Pre-participation Health History and Insurance Information
TO:
Dominican University of California Student-Athletes and ParentsFROM:
Dominican Sports Medicine StaffSUBJECT:
Pre-Participation Medical Clearance and Insurance InformationWelcome back! We are pleased to have your son/daughter returning as a student-athlete at Dominican University of California. The Department of Athletics welcomes you back and wishes you luck as you continue to strive for excellence. The enclosed information pertains to Pre-Participation Medical Clearance, Health History, and Insurance Information for
all student-athletes. Before the student-athlete can be medically cleared to participate in athletics, the attached forms must
be on file in the Athletic Training office no later than July 17th. A physical exam is required of all student-athletes
through the Sports Medicine Staff prior to participation. Physicals completed by the Sports Medicine Staff are free of charge to Dominican University student-athletes. The athletic training room will have scheduled dates for completion of these physicals after August 1st. Physicals must be completed prior to participation in any activity . Physicals required for admissions, or completed by an off-campus physician will not be accepted as a substitute. Failure to complete a physical or the enclosed forms will delay the start of active participation in athletics. The following are required prior to pre-participation physicals:
1. Pre-participation Medical History forms. The medical history forms must be completed and signed by the athlete. These forms and the subsequent physical will be acceptable for admissions. However, the admissions physical and health history form will not be accepted as a substitute for the athletic health history and
physical.
(NO SUBSTITUTE FORM IS ACCEPTABLE)
2. Athletic Insurance Policies and Procedures. The student athlete and one (1) parent/guardian must sign and return the original copy of this policy and procedures form to the Athletic Training office verifying receipt and understanding of the policies. This form must be completed and on file no later than July 17th. Parent/athlete: please retain a copy of the Athletic Insurance Policies and Procedures for your files.
3. Medical Insurance card. A photo copy of the front and back of an insurance card verifying that the student- athlete has major medical coverage. This copy must be on the form provided and on file with the Athletic Training office prior to participation in athletics.
4. Athlete insurance information. This form with all the required information must be completed and signed by the athlete and
ONE PARENT/GUARDIAN. Independent students are not required to have
parent/guardian signature.
Faxes and copies of this form will not be accepted.The Pre-Participation Health History form, Insurance Information form, and a photocopy of a medical insurance card must be completed and returned by July 17th.
This information must be returned to the Athletic Training office at the following address:
Dominican University of California Department of Athletics
Office of Athletic Training 50 Acacia Ave.
San Rafael CA, 94901
If you have any questions please call the Athletic Training office at (415) 482-1807 or (415)257-1353. Thank you,
Tara Hoff, MEd, ATC/Josh Sims, MEd, MHR, ATC/Kassi Boedeker, MS, ATC Athletic Trainers
Dominican University of California
All Forms Must Be Returned No Later Than July 17th.
Forms included in packet:
1. Acknowledgement of Insurance - FA 2. Student-Athlete Information – F1
3. Medical History Form – F2 4. Supplement Notification – F3 5. Certification – F4
6. Student-Athlete Authorization – F5 7. Medical Consent – F6
8. Authorization to Release Healthcare Information – F7
9. Brief Medical Exam – F8 10. Insurance Information – F9 11. Copy of Insurance Card – F10
Dominican University of California Athletic Insurance Policies and Procedures
1. Insurance:
a. Personal Insurance: Primary coverage.
i. All Dominican University student-athletes are required to have a full coverage medical insurance policy prior to participation in athletic activities (primary insurance).
ii. The primary insurance policy must be active prior to and during participation in athletics.
iii. Proof of primary insurance coverage must be on file with the Athletic Training office.
A copy of an insurance card evidencing current primary insurance coverage will be considered proof of insurance.
iv. Proof of insurance on file with admissions will not be accepted as proof of primary insurance for athletic participation.
v. If primary insurance is an HMO (HealthNet, Blue Shield, etc...) or has an in-network provider, call and request away from home coverage and join Meritage Medical Network and if possible select Dr. David Goltz Orthopedic Surgeon as doctor of choice to allow for doctors visits without having to travel home for care. If you live in the Bay Area and would like to stay in that network that is acceptable but could require travel to the in-network provider.
vi. If you have Kaiser and reside outside of Northern California call and request a Northern California Kaiser number to allow for quicker services while at school.
vii. Failure to provide primary insurance coverage will result in denial from secondary insurance and the student/parent will be responsible all medical costs.
