Staff of all medical appointments

a. If appointment is during a school break notify Athletic Training Staff by email or phone call. 6. Pick up a provider letter from the Athletic Training staff before any and all medical appointments.

a. If appointment is during a school break notify Athletic Training Staff of appointment and contact information for medical office and provider letter will be sent on your behalf.

7. When providing an address to medical providers make sure you give them an address that you will receive the bills in a timely fashion.

a. If you plan on giving your parent’s address, then inform your parents to be expecting mail from medical providers and give them permission to open any correspondence from those providers that arrives in the mail

8. Always inform Athletic Training staff of outcome of medical appointments so that we can ensure Ave Maria’s Athletic Insurance information is also provided to any outside facilities providing care ordered by the doctor (examples-blood work, MRIs, etc)

9. If you decide to hold off on surgeries, etc until a later date make sure that they will occur within the 104 week benefit eligible time frame.

a. This is the time frame for coverage under Ave Maria’s Secondary Insurance Policy only. You need to be aware of coverage periods for your primary insurance as they may be shorter.

10. Be mature and communicate with all involved, your parents, your Athletic Trainer, your Coach, etc. When everyone is on the same page and informed, everything goes a lot smoother

11. ASK QUESTIONS WHEN YOU ARE NOT SURE. THE ONLY DUMB QUESTIONS ARE THE ONES THAT DON’T GET ASKED.    

SEE BELOW FOR AGREEMENT FORM

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Athletic Pre-participation Screening Checklist

1. Please make sure you have a primary insurance policy that covers intercollegiate sports and that there are in-network insurance providers in this area: Be aware! Ave Maria University offers two student insurances. General student insurance does not cover intercollegiate athletics. The university does offer intercollegiate athlete student insurance. Make sure you select the correct one.

2. Provide legible front and back copy of your primary insurance card. 3. Provide doctors’ notes for any pre-existing injury, chronic pathology, and prescriptions dictating you are are allowed to participate in college varsity athletics. 4. Completely and legibly fill out the Medical and Insurance Questionnaire. If a minor, please have parent signatures in the designated areas. Please date and sign ALL designated areas. 5. Please provide first and last initials on the lines provided when reviewing each section of the Informed Consent and Medical Release Form.  

Year in School ______

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Ave Maria University Acknowledgement of Insurance Requirements

I, _________________________, as parent, guardian or legal representative, attest that (Name, please print) ___________________________ has insurance coverage under a current, in force insurance policy for (student-athlete name) injuries that occur while he/she is participating in intercollegiate athletics. If there is a change in coverage or expiration of coverage, I agree to notify Ave Maria University of this development and update the insurance information I have on file with Ave Maria University. I understand that my or my parent health insurance will serve as primary insurance for all injuries and illness. Ave Maria University Athletic Department has a secondary policy that ONLY applies for athletically related injuries which occur during an organized and supervised workout, practice or competition. The Ave Maria University secondary policy is not responsible for any non-athletic injury, illness, primary or secondary insurance deductible. I understand that all bills and related paperwork I or my parents receive from athletically related injuries must be sent to the athletic training staff at Ave Maria University within 10 days from time of receipt. I understand I or my parents are responsible for any and all medical expenses not covered by my primary insurance or the Ave Maria University Athletic secondary policy. (Signature of Parent/ Guardian) (Date) (Signature of student athlete) (Date)

YOU MUST INCLUDE A COPY (FRONT AND BACK) OF YOUR CURRENT INSURANCE CARD AND THE COMPLETED EMERGENCY

CONTACT AND INSURANCE INFORMATION FORM.  

     

