Edgewood College Sports Medicine
1000 Edgewood College Drive
Madison, WI 53711-1997
(608) 663-3326 Fax: (608) 663-3405

 

 

Medical Clearance Packet
(Deadline: Submit by August 1st)

Attention: This document does not save unfinished information. Please look over the document prior to completing the form to make sure that you have all of the information that is required. 

 

ALL FORMS MUST BE COMPLETED AND ON FILE WITH EDGEWOOD COLLEGE SPORTS MEDICINE PRIOR TO PARTICIPATION IN THE INTERCOLLEGIATE ATHLETICS PROGRAM.

PLEASE READ AND COMPLETE ALL SECTIONS CAREFULLY.

 

Insurance Requirement

All Edgewood College student-athletes are required to have medical insurance that covers injuries sustained in intercollegiate athletics prior to participating in an athletic program at Edgewood College. This coverage may be through the individual student-athlete or their parent/guardian. A copy of both sides of the insurance card must accompany the confirmation page prior to the student-athlete beginning practice or competition at Edgewood College.

When researching insurance companies about health insurance you should make sure that the policy will cover injuries sustained while participating in intercollegiate athletics; as many do not. If your insurance does not cover intercollegiate athletic participation, Edgewood Colleges' secondary insurance policy will not cover incurred expenses. It is your responsibility to check your insurance coverage and make sure that it covers injuries incurred while participating in intercollegiate athletics. 

Secondary Insurance Coverage

Edgewood College provides secondary insurance coverage for its student-athletes. Please visit the Edgewood College Sports Medicine’s web site (http://www.edgewoodcollegeeagles.com/info/sportsmedicine/secondary_insurance.asp) for frequently asked questions regarding Edgewood’s secondary insurance coverage. Please contact Edgewood College Sports Medicine at 608-663-3326 ( bhoefer@edgewood.edu )with any further questions or concerns.

NCAA Catastrophic Insurance Policy

The NCAA Catastrophic Injury Insurance Program covers student-athletes who are catastrophically injured while participating in a covered intercollegiate athletic activity (subject to all policy terms and conditions). The policy has a $75,000 deductible. This coverage does not qualify as the basic coverage required for participation in athletics at Edgewood College. It is supplemental coverage in the event of a catastrophic injury. More information on the program can be found on the NCAA's web-site at www.ncaa.org


Claim Procedure

Athletic injuries do occur and we provide our student-athletes with the very best possible care. Medical bills may be incurred when the student-athlete is treated for injuries, whether it is locally, during a road trip, or by a medical vendor in his/her own home area.

Primary Insurance Coverage: The policy that the student-athlete is covered under to participate in intercollegiate athletics is the primary policy and all medicals bills will be submitted to that insurance provider before being submitted to the secondary insurance policy. 

Secondary Insurance Coverage: The secondary insurance policy at Edgewood College provides coverage for your son/daughter for athletic injuries while participating in the play or official team practice of intercollegiate sports, including authorized and sponsored team travel. This policy will cover remaining expenses from an injury that would normally be the policy holders responsibility (subject to all policy terms and conditions). 

Claim Procedure: All medical bills for your son/daughter incurred as a result of participation in the intercollegiate athletics program will be sent directly to your son/daughter or home address. In some cases, Edgewood College may get a copy of the bill, but in no case will Edgewood College be the primary place for the incurred bill to be sent.

A. SUBMIT THE BILLS INCURRED TO YOUR FAMILY, EMPLOYER GROUP COVERAGE OR PLANS FIRST. THEY WILL DO ONE OF TWO THINGS:
1. Honor the claim and pay all or a portion of the bills incurred.
2. Not honor the claim and send you a letter of denial.
B. IF THERE REMAINS A BALANCE AFTER YOUR FAMILY, EMPLOYER GROUP INSURANCE OR PLAN HAS CONTRIBUTED TOWARDS THE CLAIM; send the Explanation of Benefits (EOB) and a copy of the itemized bills incurred to Edgewood College Sports Medicine (fax- 608-663-3405). If you receive a letter of denial from your family, employer group insurance or plan administrator, send the letter of denial and a copy of the bills incurred to Edgewood College Sports Medicine.
C. If the bills incurred and not paid by the primary insurance carrier are large enough to meet the secondary insurance deductible ($250), the claim will be sent to Edgewood College’s secondary insurance carrier – Mutual of Omaha Insurance Company. If they need any additional information, please cooperate with them and they will process the claim in the least possible amount of time. It is in your best interest to have the claim settled promptly since all bills incurred are in your name.
D. Edgewood College’s insurance policy is a SECONDARY COVERAGE POLICY. IT GOES INTO EFFECT ONLY AFTER THE STUDENT-ATHLETE’S PRIMARY INSURANCE HAS BEEN UTILIZED.
E. EXPENSES MUST BE INCURRED WITHIN 52 WEEKS OF THE INITIAL INJURY DATE.

