SPORTS MEDICINE PROGRAM A. MEDICAL SERVICES
The sports medicine program at Indiana University works under the direct supervision of the team physician who is located in Assembly Hall. If a student-athlete should be injured while participating in an intercollegiate sports program, he/she will be evaluated by a nationally certified and state licensed athletic trainer, provided immediate care, and referred to whatever medical personnel deemed necessary.
The role and function of the athletic trainers are to implement prevention of injury programs, provide immediate care and treatment, and follow rehabilitation procedures for the injured student-athlete as directed by the team physician. Certified athletic trainers will provide the student-athlete with the basic health care needs and direct him/her to the team physician, adult nurse practitioner, etc., when it is necessary. Today's athletic trainer is a well-trained professional who is an integral part of a complete athletic program.
The team physician has at his disposal medical consultants in every field of the medical profession. If a student-athlete is sent to one of the medical consultants, he/she will be given a referral form or a phone call will be made on their behalf to arrange for an appointment. If, for any reason, other than a life threatening situation, a student-athlete goes to a doctor or hospital without prior approval of the team physician or athletic trainer, the student-athlete will be responsible for those fees incurred.
The sports medicine program will provide direct medical coverage, with its staff and/or athletic training students, only if the sport activity is an approved Athletic Department scheduled event, or coach supervised practice. Every effort will be made to provide coverage for the non-traditional or out-of-season practices or workout during the academic school year. Summer conditioning workouts will only receive coverage if there is strength/conditioning supervision as mandated by NCAA.
B. MEDICAL FACILITIES
The Athletic Training Rooms located at Assembly Hall, Memorial Stadium, Cook Hall, University Gym and the SRSC are the main source of medical care for student-athletes during their competitive season. The Indiana University Health Center is an ancillary facility which is used for physician referral, pharmacy, lab tests and x-rays. IU Health Bloomington Hospital should be accessed when one is unable to locate their respective staff athletic trainer and/or team physician. The hospital is also used for physician referral, surgeries, diagnostic tests, emergencies, etc.
C. IN-SEASON AND OUT-OF-SEASON INJURIES OR ILLNESS
All injuries, cuts, abrasions, etc. must be reported after practice or competition during the athletes' traditional as well as non-traditional seasons. The athletic trainer responsible for the sport will make an evaluation and take the appropriate action of treatment or referral. If an illness occurs, the student-athletes must check with their respective athletic trainer and let him/her evaluate the problem and refer to the appropriate physician, adult nurse practitioner, or medical facility.
The Athletic Department can only provide expenses for medical treatment incurred by a student-athlete as a result of an athletically related injury (coach supervised practice or competition) or while participating in voluntary physical activities that will prepare the student-athlete for competition during the academic year (as per department policy). When out-of-season and the team physician or nurse practitioner is not available, the Indiana University Health Center or IU Health Bloomington Hospital is the source of medical service. Any costs or fees incurred at this time are the responsibility of the
student-athlete. The athletic trainers, however, will always be available for consultation about personal problems and provide any treatment and rehabilitation for injuries caused during the in-season.
D. MEDICAL CARE AFTER ELIGIBILITY
When a student-athlete's playing eligibility is completed, he/she must receive an exit physical review from a sports medicine staff member to identify any existing medical injury or problem. It is a Department policy that a student-athlete be allowed one year to take care of any medical problem, i.e., surgery, rehabilitation, etc., as a result of direct and eligible athletic participation. This should be coordinated through the team physician and staff athletic trainer. Otherwise, the Athletic Department cannot be responsible for the charges.
E. EMERGENCY TREATMENT
When the athletic training room happens to be closed and you find yourself in need of medical treatment, call either the head athletic trainer or the staff athletic trainer responsible to your sport. In extreme emergencies, and only after failing to reach either the head athletic trainer or staff trainer at home, notify the team physician as soon as possible and report directly to IU Health Bloomington Hospital.