b. Dominican University Provided Insurance: Secondary coverage.
i. Dominican University provides secondary insurance through an independent carrier that is active throughout the academic school year.
ii. All student-athletes are covered by this secondary insurance with no cost to the athlete or parents.
iii. Secondary insurance is a supplement only to primary insurance coverage.
iv. Dominican University provided secondary insurance is not a comprehensive major medical policy, as set forth below.
v. All student-athletes are covered by a separate insurance policy for catastrophic injury. This policy is provided by Dominican University according to NCAA guidelines/requirements through an independent carrier. Coverage is for accidental death and disability
2. Insurance Benefits: Secondary coverage.
a. Accident/Injury benefits for athletes are on an “excess” only basis.
b. Athlete’s own primary insurance must be billed prior to requesting secondary insurance coverage for any unpaid medical expenses that are covered by the terms and conditions of the secondary coverage
c. Benefits available through secondary coverage apply only after payment/non-payment by the primary insurance carrier.
d. Expenses that are covered in accordance with section 4 below which are not covered by primary insurance carrier will be payable through the secondary insurance carrier.
e. Dominican University shall have no responsibility to cover medical expenses that are not covered by primary and/or secondary insurance.
f. All remaining expenses, or those expenses not covered by the primary and secondary insurance carriers
3. Termination of benefits: Secondary coverage.
a. Athletic insurance benefits from secondary coverage expire two (2) years from the date of the original injury, irrespective of the date upon which the injury is reported.
b. Failure to report an injury or file a claim within the two (2) year benefits period will result in no secondary insurance coverage for medical expenses incurred by the student athlete.
c. The information provided here is intended only as a summary and overview. To the extent that the provisions of the secondary insurance policy provide benefits that differ from what is stated in these policies and procedures, the provisions of the secondary insurance policy shall prevail; provided that neither these guidelines nor the terms of the secondary insurance policy shall be interpreted to result in any direct responsibility for payments by Dominican University.
4. Specific policies and procedures
a. Dominican University provided secondary insurance is not a comprehensive/major medical insurance policy. Illness/disease is not covered by the secondary insurance policy.
b. All required co-pays for medical services or office visits that fall within the coverage of the secondary insurance are eligible to be paid by the secondary insurance.
c. Amounts that apply to deductibles required by the primary insurance carrier for medical services that are covered by secondary insurance will be eligible for reimbursement under the secondary insurance coverage.
d. Secondary insurance does not cover complications that result from or are due to injuries/conditions that are pre-existing.
e. Secondary insurance coverage does not apply to non-accidental injury, or non-athletic related injury. f. Secondary insurance coverage applies to accidental injury that is a result of participation in university
sanctioned athletics.
i. Accidental injury is any injury that results from a sudden unexpected traumatic event.
A. Covered examples:
a. Twisted knee resulting in torn ligaments/cartilage
b. Acute muscle strain/rupture from throwing or running type motion. c. Fractures/Contusions resulting from collision with another player, Ground
contact etc. B. Non-covered examples:
a. Subluxing joint due to inherent laxity.
b. Chondromalacia, Osteoarthritis secondary to previous injury or predisposition. g. All covered accidental injuries are those that occur during scheduled practice, game, or conditioning
activity that is sanctioned by the athletic department.
h. Active participation in athletics applies to all individuals included on a team’s roster, coaching staff or those individuals attempting to become a member of the team’s roster.
i. Only those athletes enrolled in classes at Dominican University are covered for accidental injury. All others must submit proof of insurance prior to participation in any university sanctioned athletics (i.e. team tryouts, team scrimmage).
j. Injury that occurs during the performance of recreational, personal, or physical education/intramural activities are not covered by secondary insurance.
5. Procedures
a. All injuries must be reported to the Athletic Training office within 24 hours. There are no
exceptions.
b. All non-emergency injuries sustained during active participation in athletics must be referred through the Athletic Training office. There are no exceptions.
c. Athletes are referred for medical care on a “needs” basis. Any athlete may request consultation with the team physician through the Athletic Training office anytime.
d. All consultations for second opinions require notification to the team physician and the Athletic Training office prior to obtaining said appointment.
e. Any athlete that self refers, or visits a medical care provider without referral, including second opinions, will be responsible for all medical costs incurred.
f. All injuries must be verified as to time, place, and cause before a claim will be considered valid. g. All primary medical care must be received within 30 days of injury.
