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Primary Insurance Information

PLEASE FILL OUT ALL INFORMATION COMPLETELY

Athlete Name Sport Home Address City State Zip 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: ______

Office of Sports Medicine of 15Incoming Student-Athlete Packet

Insurance Information – Continued

Vision Insurance PlanName of Insurance Company Address Phone ( ) Expiration Date ID # Group #

Dental Insurance PlanName of Insurance Company Address Phone ( ) Expiration Date ID # Group #

Prescription Insurance PlanName of Insurance Company Address Phone ( ) Expiration Date ID # Group # BIN #

Secondary or Additional Insurance Cards:






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 Medicine400 South Orange AvenueSouth Orange, NJ 07079Fax #: (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

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 Medicine400 South Orange AvenueSouth Orange, NJ 07079Fax #: (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**


Assumption of Risk/Liability Waiver &Consent of 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**

NAME SPORT

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 Phone Home 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.

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 if I am incapacitated.

Member Name Affiliation/PositionDr. Anthony Festa Orthopedic physicianDr. Anthony Scillia Orthopedic physicianDr. Vincent McInerney Orthopedic physicianDr. Michael Kelly Physician

Anthony Testa Director of Sports MedicineDawn Purington Assistant Athletic TrainerTheodore Cowling Assistant Athletic TrainerCatherine Lass Assistant Athletic TrainerJulia Tomaro Assistant Athletic Trainer

____________________________ (Athlete’s Name) Date _________________

____________________________ (Athlete Signature) Date _________________

____________________________ (Parent’s Signature if under 18) Date _________________


Student-Athlete Authorization/Consent for 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-Athlete Signature of Student-Athlete Date

Social Security Number Date 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.

What should I watch for?After being evaluated by your athletic trainer and/or team physician, it may be determined that you are safe to go home. Otherwise, you may be sent to the hospital. If you are sent home, you should not be left alone. A responsible adult should accompany you.

Symptoms from your concussion may persist when you are sent home but should not worsen, nor should new symptoms develop. You should watch for symptoms including:

- Increasing headache - Unusual sleepiness or difficulty being awakened- Increasing nausea or vomiting - Trouble using your arms or legs- Increasing confusion - Convulsions or seizure- Garbled speech

If you notice any of these problems or have any other problem that appears worse as compared to how you felt at the time you left the athletic trainer/team physician, immediately call public safety (973) 761-9300. If you are off campus, dial 911. Please also call your athletic trainer / team physician. (#’s located at the bottom of this handout).

Is it okay to go to sleep?Concussion many times can make you feel drowsy or tired. As long as you are not getting worse, as noted above, it is all right for you to sleep. We do want the responsible adult to be at home with you in case any problems arise.

Do I need a CT scan or MRI examination?If the athletic trainer and/or team physician determined that you are able to go home after the practice or game, these types of diagnostic tests are not necessary. If you are sent to the hospital with a concern for a more complicated injury (e.g. skull fracture, or bleeding inside the skull) a CT scan or MRI examination may be considered. If your symptoms linger for several days these examinations may also be considered.

May I take something for pain?Do not take any medication unless your athletic trainer and/or team physician has told you to do so. Normally, we do not advise taking anything stronger than Tylenol and ask you to avoid such things as aspirin, ibuprofen (Advil / Motrin), naproxen (Aleve), or any other anti-inflammatory medication that you may have been taking. We also strongly advise that you not consume any alcohol and avoid caffeine and any other stimulants. If you are taking any supplements, we would suggest that you discontinue the use of them as well. The team physician will determine when you can restart medications and supplements.


Concussion Information Sheet – Continued

May I eat after the practice or game?It is fine for you to eat if you are hungry. Remember, some athletes do have a sense of nausea and fatigue, and often find that their appetite is decreased immediately after a concussion. Do not force yourself to eat.

How long will I be observed?You will be asked to follow up in the athletic training room after your concussion. You will be assessed by the athletic trainer / team physicians and, if necessary, consultants. You will be monitored daily and your symptoms observed. You should refrain from any physical exertion including strength and conditioning until released to do so by the medical staff. Return to practice and play decisions are made at the appropriate time by the team physicians. Additional testing will be considered (e.g. neuropsychological testing) and this will be explained to you during your follow up visit. Determining if school activities (e.g. class, exams) need to be modified can be evaluated by the team physicians.

We, the undersigned, have read and understand the information on concussion symptoms and management provided above and agree to cooperate with the concussion management plan directed by the Seton Hall University sports medicine staff.