F. THE ATHLETIC TRAINING ROOM
As stated previously, the Assembly Hall, University Gym, SRSC and the John Miller (Stadium) athletic training rooms are the main facilities for the sports medicine program. During the Fall and Spring semesters, the Athletic Training Rooms will generally be open Monday to Friday, 8:00 a.m. to 6:00 p.m. for injury evaluation, treatment and rehabilitation. Other athletic training room hours will be set up between the athletic trainer and their respective athletes.
G. GENERAL TRAINING ROOM RULES
1. Student-athletes should park their vehicle only in those areas so designated. Do not block the driveway to the loading area.
2. All Athletic Training Room facilities are co-educational; therefore, be sure to be dressed properly.
3. Do not wear cleats or dirty uniforms into the Athletic Training Room. Shower first before entering to receive treatment, be evaluated for injury, or use cold whirlpools, etc.
4. The Athletic Training Room is not a self-serve facility. All taping, first aid, and treatment will be administered by the athletic trainers in charge. Be patient and wait your turn.
5. The telephones in the Athletic Training Room are for business only. Student-athletes are not to use their cell phones in the Athletic Training Room.
6. Return all loaned items to the Athletic Training Room. Each student-athlete will be charged for those items not returned and placed on a checklist until returned.
7. Remember, all the athletic trainers are dedicated to each student-athlete's health and safety. We will attempt to give each the best possible care but we expect courtesy, cooperation, and respect in return.
H. MEDICAL EXAMINATION AND CLEARANCE TO OBTAIN EQUIPMENT
Any student wishing to participate in athletics must be physically and academically cleared and provide proof of current health insurance prior to participation. Each student-athlete must have on file in the Sports Medicine Office an approved physical examination, a medical history and an insurance form in order to participate in an intercollegiate sport. Approval for participation is based on a thorough review of the student-athlete's health status. Equipment will not be issued until the manager of the equipment room is notified that the student-athlete is eligible to receive equipment.
First year scholarship, recruited walk-on and returning rostered student athletes will be given physical examinations by a designated physician in the office of Sports Medicine at scheduled times after arriving on campus. To facilitate this process, please complete the Medical History Questionnaire and Insurance Form and return by June 21st in the envelope supplied so we have this information before your son/daughter arrives on campus.
The manager of the equipment room will be given written notice of the eligibility of new scholarship and new walk-on student athletes who are to receive equipment after the appropriate staff athletic trainer has received the following information:
1. Notice of academic and compliance eligibility, 2. Determination that your health status is satisfactory,
3. Proof of current health insurance on file with photo static copies of insurance cards*
The manager of the equipment room cannot issue equipment until the signature of clearance is on file in the Athletic Training Room.
Each student-athlete and cheerleader shall have an initial physical examination when they enter a Conference intercollegiate sports program. The extent of the physical examination including laboratory studies and other diagnostic procedures will be determined by the team physician. Thereafter, an annual review of their health status shall be performed. This may include a physical examination at the discretion of the team physician.
A) The final decision on physical qualification or reason for rejection shall be the responsibility of the team physician.
B) The team physician shall have final authority regarding participation in practice and competition subsequent to an injury or illness." (Agreement for Men's and Women's Programs Section 16.4, Handbook of the Big Ten Intercollegiate Conference.)
*There are no exceptions to this policy unless specifically authorized by the Director of Athletics.
I. IMMUNIZATIONS
Indiana University is very concerned about providing a safe and healthy environment for all students. The University must comply with an Indiana state law which requires that all students must provide immunizations information to the Office of the Registrar. To be in full compliance of this state requirement, all students must:
A. Each student must have been given a Tetanus/Diphtheria (Td) booster within the past 10 years. (If your last booster was given more than 10 years ago, you will need to obtain a current booster).
B. The University is required to inform each student about the risk associated with meningococcal diseases and recommends meningitis vaccination.
C. Each student is to show dates of immunity for measles, mumps, and rubella (MMR). D. International students are required to be tested for tuberculosis (TB) in the United States.