h. An injury report signed by the Team Athletic Trainer must be completed prior to a physician visit or a claim being filed for medical expenses.
i. The Dominican University team physicians should be used at all times if possible for accidental injury of a non-urgent nature.
j. The Dominican University student health center and/or the team physicians are available for non-accidental injury or illness. These services should be utilized whenever possible.
k. The student-athlete/spouse or parent is responsible for verification of coverage prior to obtaining a visit with a health care provider.
l. All pre-authorization requirements according to primary insurance carrier policy for medical care are the responsibility of the athlete/spouse or parents.
m. The athlete/spouse or parents are responsible for ensuring that all appropriate claim forms are filed with the primary insurance carrier.
n. The athlete/spouse or parents are responsible for ensuring that all medical bills for services rendered are forwarded to the primary insurance carrier.
o. An additional copy of all medical bills must be submitted to the Athletic Training office.
p. Failure to follow the guidelines/procedures included in this document or those procedures/guidelines stipulated in the primary or secondary insurance carrier’s policy may jeopardize payment for any and all medical services rendered for an injury sustained during athletic participation.
q. The following items are required to complete a claim through Dominican University secondary insurance carrier:
i. A completed and signed injury report. ii. An itemized bill from all medical providers.
iii. An explanation of benefits (EOB) from primary insurance carrier. iv. A completed and signed secondary insurance claim form.
v. All itemized bills and EOB’s must be submitted to athletic training staff
r. No claim for payment through Dominican University secondary insurance carrier will be accepted without all items mentioned above.
FORM A
Acknowledgement of Insurance Policies and Procedures
All athletes receiving medical care from a physician are required to have written clearance from the attending/treating physician and the Team Athletic Trainer before returning to practice/play. All athletes treated through the Athletic
Training office or Student Health Center are required to have written approval from the Team Athletic Trainer and Health Center director prior to returning to practice/play. There will be no exceptions to any of the previously stated
procedures.
If primary insurance is an HMO (HealthNet, Blue Shield, etc...) or has an in-network provider, call and request away from home coverage and join Meritage Medical Network and if possible select Dr. David Goltz Orthopedic Surgeon as doctor of choice to allow for doctors visits without having to travel home for care. If you live in the Bay Area and would like to stay in that network that is acceptable but could require travel to the in-network provider.
By signing below the student-athlete/spouse and or parent/guardian acknowledges receipt and understanding of all Dominican University of California “Athletic Insurance Policies and Procedures”. The student-athlete, spouse,
parent/guardian also understands that supplying false and or misleading information on this form may result in a complete loss of all medical benefits as well as exclusion from future participation in all Dominican University of California Athletics activities.
Student-Athlete Signature Date
Print Name Date
Parent/Guardian Signature Date
(Must be signed by parent/guardian if insurance is provided through them)
Original of this page must be on file with the Dominican University Department of Athletics prior to participation in any Dominican University Athletics sanctioned activities, including preseason training.
FORM 1
STUDENT-ATHLETE INFORMATION
TO BE COMPLETED BY ALL RETURNING STUDENT-ATHLETES
Sport: Sex M F
Last Name: Middle: First:
Social Security # ___________________________ Date of Birth:_________________
Status: Sophomore Junior Senior Graduate
NOTE: Athletes are asked to provide their academic year address in the spaces immediately below
Street Address Apartment #:
Residence Hall: Room # MSC # .
City State Zip Code County
Home Phone ( ) Campus Phone ( )
Cell Phone ( ) E-Mail Address
Provide your Permanent Home Address
(where Mom & Dad Live)Street Address Apartment #: _______
City State Zip Code County
Home Phone ( )
Emergency Contact Information:
Name Relationship
Work Phone ( ) Cell:
Night Phone
( )
Address: City: State: Zip: .
Authorized Signature for contact information
___________________________ _________________________________ _____________
Signature
Print Name
Date
FORM 2
MEDICAL HISTORY FORM
CHECK APPLICABLE BOX:
Tryout Player (entry) Senior Freshman Graduate
Sophomore End of Season
Junior
Dominican Team : ____________________________________________ Date: ________________
Student-Athlete’s Name: _____________________________________________________________________ (please print)
Please have the athlete answer the following questions: (Circle one)
YES NO I am presently receiving medical treatment for medical problems or physical injuries.