Signature of Student-Athlete Date

Signature of Witness Date

EMERGENCY NUMBERSEmergency Response: 911Campus Security: X9300Health Services: X9175St. Barnabas Hospital ER: 973-533-5180

Team Physicians: Anthony Festa, MDAnthony Scilia, MDVincent McInerney, MDMichael Kelly, DO

Seton Hall University Athletic Trainers:Anthony Testa: (O) 973-761-9582, (C) 973-356-6707 Dawn Purington: (O) 973-761-9738, (C) 978-259-3126Theodore Cowling: (O) 973-275-2510, (C) 330-819-0279Catherine Lass: (O) 973-761-9499, (C) 603-554-6518Julia Tomaro: (O) 973-313-6394, (C) 908-216-8781


Sickle Cell Trait Information Sheet / Waiver

The NCAA recommends that all student athletes be aware of their sickle cell status. If the student-athlete does not know whether they are positive for sickle cell trait, the NCAA recommends that student-athletes undergo testing to determine their status.

Seton Hall is supportive of this recommendation, and requests that each student-athlete provide the Office of Sports Medicine with documentation of their sickle cell trait status. If a student-athlete opts not to provide the University with this information, s/he must sign the testing waiver below. To help you make an informed decision regarding this issue, some basic information is provided below, as well as a link to additional resources.

About Sickle Cell Trait- Sickle cell trait is an inherited condition of the oxygen-carrying protein, hemoglobin, in the red blood cells. Sickle cell trait is a common condition, which affects more than 3 million Americans Although sickle cell trait is most predominant in African-Americans and those of Mediterranean, Middle Eastern,

Indian, Caribbean, and South and Central American ancestry, persons of all races and ancestry may test positive for sickle cell trait.

Sickle cell trait is usually benign, but during intense, sustained exercise, hypoxia (lack of oxygen) in the muscles may cause sickling of red blood cells (red blood cells changing from a normal disc shape to a crescent or “sickle” shape), which can accumulate in the bloodstream and “logjam” blood vessels, leading to collapse and even death due to the rapid breakdown of muscles starved of blood.

More information regarding sickle cell trait and the rationale for the NCAA’s recommendation that all student athletes be aware of their status may be found at www.ncaa.org.

Sickle Cell Trait Testing- Testing should be conducted at a laboratory facility of the student’s choosing. If you choose to undergo testing, all costs associated are your own responsibility. Please attach results to this form

and return both with your physical paperwork. If you choose not to be tested, you must complete and sign below.

___________________________________________________________________________________________SICKLE CELL TRAIT TESTING WAIVER

I, , understand and acknowledge that the NCAA and Student-Athlete Name

Seton Hall University recommends that all student-athletes have knowledge of their sickle cell trait status. Additionally, I have read and fully understand the aforementioned facts about sickle cell trait and sickle cell trait testing. Recognizing that my true physical condition is dependent upon an accurate medical history and a full disclosure of any symptoms, complaints, prior injuries, ailments, and/or disabilities experienced, I hereby affirm that I have fully disclosed in writing any prior medical history and/or knowledge of sickle cell trait status to Seton Hall University Sports Medicine personnel.By signing this waiver, I confirm that I do not wish to undergo sickle cell trait testing as part of my pre-participation physical examination and I voluntarily agree to release, discharge, indemnify and hold harmless Seton Hall University, its officers, employees and agents from any and all costs, liabilities, expenses, claims, demands, or causes of action on account of any loss or personal injury that might result from my decision not to follow the recommendation that I be aware of my sickle cell trait status and share that information with the Department of Athletics.

I have read and signed this document with full knowledge of its significance. I further state that I am at least 18 years of age and competent to sign this waiver.

Student-Athlete Signature:

Student-Athlete Print Name:

Date:

Sport:

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


Parent/Guardian Print Name: To be completed by a Physician: DATE OF EXAM:

SETON HALL UNIVERSITYOFFICE OF SPORTS MEDICINE

PRE-PARTICIPATION PHYSICAL

NAME: SPORT: YEAR (Eligibility):

DATE OF BIRTH: SS#: SHU ID#:

SEATED BP: R ARM:L ARM:

PULSE: RADIAL:FEMORAL:

VISION:Corrected Uncorrected

LEFT:RIGHT:BOTH:

HEIGHT: WEIGHT:

SAC/BESS BASELINE: # PREVIOUS CONCUSSIONS:

ALLERGIES TO MEDICATION:

GENERAL MEDICALDATE OF EXAM:

NORMAL ABNORMAL (Comments)

General Appearance

Eyes, Ears, Nose, Throat

Lymph Nodes

Heart

Stigmata of Marfans Y/NAuscultation supine standing w/ Valsalva Notes:

Lungs

Abdomen

Skin

COMMENTS:


ORTHOPEDIC DATE OF EXAM:

NORMAL ABNORMAL (Comments)

Neck

Back

Shoulder/Arm

Elbow/Forearm

Wrist/Hand/Fingers

Hip/Thigh

Knee

Lower Leg/Ankle

Foot/Toes

COMMENTS:

PARTICIPATION STATUS (Check one)___ CLEARED

PHYSICAN/ ATC SIGNATURE DATE CLEARED

___ NOT CLEARED

The following is necessary for medical clearance: ______________________________________________________________________________


PHYSICAN/ ATC SIGNATURE DATE SIGNED


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