Instructions for Athletic Paperwork for Howard Payne

University Student-Athletes

Please note that there are two sections of paperwork:

1. Paperwork that has to be completed, printed out and sent into the athletic

training staff. These forms are found on pages 5-10 before the online

paperwork instructions. They can be mailed in, faxed, scanned and emailed,

or uploaded into the online program.

--You are greatly encouraged to make copies of these forms and bring them

to campus when you report for your sport.

--Items can be lost in the mail, poor fax quality or electronic files can be

corrupted.

--Photos of the paperwork from cell phones will not be accepted. However,

if the quality is good, cell phone photos of the insurance card will be

accepted.

You only need to complete, print out, sign and

return pages 5-10 along with a legible copy of your insurance card (front and back).

Do NOT send the paperwork to the coaches, Financial Aid/

Admissions office or to the University Nurse

2. Online Paperwork—the instructions begin on page 11 and include the link to thewebsite.

--The ID and password are not related to your HPU ID and password for

computer access. There are instructions on how to initially get into the

program and where to come up with your ID and password beginning on page 11.

--This paperwork is NOT the same as the online paperwork for Student Life/Nurse

There is a check list of all items needed to be sent into the athletic training staff.

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Thank you for your decision to participate in athletics at Howard Payne University for the 2018 – 2019 academic year. There are electronic forms and print forms that need to be completed. All forms must be com-pleted and returned by Thurdsday, July 26, 2018 to:

Howard Payne University

Rachel Smith – Athletics

1000 Fisk

Brownwood, TX 76801 Fax:

325-649-8908

rsmith@hputx.edu

All forms must be completed and verified before you can be cleared to participate in athletics (practice or games). Following this letter there are instructions on how to complete the online portion of the paperwork. Following the instructions is a check-list of what is required to be completed and then paperwork that needs to be printed out, completed and sent back into the address above.

Please pay close attention to Form D2 Insurance. HPU requires that all student athletes present proof of medical insurance coverage and maintain throughout the academic year appropriate medical coverage as out- lined on Form D2. Form D2 describes the methods and procedures for payment of expenses incurred due to athletic injury. A copy of Form D2 is provided on the athletic training website for reference. Please remember to send us a legible copy of both the front and back of your insurance card.

Incoming Freshmen and Transfer students must have a physical examination no more than 6 months pri- or to reporting to Howard Payne University for participation in NCAA athletics. Form B is the physical form to be completed by a Medical Doctor (MD,) Osteopathic Doctor (DO,) Certified Physician Assistant (PA-C), or a Nurse Practitioner (NP). A physical by a Chiropractor is not acceptable per NCAA regulations. The Athletic Training Staff will review all physicals prior to participation. The Team Physician must clear any abnormalities found by the Ath- letic Training Staff.

Our Team Physicians are Dr. Robert Hogue M.D. and Dr. Marlin Strefling MD. Dr. Hogue is a family practice physician and our Athletics’ Medical Director. Dr. Hogue has the final say on all medical questions. Dr. Strefling is our team Orthopedic Surgeon we will refer all orthopedic concerns to Dr, Strefling. Please check with your insur- ance carrier to have Dr. Hogue and Dr. Strefling in-network, if possible.

Thank you again for choosing to come to Howard Payne University and participating in athletics. We are excited about the upcoming year and you being a part of athletics at Howard Payne University.

Rachel Smith MS, LAT,ATC

Director of Athletic Training Services

Howard Payne University

O) 325-649-8102F) 325-649-8908rsmith@hptux.edu

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Checklist for Student Athlete Forms

Create/login to the ATS website

Complete/Edit/Verify ‘General’ tab

Complete/Edit/Verify ‘Insurance’ tab

Complete/Edit/Verify ‘Contacts’ tab

Complete each of the seven forms of the ‘Athlete Forms’