PLEASE NOTE: If the primary insurance coverage is through a HMO (Health Maintenance Organization) or PPO (Preferred Provider Organization) you must follow the proper procedures required by your individual plan in order for Edgewood’s insurance to satisfactorily complete its portion of the claim. This is especially important if your insurance requires pre-authorization to have your son/daughter treated out of your plan’s service area or by a specialist (i.e. orthopedic, cardiologist, etc).



Insurance Information

Many insurance companies require that subscribers follow specific instructions and procedures when scheduling medical appointments. These procedures must be followed for the insurance companies to pay incurred expenses. Edgewood College Sports Medicine needs to be familiar with the specific policies of your individual insurance company. Please complete the information below as completely as possible.

Please complete this form no matter what type of medical insurance you have (HMO, PPO, private, etc.).

Student-Athlete:           Today's Date:     

Parent/Guardian/Policy Holder:          

Relationship to Student-Athlete: 

Insurance Company:     

Company Address: 

City:       State:       Zip: 

Phone: 

Policy #:        Plan / Group #: 

Is this a Managed Care Insurance Organization?  YES   NO         If so, which? PPO    HMO

 Is a second opinion required before surgery?     YES     NO

Does primary insurance company require prior authorization from your Family Physician to visit a specialist (i.e. orthopedic, neurologist, cardiologist, physical therapist, etc.)?   YES      NO

I hereby authorize Edgewood College Sports Medicine, or its insurance agent, to inspect or secure copies of case histories, laboratory reports, diagnoses, x-rays, and any other data covering this and/or previous confinements and/or disabilities.  A copy of this authorization shall be deemed as effective and valid as the original.

  I authorize Edgewood College, or its insurance agent, to pay the medical vendors directly for any bills incurred from accidents that are covered under the coverage purchased by Edgewood College. 

I agree that all information provided in this document is accurate and complete to the best of my knowledge and that I will immediately update any changes as they occur.  I understand that any incorrect or undisclosed information can result in improper management of injuries and medical payments.

 

MEDICAL CONSENT/ AUTHORIZATION

Student-Athlete Name: 

I/We, while participating in the intercollegiate athletics program at Edgewood College, grant permission to Edgewood College Sports Medicine, Team Physician(s), Student Health Services and/or other medical professionals recommended by Edgewood College Sports Medicine to render first aid, treatment, rehabilitative and emergency services deemed reasonably necessary to the overall health and well-being of the above named student-athlete.
 

I/We, while participating in the intercollegiate athletics program at Edgewood College, grant permission to Edgewood College Sports Medicine, Team Physician(s), Student Health Services and/or other medical professionals recommended by Edgewood College Sports Medicine to shared any relevant information related to any past, present or future medical conditions that could place the above named student-athlete at risk during athletic participation while at Edgewood College. I/We authorize Edgewood College Sports Medicine to provide other medical facilities with medical and/or insurance information that would expedite my care should I need emergency or other medical services
 

ACKNOWLEDGEMENT OF RISK

I acknowledge the dangers and risks of playing, practicing and participating on any intercollegiate athletic team at Edgewood College include, but are not limited to the following: death, serious neck or spinal injuries (which may result in complete or partial paralysis), brain damage, serious injury to internal organs, bones, joints, ligaments, muscles, tendons, and other aspects of the skeletal system and serious injury or impairment to the body’s general health and well-being.
 

I acknowledge the risks and agree to the above statement.