If "YES", please give full details:__________________________________________
______________________________________________________________________
YES NO I am currently physically able to perform all of the duties required in intercollegiate athletics:
If "NO", please give full details: ___________________________________________
______________________________________________________________________
YES NO I have suffered an illness, injury or any other discomfort since my last athletic participation.
If "YES", please give full details: __________________________________________
______________________________________________________________________
Since your most recent physical examination, have you suffered any injury, illness or discomfort for which you have not sought:
YES NO Medical advice
YES NO Diagnosis
YES NO Treatment
If "YES" to any of the above, please give full details: ____________________________ ______________________________________________________________________ ______________________________________________________________________
Form 3
STUDENT-ATHLETE SUPPLEMENT NOTIFICATION FORM
I, , acknowledge that I am currently taking and/or have
Student-Athlete Print Name
(within the past 6 months) taken the following ergogenic aids, creatine powder, amino acids, protein supplements, or other similar
substances, hereinafter referred to as "Supplements." (Use the back of this form if necessary.)
NAME DOSAGE MAIN INGREDIENTS COMMENTS
I understand and agree:
a) That the Dominican University of California Department of Intercollegiate Athletics neither approves of nor condones the use of Supplements;
b) I have been informed of the Dominican University of California Department of Intercollegiate Athletics, National Collegiate Athletic Association (NCAA), and United States Olympic Committee (USOC) policies with regards to the use of Supplements, and have had any questions about these policies answered;
c) The use of Supplements may result in serious harm to me, possible permanent injury to my health, and even death. d) I understand that I risk losing my eligibility and possibly my team’s eligibility to participate in regular season and
post-season intercollegiate athletics if I test positive for any banned substance;
e) I must list all Supplements on the Chain of Custody Forms at the time of any drug test.
I fully accept any and all risks and liability if I have used in the past, continue to use, or use at anytime in the future any form of Supplements. This includes but is not limited to high dosage caffeine drinks, tablet, capsules, etc. ex. Red Bull, Rock Star.
I further understand and agree That Dominican University of California, its officers, employees, and agents are not responsible for any harm and possible permanent injury to my health caused by my past, present, and/or future use of Supplements. I agree to hold harmless, indemnify, and irrevocably and unconditionally release Dominican University of California, and their officers, employees and agents from any and all liability, and demands, claims and causes of action relating to my use of Supplements.
I understand the statements in this form, and have had all questions about the information in this form answered to my satisfaction.
Student-Athlete’s Signature Date
Parent / Guardian’s Signature (if under 18 years old) Date
FORM 4
CERTIFICATION
To the best of my knowledge, I have answered all questions in this packet fully and truthfully, and I do not have any medical problem(s) other than those listed on this physical form. I represent that I am not now suffering from any physical or mental disability, which prevents me from participating in intercollegiate athletics. I understand that by continuing to participate in intercollegiate athletics I may aggravate previous injuries and/or sustain new injuries. I also fully understand that any or all of the injuries sustained while participating in intercollegiate athletics could result in future permanent physical disability. I fully understand the possible consequences of participating in intercollegiate athletics and desire to be cleared to participate in intercollegiate athletics and hereby assume the risk of the matters set forth above. I also understand that providing false or misleading information and omission may result in a denial of medical benefits and my exclusion from participation in Dominican University of California Athletics activities.
Student-Athlete Name (Print Clearly):
Student-Athlete Signature: Date:
Witness Name (Print Clearly): Witness Signature:
Date:
Original form must be on file with the Dominican University Department of Athletics prior to participation in any Dominican University Athletics sanctioned activities, including preseason training.
Form 5
Student-Athlete Authorization/Consent to Obtain and for Disclosure of Protected Health
Information
I hereby authorize Dominican University’s Department of Athletics and Sports Medicine Staff to release and/or obtain any 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, treatment, 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, laboratories, athletics coaches, athletic trainers, medical insurance coordinators, insurance carriers, medical supply vendors and/or service companies, athletics and/or university administrators, and academic counselors.
I also authorize Dominican University’s Department of Athletics and Sports Medicine Staff to disclose my protected health information and any related information regarding any injury or illness during my training for and participation in intercollegiate athletics to the National Collegiate Athletic Association (NCAA) and its employees or agents, the National Injury Surveillance System (NISS), and the University of Virginia’s concussion research program. I understand that my protected health information will be used only by the NISS for the purpose of conducting research on injuries resulting from training for or participation in athletics. The NISS is a longitudinal research database that provides the NCAA, NCAA sports rules committees, athletic conferences, researchers and individual schools with summary (aggregate) injury and participation information that does not identify individual athletes or schools. The summary data provide the Association and other groups with an information resource upon which to base health and safety rules and policy and to examine the effectiveness of such efforts.