Authorization to Release Information

Concussion Policy

Medical Consent

Medical History

Medical Physician Release

Risk Waiver

Consent to Release Medical Information

Complete the paperwork to be sent in

D2 Medical Insurance Information

D1 Student-Athlete Information

Sickle Cell Wavier or newborn screening request or proof of testing

Have the Physical Form completed by a doctor

Send in Forms and a legible copy of the front and back of your insurance card to:

Howard Payne University

Attn: Rachel Smith1000 Fisk St

Brownwood, TX 76801

Or email to: rsmith@hputx.edu Or

fax to: 325-649-8908

Do NOT send this paperwork, insurance cards, etc. to coaches, financial aid/admissions offices

or the University Nurse

You may upload the documents into ATS, the online software described in Section 2.

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Section 1:

Complete the following forms and

return only these forms and a

legible copy of the front and back

of your insurance card. Return to:

Howard Payne University

attn: Rachel Smith

1000 Fisk St

Brownwood, TX 76801

Fax: 325-649-8908

rsmith@hputx.edu

Do NOT send this paperwork, insurance cards, etc. to coaches, financial aid/admissions offices

or the University Nurse

You may fill in certain boxes on your computer and print out, sign and return the following forms. (D2, D1, Sickle Cell, Physical, and a legible copy of your insurance card)

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Form D 2 Name 2018-19 Sport

Medical Insurance Information

Howard Payne University (HPU) requires all student-athletes (athletes) to present proof they have medicalinsurance coverage that is currently in place.

In order to play or practice intercollegiate sports at HPU, each athlete must have and maintainmedical insurance that does not exclude athletic activities and meets or exceeds the $20,000.00maximum benefit.

All medical bills for athletes must be submitted by the athlete or their parent/guardian to the athlete's insurance

company or it will be sent to the policyholder for submission to his or her company.

In cases where the athlete is covered under a PPO or HMO, the athlete must work within their

system for medical treatment. Required approvals must be obtained prior to treatment.

All medical bills for athletic injuries will first be submitted to the athlete’s insurance company for payment.

Deductibles, co-payments, co-insurance, etc. are the responsibility of the athlete or their parent/

guardian.

HPU carries a secondary accidental medical insurance plan for all athletes that covers injuries

sustained while participating in a sanctioned HPU athletic events and practices.

This policy has a $20,000 deductible per incident per athlete that must be paid by the athlete or

their parent/guardian or the primary insurance.

The athlete or their parent/guardian must have medical insurance that will cover the first $20,000 of the athlete's

medical expenses related to an athletic injury.

HPU will submit claims that exceed $20,000 to our insurance company once a claim form is com-

pleted with the athlete’s signature.

It is the responsibility of the athlete or their parent/guardian to provide the explanation of benefits

and bills for expenses exceeding $20,000 to the head athletic trainer at HPU or our insurance

company.

Please remember to advise us at once about any change in your medical insurance coverage.

An athlete is not allowed to practice or play without current medical insurance coverage.

If an athlete's medical insurance coverage lapses and an injury occurs, the athlete or their parent/

guardian will be responsible for at least the first $20,000 of medical expenses.

Policy Holder’s Signature: Date:

Student Athlete’s Signature: Date:

Return form to: Howard Payne University, attn Rachel Smith, 1000 Fisk St, Brownwood TX 76801,

rsmith@hputx.edu Fax: 325-649-8908

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Form D 1 Name

2018-19 Sport

STUDENT ATHLETE INFORMATION Last name: First Name: M.I.:

Permanent Address: City/State/ Zip: Eligibility: Fr. SO. JR. SR.

Social Security Number*: Date of Birth: Gender:

Home phone: ( ) Cell phone: ( )

Local Address:(if known) City/State/Zip

Emergency Contact #1

Name: Relationship: Home: ( ) Cell : ( )

Emergency Contact #2

Name: Relationship: Home: ( ) Cell : ( )

PRIMARY INSURANCE INFORMATION

Policy Holder Name: First: MI: Last:

Relationship to Athlete: Employer:

Work Address: City, State, Zip

Date of Birth: Social Security Number*:

Insurance Company: Type of Insurance (PPO, HMO, etc.):

Group Number: Policy Number:

Insurance Company Phone:

Returning student-athletes: Is this the same insurance from last year? YES NO

If there is other insurance, please provide the same information as above on an additional form.