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   Informed  Consent  and  Medical  Release  Form  Please  initial  by  each  section  and  sign  your  name  at  the  bottom  to  demonstrate  that  you  have  read  and  understood  each  of  the  following.  If  you  are  under  18  years  of  age,  your  parent/guardian  must  also  initial  and  sign  this  form.  If  you  refuse  to  sign  any  section,  please  write  “Refused  to  Sign,”  the  date,  and  your  initials.  Assumption  of  Risk  _____  I  am  aware  participating  or  practicing  to  participate  in  any  sport  or  sport  related  activity  could  be  a  dangerous  activity  involving  MANY  RISKS  OF  INJURY.  I  understand  that  the  dangers  and  risks  of  participating  or  practicing  to  participate  in  sports  or  sport  related  activity  include,  but  are  not  limited  to:  death;  serious  neck  and  spinal  injuries  that  may  result  in  complete  or  partial  paralysis;  brain  damage;  serious  injury  to  virtually  all  bones,  joints,  ligaments,  muscles,  tendons,  other  aspects  of  the  musculoskeletal  system  and  vital  organs;  and  serious  impairment  to  other  aspects  of  the  body,  general  health,  and  well-­‐being.  I  understand  the  dangers  and  risks  of  participating  or  practicing  to  participate  in  any  sport  or  sport  related  activity  may  result  not  only  in  serious  injury,  but  in  a  serious  impairment  of  my  (the  participant’s)  future  abilities  to  earn  a  living;  to  engage  in  other  business,  social,  and  recreational  activities;  and  generally  enjoy  life.  Because  of  the  dangers  of  participating  or  practicing  to  participate  in  any  sport  or  sport  related  activity,  I  recognize  the  importance  of  following  the  coaches’,  officials’  and  medical  staff’s  instructions  regarding  playing  techniques,  training,  and  other  team  rules,  etc.,  and  agree  to  obey  such  instructions.  Furthermore,  I  hereby  agree  to  hold  Ave  Maria  University,  its  direct  and  contracted  employees,  agents,  representatives,  coaches  and  volunteers  harmless  from  any  and  all  liability,  actions,  causes  of  action,  debts,  claims,  or  demands  of  every  kind  and  nature  whatsoever  that  may  arise  by  or  in  connection  with  participation  of  myself/son/daughter  in  any  activities  related  to  Ave  Maria  University.  The  terms  hereof  will  serve  as  a  release  for  my  heirs,  estate,  executor,  administrator,  assignees,  and  for  all  members  of  my  family.    Informed  Medical  Consent  _____  I  hereby  give  my  permission  to  Ave  Maria  University,  its  direct  and  contracted  employees,  agents,  representatives,  coaches  and  volunteers  to  authorize  any  emergency  action  necessary  to  ensure  the  safety  of  the  student-­‐athlete.  I  also  hereby  authorize  the  athletic  trainers  at  Ave  Maria  University  who  are  under  the  direction  and  guidance  of  Ave  Maria  University  athletic  team  physicians,  to  render  to  myself/son/daughter  any  preventative,  first  aid,  or  rehabilitative  treatment  that  they  deem  reasonably  necessary  to  the  health  and  well-­‐being  of  the  student-­‐athlete.  The  intention  hereof  being  to  grant  authority  to  administer  and  perform  all  and  singularly  any  examinations,  pre-­‐participation  physical  examinations,  treatments,  hospitalizations,  anesthetics,  operations,  and  diagnostic  procedures  which  may  now,  or  during  the  course  of  this  student  athlete’s  care,  be  deemed  advisable  or  necessary.  This  does  not  hold  Ave  Maria  University,  its  direct  and  contracted  employees,  agents,  representatives,  coaches  or  volunteers  financially  responsible  for  any  medical  care  given.                

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Authorization  to  Obtain  Medical  Information  _____  I  hereby  authorize  any  physician,  any  hospital  or  medically  related  facility,  or  any  other  individual  or  organization  which  has  provided  health  care  services  to  myself/son/daughter  to  give  any  and  all  information  about  my/son’s/daughter’s  medical  history,  mental  or  physical  condition,  and/or  treatment  to  Ave  Maria  University,  its  direct  and  contracted  employees,  agents,  or  representatives,  for  the  purpose  of  determining  eligibility  for  the  benefits  I  have  requested.  I  understand  that  a  photocopy  of  this  authorization  shall  be  as  valid  as  the  original.  I  know  that  I,  or  my  authorized  representative,  may  receive  a  copy  of  this  authorization  upon  request.  This  authorization  shall  remain  valid  for  the  duration  of  my  claim.      Release  of  Medical  Information  –  Part  I  _____  General  Disclosure:  I  hereby  authorize  the  Ave  Maria  University,  its  direct  and  contracted  employees,  agents,  and  representatives  to  release  information  from  my  medical  records  for  the  purpose  of  payment,  treatment  or  operations  to  their  Business  Associate  Partner  (which  includes;  the  Attending  School’s  Coaching  Staff  and  Administrators)  and  any  Hospital  in  case  of  an  Emergency  Situation.  This  authorization  shall  be  valid  for  the  duration  of  the  2009-­‐2010  school  year.  It  is  subject  to  revocation  by  the  patient,  or  the  parent/guardian  at  any  time  except  to  the  extent  that  action  has  been  taken  in  reliance  thereon.  I  am  aware  that  once  the  Ave  Maria  University,  its  direct  and  contracted  employees,  agents,  or  representatives  discloses  this  information  per  my  instructions,  the  information  is  subject  to  re-­‐disclosure  and  may  no  longer  be  protected  by  the  HIPAA  (Health  Insurance  Portability  and  Accountability  Act)  of  1996.  I  understand  that  a  photocopy  of  this  authorization  shall  be  as  valid  as  the  original.  I  know  that  I  or  my  authorized  representative  may  receive  a  copy  of  this  authorization  upon  request.    Release  of  Medical  Information  –  Part  II  _____  I  hereby  authorize  the  Ave  Maria  University  athletic  trainers,  team  physicians,  athletic  coaches,  and  administrators  to  release  to  the  Ave  Maria  University  Sports  Information  Department  and  the  media  at  any  time,  medical  information  regarding  myself/son/daughter,  concerning  illness  or  injury  relative  to  my  past,  present,  or  future  participation  in  athletics  at  the  Ave  Maria  University.        Student-­Athlete  Responsibilities  _____  I…  1.  Understand  that  it  is  my  responsibility  to  report  all  injuries  and  illness  to  my  coach  and/or  team  athletic  trainer  as  soon  as  possible.  2.  Understand  that  I  am  expected  to  report  promptly  as  scheduled  for  treatment  and/or  rehabilitation.  3.  Understand  that  I  will  continue  to  receive  treatment/rehabilitation  until  released  by  my  team  physician  and/or  athletic  trainer.  4.  Understand  that  Ave  Maria  University  cannot  be  held  responsible  for  any  previous  medical  condition(s)  that  I  might  have.      __________________________________________________________________________    Signature  (parent/guardian  if  a  minor)  Date    Printed  Name  