New students are required to complete and submit the On-line Immunization Compliance Form in OnStart before the first day of classes. Failure to comply will prevent students from registration for the second semester. We ask that this immunization information also be printed on the bottom of the enclosed MEDICAL HISTORY QUESTIONNAIRE.
Moreover, there is a major concern among health care professionals about the rise of infectious disease in this country and the worry about the risk of transmission of blood pathogens in contact/collision sports. The Hepatitis B Virus (HBV) is 100 times more contagious than the more publicized Human Immunodeficiency Virus (HIV). Thus, the Center for Disease Control (CDC) and now the NCAA are recommending that all adolescents and young adults receive hepatitis B immunization. J. DENTAL CARE
While a student-athlete attends Indiana University, the Athletic Department will be responsible for all dental problems caused by injury while participating in an authorized practice or intercollegiate contest. All dental injuries are to be reported to the athletic trainer assigned to that particular sport during that practice or contest, or immediately thereafter. Routine dental care such as routine examinations, dental cavities, wisdom teeth extractions, etc., are the responsibility of each individual athlete.
K. EYE GLASSES AND CONTACT LENSES
All athletic eye glasses must be safety glasses with shatterproof lenses and frames. Contact lenses will be purchased for only those athletes who, in the opinion of the staff athletic trainer, are in definite need of visual correction in order to participate in intercollegiate athletics. Replacement of lost lenses and glasses will be furnished by the Athletic Department only if they are lost or damaged during practice or a game. The loss or breakage of lenses must be reported immediately.
L. INSURANCE
1. The Department of Athletics is responsible for medical services administered to student-athletes who are ill or become injured in a practice or game, which was under the coaches' supervision or while participating in voluntary physical activities that will prepare the student-athlete for competition during the academic year.
The word "injury" applies only to those ailments that are caused by the participation in a coach supervised practice or a game. The removal of tonsils or appendix by surgical procedure are examples of the medical problems for which the Department of Athletics cannot be
responsible. The participation in sports will not cause conditions such as these and, according to department policy, we cannot be responsible for their remediation. For the above reason, we highly recommend that student-athletes or their parents carry an adequate medical and hospitalization plan on their son/daughter while he/she is in school.
2. The Department of Athletics utilizes a self-insurance program with the Office of Risk Management; however, medical expenses are continually rising. We ask that each athlete review his/her personal medical insurance to help cover the hospitalization and medical fees incurred. The student-athletes' and parents' cooperation will allow the Department of Athletics to utilize your health insurance information. If one belongs to a group policy, such claims typically do not affect the premium. However, if the insurance happens to be an individual policy, discretion should be used.
3. If there is no insurance coverage, we highly recommend that you enroll in the voluntary health coverage plan that is offered by Indiana University called the Aetna-Chickering Health Insurance. This plan would provide coverage of potential non-athletic problems. You may enroll for the Aetna-Chickering Health Insurance plan at Poplar Building, Room 165 or obtain other similar coverage on your own. This policy should be obtained prior to matriculation. 4. After completing the enclosed insurance form, please make sure you attach a copy of your
insurance and prescription card(s) (front and back). M. ADD/ADHD POLICY
Indiana University Sports Medicine is committed to providing optimal and ethical care to
our student athletes. Concerns in the medical field have surfaced about over diagnosis and
misdiagnosis of Attention Deficit Hyper-activity Disorder (ADHD). Some of the concerns are
the lack of empirically validated criteria for diagnosis and the potential for acute and
permanently debilitating side effects of stimulant medication prescribed to treat the condition
(the FDA requires the most serious type of warning label for these drugs and they are monitored
by the DEA). Additionally, stimulant medications (i.e. Adderall, Ritalin, Vyvanse, Concerta and
others) might actually worsen conditions that masquerade as ADHD such as depression, anxiety,
behavioral problems and addiction.