YOU MUST INCLUDE A LEGIBLE COPY OF BOTH THE FRONT & BACK OF YOUR INSURANCE CARD!

PLEASE READ CAREFULLY AND COMPLETELY

I/We have read the attached letter and have been informed of the medical insurance program and policies of Howard Payne University. I/We further agree to carry medical and hospital insurance for my child (or dependent) during the time in which he/she is participating in the HPU athletic program.

I/We agree that all information provided in this document is accurate and complete to the best of my/our knowledge. I/We understand that any incorrect or undisclosed information can result in duplicate payments creating a substantial overpayment. The responsibility of such overpayment will be the obligation of the undersigned to reimburse in full, upon request, all amounts deemed refundable.

Student Athlete:

Guardian/Father:

Date:

Date:

Guardian/Mother: Date:

* Social Security Numbers are only used to make doctor appointments or file insurance claims.

Return form to: Howard Payne University, attn Rachel Smith, 1000 Fisk St, Brownwood TX 76801,

rsmith@hputx.edu Fax: 325-649-8908 6

Howard Payne University

Sickle Cell Trait Form for NCAA Intercollegiate Athletics

Sickle Cell Trait:

Is an inherited condition that affects the red-blood cells and is a common condition.

Affects mainly the African-American community, but can affect Caucasians of Mediterranean and Middle East decent.

Usually has no symptoms. Occasionally during intense sustained physical activity certain dangerous conditions can develop leading to

medical emergencies and/or death.

Sickle Cell Trait Testing:

The NCAA recommends that all student-athletes have knowledge of his/her sickle cell trait status.

There are four options for student-athletes desiring to participate in intercollegiate athletics at Howard Payne University:

• Show proof of his/her Sickle Cell Trait status

• Request newborn test results from the State in which the student-athlete was born (if available)

• Get a Sickle Cell Trait test performed at the student-athletes expense

• Sign a waiver releasing Howard Payne University from any liability due to not providing Sickle Cell Trait status (additional

education is required for this option)

Please choose ONE of the following options:

Attached is proof of my Sickle Cell Trait status

Attached is the request to the State of Texas for my newborn test results. Please mail in thethe athletic training staff and we will submit it to the State.

I am being tested for Sickle Cell Trait status and will provide the results as soon as

Attached is a signed waiver for not knowing Sickle Cell Trait Status

they are completed.

Initial

Initial

Initial

Parent/Guardian Signature (if under 18 years of age) Date

Parent/Guardian Printed name

Return form to: Howard Payne University, attn Rachel Smith, 1000 Fisk St, Brownwood TX 76801

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Initial

Sickle Cell Trait Testing Waiver:

I, , understand and acknowledge that the NCAA recommends that all student-athletes have

knowledge of his/her Sickle Cell Trait status. I have read the information above and HPU’s Sickle Cell Trait policy.

I further agree that my medical history is accurate and true to the best of my knowledge and that I have fully disclosed any symp-

toms, past injuries and/or conditions relating to Sickle Cell Trait status to Howard Payne University.

I do not wish to undergo Sickle Cell Status testing nor show proof of my status. I voluntarily agree to release, discharge, indemnify

and hold harmless Howard Payne University, its officers, employees and agents from any and all costs, liability, expenses,

claims, demands or causes of action on account of any loss or personal injury that might result for my decision not to be tested

for Sickle Cell Trait.

I have read and signed this document with full knowledge of its significance.

