2021 Returner Pre-Participation Packet

The packet you are receiving includes important information regarding Harding University's Athletic Insurance Policy. This packet must be read in its entirety and signed. Included in this packet is an explanation of Harding University Sports Medicine's privacy information. This is an explanation of FERPA and how Harding University Sports Medicine will protect the student athletes' private medical information. This packet also explains the importance of being able to communicate with other healthcare providers who could potentially work with our student athletes. If you are a student athlete who came to Harding prior to the 2017 school year, then the $2500 deductible maximum payout from Harding does not apply.

In the remainder of this packet, there will be information which will need to be input into the electronic medical record (EMR), so the Harding University Sports Medicine Staff can better serve each individual student-athlete. There are several areas which are REQUIRED to fill out and/or sign. It is very important each question is answered and all information is filled out.

Thank you for taking the time to fill out this packet in its entirety and doing so to the best of your knowledge.

The Harding University Athletic Department wish to welcome your son/daughter as a participant on one of our athletic teams. Every sport carries with it some degree of risk to the participant. Our medical staff provides specialized services, care, and supervision to safeguard their health and wellbeing.

Medical Expense Payment Policies

A. All student-athletes are required to provide proof of existing medical insurance in conjunction with having their initial or annual physical examination. This policy should provide benefits for athletic related injury. A front and back copy of the participants' primary insurance card must be on file with the Harding University Sports Medicine Department before the student-athlete will be allowed to participate in any practice or competition.

B. The Harding University Department of Athletics will ONLY be financially responsible for injuries occurring while a student-athlete is representing the University in formal intercollegiate activity. Injuries occurring outside official practices, formal workouts, or scheduled games are not covered by the Harding University Athletic Department. Such incidents are the financial responsibility of the student-athlete and/or the respective parent(s) and/or guardian(s). Treatments and diagnosis of illnesses such as colds, flu, etc. will not be covered by the Harding University Athletic Department.

C. The Harding University Department of Athletics requires bills or claims be submitted first to the primary health insurance company of the student-athlete and/or his/her parent(s) and/or guardian(s). The Harding University Department of Athletics retains a secondary excess policy. This secondary policy will pay ONLY AFTER primary insurance has been engaged and only for athletic-related injuries.

D. As of fall 2018, if the student-athlete has Medicaid (government issued health insurance) or Tri-Care {military issued insurance), the student-athlete will be required to sign a waiver releasing the right to Harding University secondary excess insurance. The waiver will be given to the student-athlete once the Sports Medicine staff has reviewed their pre-participation packet.

E. If the primary medical insurance is HMO or PPO and the student-athlete will be out of coverage plan. It is recommended the student-athlete or parent request a "rider" for out of area coverage or purchase an in-network insurance plan with the school. If the primary insurance requires a referral from a PCP (Primary Care Physician) to see a specialist, it is the responsibility of the student-athlete and/or parent{s) and/or guardian{s) to request the referral and have it submitted to the specialist.

F. Student-athletes and/or parent{s) and/or guardian{s) should review the details of their insurance plan to make sure it provides adequate coverage for injuries and illnesses, understand their insurance company's filing procedures and what must be done if injuries or illnesses occur while away from home. Student-athletes should carry their insurance ID card {and prescription card if one exists) on their person.

G. It is the responsibility of the student-athlete and or parents or guardians to inform the Sports Medicine Staff of any peculiarities and changes in his/her medical insurance coverage {i.e. HMO, PPO). If services are rendered while there is a lapse in coverage, the student-athlete and/or parent{s) and/or guardian(s) may be responsible for all charges incurred during this lapse. Please let the Sports Medicine Staff know of any questions that may arise concerning the medical coverage of an athlete.

H. All requests made by insurance carriers for applicable information will be handled in the most expedient and timely manner possible. Student-athletes and parent(s) and/or guardian{s) have the responsibility to immediately notify the Athletic Insurance Coordinator with all requests, letters, claims, or billing related to insurance for care and treatment received by the student-athlete from healthcare providers and insurance companies. This policy will ensure timely handling of all matters.

I. Arrangements for follow-up care with a physician for injuries incurred during athletic activity must be completed within a 14-day period after completion of the competitive season, eligibility or termination from the team. After said period, Harding University Department of Athletics is no longer financially responsible for any expenses incurred as a result of said injury unless other arrangements have been made with the Sports Medicine Staff.

J. Athletic related injuries are covered by Harding University for a period of two years from the date of injury, within the limits of our insurance policy. Failure to document an athletic related injury and be evaluated by Harding University Sports Medicine Staff will forfeit this coverage and leave the student-athlete and/or parent(s) and/or guardian(s) personally responsible for medical costs.

K. Please fill out this packet in its ENTIRETY. The student-athlete will not be allowed to participate until this requirement is met.

Medical Referral Policies

A. Except in emergencies, a staff athletic trainer MUST screen all conditions prior to referral to a team physician or other healthcare provider. This policy assures proper and immediate care, close follow-up and smooth injury management for the student-athlete and the Harding University Department of Athletics Sports Medicine Staff.

B. The Sports Medicine Staff will make all referral appointments. Transportation to medical facilities/offices located off-campus will be provided by the Sports Medicine Staff ONLY if the student-athlete is unable to arrange personal transportation.

C. Medical care and treatment of all student-athletes will be done through team physicians, consultants, and healthcare providers associated with Harding University Sports Medicine team as approved by the Sports Medicine Staff.

D. If a student-athlete desires a second opinion, the student-athlete is required to request such through their respective Staff Athletic Trainer for approval before the physicians visit or procedure is allowed. Expenses related to care or treatment without following this policy will not be the responsibility of the Harding University Athletic Department. The student-athlete and/or parent(s) and/or guardian(s) must provide for a release of information from the healthcare provider to the Harding University Sports Medicine Staff.

I have read and understand the above mentioned policies of Harding University Athletic Department.

Student-Athlete Signature*

Date*

Date

Parent/Guardian Signature*

Date*

Date

HARDING UNIVERSITY SPORTS MEDICINE PRIVACY INFORMATION

It is the intent of the Harding University Sports Medicine Department to provide appropriate and necessary medical care for each student-athlete as part of our intercollegiate Athletics Program. Communication needs to be open between the sports medicine staff and healthcare providers allowing for continuity in the care provided to our student-athletes.

The Family Educational Rights and Privacy Act (FERPA) is a federal law that protects the privacy of student education records. This law applies to Harding University, including personnel dealing with certain information concerning student-athletes. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal law protecting the privacy of a patient's health information created, received or maintained by a healthcare provider. HIPAA may apply to healthcare providers (including physicians) who independently contract with Harding University Athletic Department. Each healthcare provider may have separate privacy procedures.

Under FERPA, you have the right to decline a request for the release of your student education records (including covered medical information), except to the extent that release of your information is required or authorized by law without your consent. Pursuant to your authorization, we may use or disclose your medical information for proper treatment of injury/illness by sports medicine staff and healthcare providers (including physicians), for payment of healthcare services (i.e. billing information) and/or for professional development (i.e. comparison studies about injury/illness Furthermore, with your authorization, we may release and discuss your medical information with parents, academic staff, instructors, coaches, sports information, media, talent scouts, representatives of professional and/or amateur sports organizations, your primary insurance company, the university's excess insurance company, business office personnel and/or university accounts payable department.

Your rights apply to all medical information acquired while you are enrolled at Harding University. You may request, in writing, that we do not disclose/release any medical information for certain cases or circumstances. However, FERPA allows the discloser of medical records, without consent, to university officials with legitimate educational interest, to other universities to which a student-athlete is transferring and/or to appropriate officials in cases of health and safety emergencies, among other circumstances. You have the right to request access to or a copy of your medical file.

The sports medicine staff may require from your healthcare provider certain medical information in order for our staff to continue with the appropriate care necessary for any specific incidents for which you have obtained medical treatment or advice. To enable our staff to obtain the appropriate medical information about you, we will provide you and "Authorization to Release Medical Information" to sign permitting your physician(s) release your pertinent medical information to our sports medicine staff in compliance with the HIPAA regulations. The Authorization is good for the duration of your association with the Athletics Department at Harding University or until the revocation of this authorization in writing.

AUTHORIZATION FOR HARDING UNIVERSITY SPORTS MEDICINE TO RELEASE MEDICAL INFORMATION FROM STUDENT RECORDS (FERPA AUTHORIZATION)

Student-Athlete Full Name*

Date of Birth*

Date

As a participant of Harding University Intercollegiate Athletics programs, I, the undersigned student- athlete, do hereby authorize and give permission for:

The Athletic Department's sports medicine staff and the Athletic Department's designated health care professionals, health care facilities, and other health care providers and administrators charged with my medical care (collectively "Authorized Persons") to share my "education records" as defined in the Family Educational Rights and Privacy Act, including, but not limited to, an medical records and information, with each other for diagnosis and treatment purposesas well as with other professionals for education purposes (i.e. Comparison studies about injury/illness

The Authorized Persons as well as the Athletic Department administrative staff to release and discuss with my parents and/or legal guardians any educations records and/or medical information due to an emergency, illness, or injury.

The Authorized Persons as well as the Athletic Department's academic staff members to release and discuss with my instructors' medical information that may affect my ability to attend and participate in any aspect of class, including homework and tests.

The Authorized Persons to release and discuss any of my medical information that may affect my participation in my sport with any members of the coaching staff.

The Authorized Persons as well as the Athletic Department's communication staff to release and discuss medical information related to an injury/illness that may affect my participation in my sport with the media.

The Authorized Persons to share medical information with the NCAA or Great American Conference for the purpose of petitioning for a medical redshirt, hardship, or exemption or for reporting/compliance purpose. The Authorized Persons to release and to discuss my medical records with talent scouts or representatives of professional and/or amateur sports organizations.

This consent applies to all medical records (including prescription information) maintained by the Harding University Athletic Department, including but not limited to, health histories, physician's notes, diagnostic testing results, and/or laboratory test results. Furthermore, I authorize the following regarding payment for services for any medically-related service that may affect my athletic participation:

The Authorized Persons charged with my care, including their business offices and medical records departments, to utilize, release and discuss any record necessary for the payment of services with respect to any claim filed on my behalf.

The Authorized Person as well as the Athletic Department staff to release and discuss with my primary insurance carrier as well as the University's excess insurance carrier any medical information needed to process such a claim.

The Authorized Persons as well as the Athletic Department's business office and the University's accounts payable department, to utilize, release, and discuss such medical information needed to process the payment of services which the Athletic Department has authorized.

I understand that once information is disclosed per my authorization the information is subject to re- disclosure and may no longer be protected.I understand that I can revoke this authorization with respect to any of the aforementioned persons at any time, in writing, including limiting the authorization of medial information at my discretion. I understand that the permission I am granting in this consent form cannot be revoked for records already released in reliance upon this authorization. Also, I understand the Sports Medicine Staff will provide a copy of this authorization to me and the Authorized Persons upon

This consent form shall be valid for the duration of my association with the Athletic Department at Harding University or until I revoke this authorization in writing.

Student-Athlete Signature*

Date*

Date

Parent/Guardian Signature*

Date*

Date

First Name*

Last Name*

Sport*

Sex*

SS#*

H#

Cell Phone Number*

PERMANENT ADDRESS

CITY*

STATE*

ZIP CODE*

HARDING EMAIL*

example@harding.edu

NAME*

Relationship*

CELL PHONE*

PARENT/GUARDIAN*

Relationship*

ADDRESS*

CITY*

STATE*

ZIP CODE*

CELL PHONE*

EMAIL*

example@example.com

PARENT/GUARDIAN

Relationship

ADDRESS

CITY

STATE

ZIP CODE

CELL PHONE

EMAIL

example@example.com

INSURANCE COMPANY NAME*

INSURANCE CO CLAIMS ADDRESS*

CITY*

STATE*

ZIP*

PHONE*

POLICY/ID#*

GROUP#*

Insurance Type*

HMOPPOTricare/ChampusOther

EFFECTIVE DATE*

Date

Deductible Amount*

POLICY EXEMPTIONS or REQUIREMENTS

PRECERTIFICATION REQUIRED?*

YesNo

IF YES, PLEASE EXPLAIN

PRECERTIFICATION PHONE #

NAME*

RELATIONSHIP TO ATHLETE*

SS#*

BIRTHDATE (MM/DD/YYYY)*

Date

ADDRESS*

CITY*

STATE/ZIP*

PRIMARY EMAIL ADDRESS*

example@example.com

CELL PHONE*

EMPLOYED BY*

Employer Address*

ADDRESS

Street Address Line 2

CITY/STATE/ZIP

Dental Coverage

YesNo

Vision Coverage

YesNo

RX Coverage

YesNo

Upload Front Image of Insurance Card*

Upload Back Image of Insurance Card*

Athlete Signature*

Date*

Date

Parent Signature*

Date*

Date

Statement of Student Athlete Responsibility

What is a Concussion?

A concussion is a brain injury caused by a blow to the head, face or elsewhere on the body with a force transmitted to the head. Concussions can result from hitting a hard surface such as the ground or floor, from players colliding with each other or from being hit by a ball, bat or other sporting equipment.

Facts about a concussion:

1. A concussion is a serious brain injury

2. Concussions can occur without loss of consciousness or other obvious signs

3. Concussions can occur from blows to the body as well as to the head 4. Concussions can occur in any sport

5. Athletes can still get a concussion even if they are wearing a helmet

6. Recognition and proper response to concussions when they first occur can help prevent further injury or even death

Signs and Symptoms of CONCUSSIONS include:

1. Headache or "pressure" in the head

2. Nausea or vomiting 3. Balance problems or dizziness

5. Sensitivity to light and/or noise

6. Feeling sluggish, hazy, foggy, or groggy

7. Concentration or memory problems

8. Confusion

9. Sensation that one does not "feel right"

Why knowing you have a CONCUSSION is important

Most concussions resolve but some concussions can lead to chronic symptoms such as a headache, decreased memory, sleeping problems or personality change. Rest, avoiding another blow to the head and following the advice of your medical staff are critical in helping you recover as fast and as safely as possible. Sustaining another concussion prior to recovery from the first increases your chance of long- term symptoms. There have been reports of death with a second concussion in younger athletes. It is very important for you to report any concussion symptoms as described above to your athletic trainer or team physicians at the time of injury. This includes alerting the medical staff to symptoms in your teammates if you notice these.

Statement of Student Athlete Responsibility

I accept responsibility for reporting all injuries and illnesses to the Harding University Sports Medicine Staff (athletic trainers and team physicians) including any signs and symptoms of CONCUSSION. I have read and understand the above information on concussions. I will inform the supervising athletic trainer or team physician immediately if I experience any of these symptoms or witness a teammate with these symptoms.

Signature of Student Athlete*

Date*

Date

Harding University Athletic Department

I hereby consent to the Harding University Sports Medicine staff, or anyone they may designate, to render care, including evaluation, diagnostic procedures, treatment and rehabilitation for any illness or injury I may incur while participating as an intercollegiate athlete for Harding University. I acknowledge no guarantees have been made that the evaluation, treatment and rehabilitation of an injury or illness will cure or fully return me to participation.

I consent to necessary medical treatment and admission to any medical facility designated by the Harding University Sports Medicine staff. I understand I have the right to make decisions concerning my health care including the right to refuse medical and surgical procedures. I also understand the final decision on whether I may continue to participate rest solely with the HU Sports Medicine Staff and Medical Team.

Signature of Student-Athlete*

Date*

Date

Signature of Parent*

Date*

Date

I am aware involvement in intercollegiate athletics constitutes an assumption of risk because of the nature of the activity.

In consideration of myself being permitted to participate in the varsity athletics program at Harding university, I hereby waive and release Harding University, the Athletics Department, and/or the faculty or staff involved in this program from liability for any personal injuries incurred as a result of my participation in this sport.

It is my intent to release and not hold responsible Harding University, Athletic Department, and its faculty and staff for injuries received both while traveling to and from the site of contest using private vehicles or any other mode of transportation, and while participating in activities associated with the sport. In addition, I agree that I have made a full and complete disclosure to the Harding University Sports Medicine staff of all present or prior physical or mental defects, illnesses, injuries or conditions known to me which might prevent, hinder, or impair the performance of my services to my team and/or institution. The information I have provided on all forms is, to the best of my knowledge and believe, true, correct and complete.

Student Athlete Signature*

Date

Parent Signature*

Date

Over the last 2 weeks, how often have you been bothered by any of the following problems?*

	Not at all (1 point)	Several Days (2 points)	More than half the days (3 points)	Nearly Everyday (4 points)
1. Little interest or pleasure in doing things
2. Feeling down, depressed, or hopeless
3. Trouble falling or staying asleep, or sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself-or that you are a failure or have let yourself or your family down
7. Trouble concentrating on things, such as reading the newspaper or watching television
8. Moving or speaking so slowly that other people could have noticed. Or the opposite -being so figety or restless that you have been moving around a lot more than usual
9. Thoughts that you would be better off dead, or of hurting yourself

If you checked off any problems, how difficult have these problems made ii for you to do your work, take care of things at home, or get along with other people?

Not difficult at allSomewhat difficultVery difficultExtremely difficult

HARDING UNIVERSITY

EMERGENCY CONTACT

ATHLETE INSURANCE INFORMATION

PRIMARY MEDICAL INSURANCE

INFORMATION ON POLICY HOLDER (THE ONE WHO PAYS THE PREMIUM):

PLEASE ATTACH LEGIBLE FRONT AND BACK COPY OF INSURANCE CARD(S)

HARDING UNIVERSITY SPORTS MEDICINE

PATIENT HEALTH QUESTIONNAIRE (PHQ-9)