Stimulant medications are BANNED SUBSTANCES by the NCAA and Big Ten for
athletic competition without “appropriate documentation.” The NCAA requires
documentation to include proof of Formalized Testing that confirms the diagnosis of
ADHD for student-athletes to be allowed stimulant medication. Furthermore, non-approved
use of stimulant medication can fall under both the illicit street drug AND performance
enhancing substance categories depending on the testing organization. The NCAA and Big Ten
test for stimulant medication in their respective Year Round Performance Enhancing Drug
Testing Programs. Generally, penalties for performance enhancing drugs are more severe than
penalties for illicit drugs. Stimulant medications are strictly prohibited in Olympic and most
International competitions.
Student-Athlete First-Time or New Evaluation:
1. Referred to a healthcare provider for an appropriate screening process.
2. Based on the screening, the athlete may be referred to a local physician for appropriate
medical management of ADD/ADHD.
3. Prescriptions for medication will be written by a local physician and the athlete will be
responsible for the cost of the medication. The athlete will NOT obtain their
prescriptions for stimulant medication from the IU Sports Medicine Department.
4. All documentation of testing and medication use should be provided to the Team
Physician to keep in the student-athlete’s medical record.
Incoming or Returning Student-Athlete with a diagnosis of ADHD already taking
prescribed stimulants:
1. Must submit documentation of appropriate testing to the Team Physician to keep in
the student-athlete’s medical record.
2. Will be referred to a local physician for stimulant medication prescriptions while the athlete is
on campus. Alternatively, the athlete may continue to get prescriptions from the original
prescribing physician at home. In either case, the athlete will be responsible for the cost of
the medication. The athlete will NOT obtain their prescriptions for stimulant medication
from the IU Sports Medicine Department.
N. HOSPITALIZATION AND SURGERY
If a student-athlete requires either hospitalization or surgery, the team physician or the team trainer will call the parents and advise them of the information concerning the case.
O. SHARED RESPONSIBILITY FOR INTERCOLLEGIATE SPORTS SAFETY
Participation in intercollegiate athletics involves unavoidable exposure to an inherent risk of injury. However, student-athletes rightfully assume that those who sponsor intercollegiate athletics have taken reasonable precautions to minimize the risks of injury from athletics participation. In an effort to do so, the NCAA collects injury date in intercollegiate sports. When appropriate, the NCAA Committee on Competitive Safeguards and Medical Aspects of Sports makes recommendations to modify safety guidelines, equipment standards, or a sport’s rules of play.
It is important to recognize that rule books, safety guidelines and equipment standards,
while helpful means of promoting safe athletics participation, are themselves insufficient to
accomplish this goal. To effectively minimize the risks of injury from athletics participation,
everyone involved in intercollegiate athletics must understand and respect the intent and
objectives of applicable rules, guidelines and standards.
The institution, through its athletics director, is responsible for establishing a safe
environment for its student-athletes to participate in its intercollegiate athletics program.
The team physician and athletic health care team should assume responsibility for
developing an appropriate injury prevention program and providing quality sports medicine care
to injured student-athletes.
Student-athletes should fully understand and comply with the rules and standard of play that
govern their sports and follow established procedures to minimize their risk of injury.
In summary, all persons participating in, or associated with, an institution’s intercollegiate
athletics program share responsibility for taking steps to reduce effectively the risk of injury
during intercollegiate athletic competition.
Revised 4/13
ATTENTION
BEFORE MAILING OR FAXING THIS TO US, PLEASE USE THE CHECKLIST
BELOW TO MAKE SURE YOU HAVE ALL THE INFORMATION NEEDED.
Medical History questionnaire is completed (front and back)
Immunization dates are completed
Insurance form is completed (front and back) and signed by parents and athlete
Clear readable copies of both front and back of all Insurance and Pharmacy cards
are enclosed.