Student-Athlete Signature Date

Sport

Return form to: Howard Payne University, attn Rachel Smith, 1000 Fisk St, Brownwood TX 76801 rsmith@hputx.edu Fax: 325-649-8908

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Release of Newborn Screening Records Authorization Form

For the State of Texas

Athlete’s Full Name at birth:

Athlete’s Date of birth:

City/State of birth:

Full name of athlete’s mother at time of athlete’s birth:

If athlete is under age 18:

I, ________________________________, (name of parent or guardian), hereby authorize the Texas Department of StateHealth Services Newborn Screening Lab to release all newborn screening results of my son/daughter to Dr. Robert Hogue, the treating physician and representative of Howard Payne University, Athletics Department.

Parent/guardian signature:

Athlete’s signature:

If athlete is age 18 or older:

I, ___________________________________, (name of student-athlete), hereby authorize the Texas Department of State Health Services Newborn Screening Lab to release all of my newborn screening results to Dr. Robert Hogue, the treating physician and representative of Howard Payne University, Athletics Department.

Athlete’s signature:

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Form B Name

2018-19 Sport

General Medical Examination

Name: Sex: M F Date:

Height: Weight:_ BP: Vision: L)_ R)

Region Normal Abnormal Description & Comments

HEENT

Teeth &

Tongue

Heart & Lungs

Neurological

Skin

GI System

Hernia

(males only)

Elbows &

Hands

Shoulders

Spine

Hips

Knees

Ankles

Other Information:

Pass: Fail: Cleared Pending further rehabilitation/documentation:

Further Comments:

Signature:

Physician M.D. D.O. PA-C NP

Date:__

Physician Name Printed:_

Physician’s Address: Phone: _________________

****Please note that the NCAA will not accept a physical from a Chiropractor (DC)****

Return form to: Howard Payne University, attn Rachel Smith, 1000 Fisk St, Brownwood TX 76801, rsmith@hputx.edu Fax: 325-649-8908

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For ID and Password use: NEW

for both ID and password.

You will have to come up with

your individual ID and password

on the next page.

Section 2: Instructions for Completing Athletic

Medical Paperwork Please make sure you read the instructions on the following pages

Go to hputx2.atsusers.com (no www., etc.) (if you have trouble opening the link, cut and paste it to your browser)

INTERNET EXPLORER IS NOT THE PREFERRED BROWSER FOR THIS APPLICATION. PLEASE

USE FIREFOX, CHROME OR SAFARI TO COMPLETE THE FORMS

hputx2.atsusers.com

You can now use your tablet or smart phone

to fill out the forms and sign them with your

finger or a stylus.

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Fill out Athlete Information. All boxes that

are yellow are required

All three tabs at top must be completed before you can save the information.

Additional tabs will appear after you save.

All three tabs must be completed before you hit ‘save.’

Create a unique ID

and password.

You will need this in the future

‘New can not be in

the ID or password

If you have no medical

alerts, allergies, or current

medications, put none.

12

If your insurance company is not on the drop down list, you can

add a new insurance company by clicking this

You can upload a legible copy of your front and back of your

insurance card here. You do not have send in another copy if you

upload a copy here.

Complete as much of the information as possible. You are required to have primary health insurance to

participate in athletics.

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Fill out a contact with a good phone number. This is used in case of an emergency that we have

to contact someone about an injury/illness.

Try to have at least two contacts.

After you have completed the contact information, hit

save button.

After you hit save, more tabs will

appear at the top of the page.

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Press the Forms tab.

Click the drop down menu.

Select the first form and press ‘new’ button.

You will repeat this step until all seven forms are completed.

You may skip the Immunizations/Paperwork tab.

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After you have completed each form and click save, use the drop down menu to

go to the next form, click on the form and hit new. There are seven forms online

that you must complete.

After reading the form, sign with the mouse (or finger on

smartphone or tablet), type your name and click sign.

AFTER you click sign, press save. Do not forget to save or you

will have to redo the form!!

You do NOT need to print out these seven forms. They

are saved in the program.

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The eFiles tab allows you to upload additional paperwork. You may upload the forms that need to

be sent in here, if you wish.

You do NOT have to print out the forms from the ‘Forms’ tab. They are saved in the program.

This is the most secure way of sending in the printed documents, besides physically bringing them

the athletic training staff.

Optional

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