I understand that my signing of this authorization/consent to disclosure to the NCAA, the NISS, and the University of Virginia’s concussion research program is voluntary and that Dominican University will not condition or withhold any health care treatment or payment, enrollment in a health plan or receipt of any benefits (if applicable) on whether I provide the consent or authorization requested for this disclosure. I understand that the protected health information will be encoded before being transmitted from Dominican University to the NCAA, the NISS and University of Virginia and that none of the aforementioned institutions will identify me personally in any publication or utilize the medical information obtained during the course of my treatment in medical research and education programs so long as my name and likeness are not revealed and my privacy is completely protected.
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 (the 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 re-disclosure 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 Head Athletic Trainer, but if I do, it will not have any effect on actions Dominican University took in reliance on this authorization/consent prior to receiving the revocation.
Dominican University’s Head Athletic Trainer is hereby authorized to request and receive copies of all records pertaining to my current and past health, including all physicals, athletic trainer’s records, medical diagnosis, treatments, history and prognosis of any and all past or present medical conditions. A copy of this authorization shall be considered as effective and valid as the original.
Original form must be on file with the Dominican University Department of Athletics prior to participation in any Dominican University Athletics sanctioned activities, including preseason training.
Student-Athlete Name (Print Clearly):
Form 6
MEDICAL CONSENT
I hereby grant permission to the Dominican University Athletic Training Staff and Team Physicians/Consultants to render to my son or daughter, or to myself, any treatment or medical care deemed reasonably necessary. This includes
preventive care, first aid, rehabilitation, treatment modalities and emergency treatment. Also, if deemed necessary, I grant permission for hospitalization.
_________________________________ _____________________________________ Print Student-Athlete Name Student-Athlete Signature
_________________________________ _____________________________________ Date Parent/Guardian Signature
(If under 18 years of age)
Original form must be on file with the Dominican University Department of Athletics prior to participation in any Dominican University Athletics sanctioned activities, including preseason training.
May 1, 2013 Original form must be on file with the Dominican University Department of Athletics
FORM 7
AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION
Patient’s Name:
Date of Birth:
Kaiser # (if applicable):
Telephone #:
Email address:
I request and authorize the Dominican University of California Student Health Center and its staff to release,
discuss, and coordinate ongoing healthcare information of the patient named above to/with the Dominican
University of California athletic trainers and/or team physicians.
This request and authorization applies only to healthcare information that may affect the patient’s
participation in intercollegiate athletics.
Duration and revocation: This authorization shall become effective immediately and shall remain in effect until
revocation in writing by the undersigned is received by Dominican University Sports Medicine and/or Health
staff.
Patient signature:
Date signed:
Parent/Guardian signature:
Date signed:
(if under 18 years old)
May 1, 2013 Original form must be on file with the Dominican University Department of Athletics FORM 8
BRIEF MEDICAL EXAMINATION FORM
Please indicate if you have had any of the following since the completion of your last athletics season:
CHECK APPLICABLE BOX:
Sophomore Senior
Junior Graduate
Name ________________________________________ Date __________________ YES NO (Explain “yes” answers below)
1. Have you had surgery or been hospitalized for any reason?
2. Are you presently under a doctor’s care, on any medication, or have any other medical problems? 3. Do you have any new allergies to medicines, bee stings, foods, or any other substances?
4. With exercise, have you passed out, been dizzy, had chest pain, shortness of breath, or cough?
5. Have you been told that you have high blood pressure or a heart murmur since your previous evaluation? 6. Do you tire more quickly than your friends during exercise?
7. Have you had unexplained racing of your heart or skipped heartbeats?
8. Has anyone in your family died of heart problems or died suddenly before age 50 since your previous evaluation? 9. Do you have any skin problems (itching, rashes, acne)?
10. Have you had a serious head injury, been knocked out, or had a seizure? 11. Have you had a stinger, burner, or pinched nerve?