(This information must be received BEFORE you come to campus)
If you have checked all these boxes then mail completed packet to the below address
Indiana University
Sports Medicine Department
Assembly Hall
1001 E. 17
thStreet
Bloomington, IN 47408-1590
IMMUNIZATIONS: (Specific measles, rubella, mumps & tetanus dates are required)
Required Recommended
MMR 1._________ 2._________ Hepatitis B 1._____2._____ 3._____
Meningitis Vaccine______________ TD__________ Tdap______________
Yearly influenza vaccine?____________
Indiana University Athletic Department
MEDICAL HISTORY QUESTIONNAIRE 2014-2015
Please answer every question below as best you can. This is the only way you can help us serve you better, know more about you and your medical background, as well as give you the best possible medical care and continuation of service. If the space provided to answer questions is not adequate, attach sheet with additional information. Note: PLEASE PRINT AND FILL IN ALL INFORMATION.
══════════════════════════════════════════════════════════════════════════════════════════ Name:_______________________________________________________________________________________ UID. #:____________________________ (Last or family) (First) (Middle/maiden)
Sex: F___M___ Date of Birth:______ /_____/______ Date of Entry to IU______________ I am a candidate for the ___________________________team
(month/year) (SPORT)
Home Address:_______________________________________________________________________Email:_____________________________________ (STREET/PO Box/Rural Route)
CITY: ______________________________________STATE:_______ ZIP CODE:______________ Home Phone #: (______)____________________ (area)
Bloomington Address, if known:________________________________________Local Phone #:_____________________Cell #______________________ IN CASE OF EMERGENCY, PERSON TO NOTIFY:
Name:_____________________________________________Relationship:______________________Phone:(_____)__________________ Home Address:__________________________________________________________________________________________________________
("same" if same as above) (City/State/Zip) HOME PHYSICIAN, HEALTH CLINIC OR FACILITY:
Name:__________________________________________________________________________Phone:(_____)_________________________________ Address:_____________________________________________________________________________________________________________________
(STREET) (CITY) (STATE) (ZIPCODE)
══════════════════════════════════════════════════════════════════════════════════════════ Please check in the appropriate column indicating past and present disease(s) you or members of your family have had.
Family Self Family Self Family Self
Alcoholism Drug Addiction/abuse Stroke
Severe Allergy Epilepsy/Seizures Suicide Attempt/Act
Asthma Fainting Spells Ulcer
Bleeding Disorder Heart Attack Serious Mental Illness
Blind-right eye Heart Disease Measles
Blind-left eye Heart Rhythm Problem German Measles-3 days
Deaf-left ear Hyperventilation Mumps
Deaf-right ear Blood Clot in Lung Chicken Pox
Depression-severe Sickle Cell Disease
Diabetes Speech Disability
Deaths in immediate family:_____________________________________________________________ List allergies (medicine, foods, insects, etc): _________________________________________ ___________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________
1. Yes No
Has a doctor ever denied or restricted your
participation in sports for any reason? 22. Yes No
Has a doctor ever told you that you have asthma or allergies?
2. Yes No
Do you have an ongoing medical condition (like
diabetes or asthma)? 23. Yes No
Do you cough, wheeze, or have difficulty breathing during or after exercise?
3. Yes No
Are you currently taking any prescription or nonprescription (over the counter) medicines or
pills? 24. Yes No
Have you ever used an inhaler or taken asthma medicine?
4. Yes No
Do you have allergies to medicines, pollens, foods,
or stinging insects? 25. Yes No
Is there anyone in your family who has asthma?____________
5. Yes No
Have you ever passed out or nearly passed out
DURING exercise? 26. Yes No
Have you had infectious mononucleosis (mono) within the last month?
6. Yes No
Have you ever passed out or nearly passed out
AFTER exercise? 27. Yes No
Do you have rashes, pressure sores, or other skin problems?
7. Yes No
Have you ever had discomfort, pain, or pressure in your chest during exercise?
28. Yes No
Have you had a herpes skin infection?
8. Yes No
Does your heart race or skip beats during exercise?
29. Yes No
Have you ever been diagnosed with a concussion? Number of previous concussions? ____ Date of most recent?________
9. Yes No
Has a doctor ever told you that you have (check all that apply) ___high blood pressure ___high cholesterol ___heart murmur
30. Yes No
Have you been hit in the head and been confused or lost your memory?
10. Yes No
Has a doctor ever ordered a test for your heart? (for
example, ECG, echo) 31. Yes No Have you ever had a seizure? 11. Yes No
Has anyone in your family died for no apparent
reason? 32. Yes No Do you have headaches with exercise? 12. Yes No Does anyone in your family have a heart problem? 33. Yes No
Have you ever had numbness, tingling, or weakness in your arms or legs after being hit .
13. Yes No
Has any family member or relative died of heart problems or of sudden death before age 50?
34. Yes No
Have you ever been unable to move your arms or legs after being hit?
14. Yes No Does anyone in your family have Marfan syndrome? 35. Yes No
When exercising in the heat, do you have severe muscle cramps or become ill?
15. Yes No
Have you ever spent the night in a hospital?
36. Yes No
Has a doctor told you that you or someone in your family has sickle cell trait or sickle cell disease? 16. Yes No Have you ever had surgery? 37. Yes No
Have you had any problems with your eyes or vision?
17. Yes No Have you ever had a stress fracture? 38. Yes No Do you wear glasses or contact lenses? 18. Yes No Do you regularly use a brace or assistive device? 39. Yes No
Do you wear protective eyewear, such as goggles or a face shield?
40. Yes No Are you happy with your weight?
19. Yes No
Have you ever had an injury, like a sprain, muscle or ligament tear, or tendinitis, that caused you to miss a practice or a game? If yes, circle affected area below:
41. Yes No
Has anyone recommended you change your weight or eating habits?
20. Yes No
Have you had a broken or fractured bone or dislocated joints? If yes, circle below:
21. Yes No
Have you had a bone or joint injury that required x-rays, MRI, CT, surgery, injections, rehabilitation, physical therapy, a brace, a cast, or crutches? If yes, circle below:
42. Yes No A.) Do you limit or carefully control what you eat? B.) Have you ever been diagnosed with an eating
disorder? Head Neck Shoulder Upper Arm Elbow
Forearm Hand/Finger Chest Upper Back Lower Back Hip Thigh Knee Calf/Shin Ankle Foot/Toes
43. Yes No Do you have any concerns that you would like to discuss with the doctor or sports dietician______?
Females Only 45. Yes No
Do you take nutritional
supplements?______________ If so, please list below.
48.
How old were you when you had your first menstural
period?_____ 46. Yes No
Have you ever been diagnosed with ADD/ADHD? 49.
How many periods have you had in the last 12
months?____ 47. Yes No
Do you take medication for ADD/ADHD? If so, what medication?________________________________ _______ 50. Yes No Area you currently using any form of birth control? Revised 4/13
Explain "Yes" Answers here:
I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct:
Athlete: ________________________________________________ Parent/Guardian:__________________________
Explain "Yes" answers below.
MEDICAL INSURANCE INFORMATION FORM 2014-2015
SPORT: UID:__________________________________ THIS FORM MUST BE COMPLETED ANNUALLY
(PLEASE COMPLETE BOTH SIDES OF FORM)
COORDINATED COVERAGE CANNOT BEGIN UNTIL THIS INFORMATION IS ON FILE PATIENT INFORMATION
(STUDENT-ATHLETE)
STUDENT ID# E-MAIL ADDRESS: DATE OF BIRTH
NAME:
LAST FIRST MIDDLE
Campus/Local Phone:
CAMPUS ADDRESS:
STREET CITY STATE ZIP CODE
CELL PHONE:
EMERGENCY CONTACT INFORMATION
NAME: RELATIONSHIP TO
STUDENT-ATHLETE: ADDRESS (Must be in USA)
STREET CITY STATE ZIP CODE COUNTY
DAYTIME PHONE:
EVENING PHONE: E-MAIL ADDRESS:
ALLERGIES IS THE STUDENT-ATHLETE ALLERGIC TO ANY DRUGS OR MEDICATIONS?
YES NO
IF YES, PLEASE SPECIFY: PRIMARY
INSURANCE
INSURANCE COMPANY NAME INSURANCECOMPANYPHONE:
POLICY NUMBER (please provide SS# of Policy holder if this is the ID)
GROUPNUMBER: PLANNUMBER: PRIMARYPHYSICIANSNAME:
INSURANCECOMPANYMAILINGADDRESS: PHYSICIAN’S PHONENUMBER:
POLICY HOLDER INFORMATION
POLICY HOLDER FULL (LEGAL) NAME RELATIONTOSTUDENT-ATHLETE:
POLICY HOLDER DATE OF BIRTH: / / POLICY HOLDER EMPLOYER:
DOES THIS POLICY REQUIRE PRE-AUTHORIZATION FOR OUT OF NETWORK CARE? YES NO
PLEASE EXPLAIN:
ARE THERE TREATMENTS, CONDITIONS OR ILLNESSES THAT ARE NOT COVERED BY THIS POLICY? YES NO
PLEASE EXPLAIN:
IS THERE A DEDUCTIBLE AMOUNT PER INDIVIDUAL/PER YEAR/PER FAMILY? YES NO
PLEASE EXPLAIN:
SECONDARY INSURANCE (IF APPLICABLE)
INSURANCE COMPANY NAME: PHONE NUMBER:
POLICY NUMBER: GROUP NUMBER: PLAN NUMBER:
INSURANCE MAILING ADDRESS:
POLICY HOLDER NAME: RELATION TO STUDENT-ATHLETE:
POLICY HOLDER DATE OF BIRTH: POLICYHOLDER’SEMPLOYER:
• We recommend that you keep a copy of this form for your records. If the information you have given us changes, please notify Kutina England, Office of Insurance, Loss Control, and Claims, 400 E. 7th Street, Room 705, Bloomington, Indiana, 47405 or at (812) 855-9758.
• Please copy your health insurance card (front & back) to the space below or attached to a separate sheet of paper.
• We are now asking medical providers (doctors, hospitals) to file their claims directly with your insurance company. We are requesting that they contact us if any problems with the insurance coverage is encountered and for payment of any non-covered charges or co-pay amounts as long as the injury/illness is sports related and/or approved by
appropriate personnel within the Athletic Department. We ask you to help us by sending any correspondence you
receive about these claims – whether from your insurance company or from a medical provider – to Kutina England at the address above.
• If your insurance carrier requires services to be performed in network or requires a referral from the primary care physician, please contact your carrier to see if special arrangements need to be made to insure that charges will be covered. Please make note of these arrangements at the bottom of the form or on a separate sheet of paper.
• If we file a claim with your insurance company (i.e., a medical provider such as the IU Health Center does not bill private insurance companies), we will send you a letter with an explanation of the bill.
• Please contact Kutina England at the above telephone number and address or by Email (kudavis@indiana.edu) if you have questions about payments of bills.
• Please contact the Athletic Department, Sports Medicine Office, at (812) 855-4509 if you have questions regarding this form or department medical procedures.
Please read the following statement and then sign the form before returning it to use.
We (or I) have read the reverse side of this document and agree to let Indiana University file insurance claims with my insurance company for costs arising from injuries, illnesses, or other related medical treatment covered by NCAA rules, and on behalf of the above named athlete. Indiana University will notify me when these claims are filed and I will provide IU with copies of any related correspondence, such as explanations of benefits, from the insurance company. In the event my checks are sent to me covering these expenses and provided I have no outstanding expenses on this particular bill, I agree to immediately endorse the check to Indiana University and forwarded it to the address on the reverse side. Indiana University is authorized to release related
medical information concerning these covered claims to my insurance company and shall provide us (as parents or guardians and owners of the insurance policy) with information about the illness or injury and treatment received. Please return this form for
information purposes regardless of insurance coverage.
Policy Holder’s Signature (If child is minor) Date Student-Athlete Signature Date
________________________________________________ Other Responsible Party (if any) Date