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Name_______________________SSN________________DOB________Year______Sport______ Athletic Health History Questionnaire 1. What is the date of your last physical examination _________________________ YES NO 2. Have you had a medical illness or injury since your last checkup or sports physical? � � 3. Do you have an ongoing or chronic illness? � � 4. Have you ever been hospitalized overnight? � � 5. Have you ever had surgery? � � 6. Are you currently taking any prescription or nonprescription (over-the-counter) medications, pills or using an inhaler? � � 7. Are you taking any supplements or vitamins to help you gain or lose weight or improve your performance? � � 8. Do you have any allergies (pollen, medicine, food, or stinging insects)? � � 9. Have you ever been dizzy or passed out during or after exercise? � � 10. Have you ever had chest pain during or after exercise? � � 11. Have you ever had racing of your heart or skipped heartbeats? � � 12. Have you had high blood pressure or high cholesterol? � � 13. Have you ever been told you have a heart murmur? � � 14. Has any family member died of heart problems or of sudden death before age 35? � � 15. Have you had a severe viral infection (e.g. myocarditis, mononucleosis) within the past 6 months? � � 16. Have you ever had an electrocardiogram (ECG/EKG) of your heart? � � 17. Has a physician ever denied or restricted your participation in sports for heart problems? � � 18. Is there a history of Marfan’s Syndrome in your family? � � 19. Is there a history of premature (prior to age 50) onset of diabetes in your family? � � 20. Do you have any current skin problems (itching, rashes acne, warts, fungus, or blisters)? � � 21. Have you ever had a head injury or concussion? � � 22. Have you ever been knocked out, become unconscious, or lost your memory? � � 23. Have you ever had a seizure? � � 24. Do you have frequent or severe headaches? � � 25. Have you ever had numbness or tingling in your arms, legs, or feet? � �

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26. Have you ever had a stinger, burner, or pinched nerve? � � 27. Have you ever become ill from exercising in the heat? � � 28. Do you cough, wheeze, or have trouble breathing during or after activity? � � 29. Do you have asthma? � � 30. Do you have seasonal allergies that require medical treatment? � � 31. Do you have only one of two paired, functioning organs (e.g. eyes, kidneys, ovaries)? � � 32. Do you use any special protective or corrective equipment or devices that aren’t usually used for your sport or position (e.g. knee brace, neck roll, foot orthotics, retainer, hearing aid)? � � 33. Have you ever had an injury (e.g. sprain, strain, fracture) to any of the following: Head __________________ Neck __________________ Back __________________ Chest __________________ Shoulder __________________ Upper Arm __________________ Elbow __________________ Forearm __________________ Wrist __________________ Hand __________________ Finger __________________ Hip __________________ Thigh __________________ Knee __________________ Calf/Shin __________________ Ankle __________________ 34. Do you want to weigh more or less than you do now? � � 35. Do you lose weight regularly to meet weight requirements for your sport? � � 36. Record the dates of your most recent immunizations (shots) for: Tetanus________________________ Measles___________________________ Hepatitis B______________________ Chickenpox________________________ Explain YES answers here (may use another sheet of paper, also) I, the undersigned, hereby acknowledge, affirm, and represent that all above statements are true and accurate to the best of my knowledge; and that no answers or information have been withheld. If any information and/or statements are false and/or have been omitted in reference to my past and/or present medical history, I fully understand that the Ave Maria University, its direct and contracted employees, agents, representatives, coaches and volunteers disclaim liability, and will not be held liable for any injuries and/or illnesses not noted. ___________________________________________________ ______________Student-Athlete Signature and Parent/Guardian Signature Date

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Name_________________________SSN________________DOB__________Year______Sport______ Physical Examination Height__________ Weight__________ BP________/________ Pulse__________ Vision R 20/______ L 20/______ Corrected: Y N Pupils: Equal Unequal

NORMAL ABNORMAL INITIALS

MEDICAL Appearance Eyes/Ears/Nose/Throat Lymph Nodes Heart Pulses Lungs Abdomen Genitalia (males only) Skin MUSCULOSKELETAL Neck Back Shoulder/Arm Elbow/Forearm Wrist/Hand Hip/Thigh Knee Leg/Ankle Foot

MEDICAL CLEARANCE q Cleared q Cleared after completing evaluation/rehabilitation for: ______________________________________________________________________________________ q Not Cleared Reason: __________________________________________________________________ Recommendations: ______________________________________________________________________ ______________________________________________________________________________________ Name of Physician (print/type): ___________________________________________Date______________ Address: _____________________________________________________________Phone_____________ Signature of Physician___________________________________________________________MD or DO