12. Have you been dizzy, passed out, or had muscle cramps due to heat?
13. Have you used any special equipment (pads, braces) since your previous evaluation?
14. Have you started wearing glasses, contacts, or protective eyewear, or have any problems with your eyes?
15. Have you sprained/strained, dislocated, fractured, broken or had swelling or other injuries of any bones or joints? Head Shoulder Thigh Neck Elbow Knee Forearm Shin/calf Back Wrist/Hand Ankle/Foot Hip
16. Have you sustained any serious lacerations or puncture wounds requiring medical attention? YES NO 17. Did you receive a tetanus shot? If “no” When was your last tetanus shot?_________
Explain, “yes” answers: (use back if necessary)
________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________
May 1, 2013 Original form must be on file with the Dominican University Department of Athletics
Health Habits - All Student-Athletes Must Complete The Following Questions
42.What is your current
: WEIGHT (in lbs.) ____ and HEIGHT (in inches) ___
43. Do you usually take any of the following dietary supplements? (Check all that apply)
o Vitamins o Calcium
o Minerals (iron, magnesium, zinc, etc.) o Protein (drinks, powders, capsules, etc) o Calorie supplements
o Creatine Monohydrate
44. Have you gained or lost more than 5 pounds in the past 6 months? Yes No
45. Are you happy with your current weight? Yes No
46. Would you like to be smaller or larger? Yes No
47. Do you regularly skip breakfast? Yes No
48. Does your diet change during your athletic season? Yes No
49. Do you exercise regularly during the off season? Yes No
May 1, 2013 Original form must be on file with the Dominican University Department of Athletics
Female Student-Athletes - please complete the following:
50. Date of last menstrual period: _________________________ 51. Date of last gynecological exam/pap smear: _______________ 52. My periods are now (check one)
o Regular (every 24-35 days) o Irregular (every 36 days or more)
o Absent (no periods for more than three months)
53. Yes o No o Do you have any gynecological problems (i.e. cramps, PMS, discharge, etc.)? Explain:
54. Yes o No o Have you ever missed periods for 6 months or more? Explain:
55. Yes o No o Do you perform breast self-examination(s)? 56. Yes o No o Do you have any other gynecological problems?
Explain:
May 1, 2013 Original form must be on file with the Dominican University Department of Athletics FORM 9
Insurance Information
The following information is required of all athletes to assure that medical expenses are adequately and/or completely covered by an insurance policy. Inadequate or incomplete information may delay insurance payments or void
coverage for medical expenses. It is the sole responsibility of the athlete to ensure that all information is correct and
current prior to participation in Dominican University Athletics. No claim for medical expenses will be filed through Dominican university secondary insurance carrier without this information.
Name: D.O.B. Sex:
Campus Address: City:
Home Address: City:
State: Zip code: Phone : Cell Phone:
Policy Holder: Date of Birth:
SSN: (needed for insurance verification) Relationship to Student-Athlete:
Address:
City: State: Zip code:
Insurance Carrier: Plan Type: POS PPO HMO (circle one)
Group Policy No.: I.D. #: Phone:
Insurance Carrier Mailing Address:
City: State: Zip code:
Pre-Authorization required: Y N (circle one) Phone: . I/We the undersigned certify that the foregoing is true and correct to the best of our knowledge. I/We authorize
Dominican university sports medicine to contact the aforementioned insurance carrier to verify type of plan and coverage.
Signed: Print Name: Date:
(Student-Athlete)
Signed: Print Name: Date:
(Parent/Guardian)
May 1, 2013 Original form must be on file with the Dominican University Department of Athletics FORM 10
Copy of Insurance Card
Please make a copy of the front and back of a current medical insurance card on this page or attach a
copy to this packet.
May 1, 2013 Original form must be on file with the Dominican University Department of Athletics Form 11 Name: Hgt: Wgt: Sport: .
Medical Examination
This form must be completed by Dominican University team physicians only
Head and Face Pass Fail Problems:
Cervical Spine Pass Fail Problems:
Upper Extremity Pass Fail Problems:
Thoracic Area Pass Fail Problems:
Abdominal Pass Fail Problems:
Lumbar Spine Pass Fail Problems:
Hips Pass Fail Problems:
Lower Extremity Pass Fail Problems:
Heart N AN Lungs N AN
Problems:
Athlete Cleared to Participate
Athlete Cleared with restrictions: Conditioning: Y N light Moderate Contact Y N Rehabilitation required – Reason:
Athlete Not Cleared to Participate- Reason: Second Evaluation required – Reason:
