UMBC Sports Medicine 1000 Hilltop Circle, Baltimore MD 21250 2016 - 2017 Academic Year
Last updated 4/29/2016
Athlete: ______
Date of Birth: ______
Campus Address: ______
______
Current Medications: ______
Campus Id. #: ______
Sport: ______
Email: ______
Cell Phone #:______
RX Allergies/Asthma: ______
Last updated 4/29/2016
Last updated 4/29/2016
This authorization permits the UMBC Sports Medicine Staff (SMS), Physicians and Consultants to obtain and release medical records and information in course of medical treatment, and for the purpose of processing insurance claims. I authorize the UMBC SMS to file on my insurance for any illness or injuries related to intercollegiate sport participation. I authorize my insurance company to pay direct to the medical provider. I further authorize the release of my medical or patient accounting records to my insurance company and/or to UMBC SMS. The Release and Authorization is required condition for participation in the Athletic Program and shall remain valid until revoked in writing.
Last updated 4/29/2016
Athlete’s Signature: ______
Parent/Guardian Signature: ______
Date: ______
Date: ______
Last updated 4/29/2016
□ Call First EMERGENCY CONTACT INFORMATION □ Call First
Last updated 4/29/2016
Father: ______
Address: ______
______
Cell Phone: ______Home:______
Work Phone: ______
Mother: ______
Address: ______
Cell Phone: ______Home:______
Work Phone: ______
Last updated 4/29/2016
Other than Parent Please Indicate: □ Work or □ HomeEmergency Contact: ______Cell: ______Other : ______
INSURANCE INFORMATION
We require an attached front and back copy of insurance AND prescriptions cards with this form. Please provide following information.
Last updated 4/29/2016
Policy Holder: ______
Policy Holder Date of Birth: ______
Medical Insurance Carrier: ______
Policy #: ______
Group Name / #: ______
Employer: ______
Mother’s maiden name: ______
Insurance Authorization Phone #:______
Insurance Company Address: ______
______
City State Zip
Last updated 4/29/2016
Please Circle Type of Insurance:
Preferred Provider Org. (PPO) / Exclusive Provider Org. (EPO) Supplemental Plans (Please attach card and/or plan information):
Health Maintenance Organization (HMO)/ Point Of Service (POS) Dental Plan o Yes o No
Commercial (i.e. Mail handlers/Union Contracts, etc.) Prescription Plan: o Yes o No
Health Savings Account (HSA) - Deductible Amount = $______Rx Card # ______Does your insurance require you to see a primary physician for a referral for diagnostic tests or to see a specialist? o Yes o No
Primary Physician (PCP) is Phone______
(Required for HMO, POS, and HMO/PPO combination plans)
Away from Home/Guesting PCP is______Phone______
(Strongly recommended for out of state athletes in HMO and POS plans)
Is this athlete covered by a secondary insurance policy? o Yes o No If yes: Please refer to the back of this page
Last updated 4/29/2016
SECONDARY INSURANCE INFORMATION
Please provide the following information to assist us in processing insurance claims. We require that you attach copy of the front and back of the insurance and prescription cards to this form.
Last updated 4/29/2016
Policy Holder: ______
Policy Holder Date of Birth: ______
Insurance Carrier: ______
Policy #: ______
Group Name / #: ______
Employer: ______
Mother’s maiden name: ______
Insurance Authorization Phone #: ______
Insurance Company Address: ______
______
City State Zip
Last updated 4/29/2016
Please Circle Type of Insurance
Preferred Provider Org. (PPO) / Exclusive Provider Org. (EPO) Supplemental Plans (Please attach card and/or plan information):
Health Maintenance Organization (HMO)/ Point Of Service (POS) Dental Plan o Yes o No
Commercial (i.e. Mail handlers/Union Contracts, etc.) Prescription Plan: o Yes o No
Health Savings Account (HSA) - Deductible Amount = $______Rx Card # ______
Does your insurance require you to see a primary physician for a referral for diagnostic tests or to see a specialist? o Yes o No
Primary Physician (PCP) is Phone______
(Required for HMO, POS, and HMO/PPO combination plans)
Away from Home/Guesting PCP is______Phone______
(Strongly recommended for out of state athletes in HMO and POS plans)
PLEASE READ CAREFULLY!
¨ The UMBC Department of Intercollegiate Athletics’ accident policy provides insurance for student-athletes with injuries occurring only when participating in the play or practice of intercollegiate athletics. This accident policy is considered “EXCESS” or “SECONDARY” to any other collectible group insurance benefits. Therefore, any claims for benefits must first be filed with the group insurance company providing coverage. Only after all available benefits have been exhausted will the UMBC Department of Intercollegiate Athletics’ insurance carrier consider payment for any remaining balances.
¨ I hereby authorize the UMBC Department of Intercollegiate Athletics, hospitals, & physicians connected with or provided, to furnish information to insurance carriers concerning any illness, injury, & treatments & I hereby assign to the party all payments for medical services rendered to the student-athlete.
¨ I agree to supply any & all information requested by my primary insurance, the UMBC Department of Intercollegiate Athletics & their excess insurance company in a timely manner.
¨ I hereby authorize the UMBC Department of Intercollegiate Athletics and their excess insurance company to secure & inspect copies of case history records, lab reports, diagnoses, x-rays, & any other data pertaining to the injury/illness I am receiving care for or previous confinements of disabilities relevant to the care of the injury/illness.
¨ I hereby authorize the UMBC Sports Medicine Department and/or my coach to hospitalize & secure treatment for me for any athletic injury/illness.
¨ A photocopy of this authorization shall be deemed as effective & valid as the original.
¨ I agree to notify the UMBC Sports Medicine Department immediately upon any change in the above health insurance information. If I fail to do so, I fully understand that I may be responsible for any & all charges incurred.
¨ I hereby certify that I have read & understand the above statements, that any & all questions have been answered to my satisfaction, & that the answers provided are true, complete, & correct to the best of my knowledge.
Policy Holder Signature: Date:
Student-Athlete Signature: Date:
Last updated 4/29/2016