Primary Physician Information


Primary / Family Physician: 

Physician's Address: 

City:       State:       Zip: 

Phone:       Fax: 

 

Emergency Room Procedures:          

Out of Network Procedures:          

ALL STUDENT-ATHLETES PARTICIPATING IN INTERCOLLEGIATE ATHLETICS MUST HAVE THIS FORM ON FILE WITH EDGEWOOD COLLEGE SPORTS MEDICINE PRIOR TO PARTICIPATION.

 Edgewood College Sports Medicine 1000 Edgewood College Drive Madison, WI 53711-1997 (608) 663-3326  Fax: (608) 663-3405


 PERSONAL INFORMATION

Student-Athlete's Name:       Sport(s):     

Year In College:       Birth Date:       Campus / Cell Phone: 

Permanent Address:       City: 

State:       Zip:         Phone:       Cell: 

 

Name of Father/ Guardian:                         Name of Mother/ Guardian: 

Address:                                Address:          Same as Father

City:       State:                                         City:        State: 

Zip:                                                                                         Zip: 

Phone:                                                            Phone:                                                 

Employer:                               Employer: 

Work Phone:                                                 Work Phone: 

Cell:                                                                  Cell: 

In case of emergency please call:      Name:     

                                                                 Relation:      Phone: 

If no answer call:   Name: 

                                 Relation:             Phone:     
 

MEDICAL HISTORY FORM

Instructions: When the reply is yes, please give date of injury or treatment. Please indicate as near as possible the site of injury, left or right. Please be sure to answer completely, thoroughly and accurately, and remember that any medical information withheld, incomplete, or incorrect relieves Edgewood College from all Medico-Legal liability and may disqualify you from participation on any Edgewood College athletic team.

General Medical

 YES   NO   1. Have you ever experienced an epileptic seizure or been informed that you may have epilepsy? Date:

 YES     NO    2. Have you had hepatitis during the past three years?  Date:

 YES     NO    3. Have you been treated for infections, mononucleosis, virus pneumonia, or any other infectious disease during the past 12 months?
                                    Date:

 YES     NO     4. Have you or anyone in your family ever been treated for diabetes? Who? Date:

 YES     NO     5. Have you ever been told that you have a heart murmur, heart disease or heart irregularities? Date:

 YES     NO     6. Has anyone in your family under the age of 30 been treated for, or is being treated for, a heart condition?

 YES     NO     7. Have you ever had chickenpox, measles, mumps or small pox? Date:     If so, which one(s)?

 YES     NO     8. Have you ever had kidney disease, bladder problems, or painful urination? Date:     If so, which one(s)?

 YES     NO     9. Are you susceptible to colds, or sore throats?

 YES     NO     10. Have you ever had an ulcer? Date:

 YES     NO     11. Have you ever had bronchitis?

 YES     NO     12. Have you ever had asthma? If yes, what medications are you presently taking?

                                            a. Do you cough, wheeze, or have trouble breathing during or after activity? If yes, please explain.

                                                                

 YES     NO     13. Have you ever had tonsillitis or a tonsillectomy? Date:

 YES     NO     14. Have you ever had tuberculosis? Date:

 YES     NO     15. Have you ever had appendicitis or appendectomy? Date:

 YES     NO     16. Have you ever had a hernia? Date:

 YES     NO      17. List any allergies that you may have.

                                             Bee Sting/ Insect Bite:

                                             Drugs:

                                             Food:

                                             Other:

 YES     NO     18. Have you had any illness requiring bed rest of one week or longer during the past year?

                                            If so, give date and nature of illness.

 YES     NO     19. Have you ever experienced heat exhaustion and/or heat stroke? Date:  

 YES     NO     20. Have you had any operation during the past two years? If yes, indicate site of operation and date.

                                            

 YES      NO     21. Have you ever been advised by a physician not to participate in sports? For what reason?

                                          

 YES     NO     22. Are you currently taking any prescription medication? If yes, please list.

                                          

 YES     NO     23. Do you currently take any nutritional or performance aids? (ex. Vitamin/mineral supplements, creatine, androsteindione, etc)

                               

 YES     NO     24. Have you had any organs removed? If yes, why and when?

                                           

                                      25. What is the date of your most recent immunizations?

                                                            Tetanus:

                                                            Hepatitis B:

                                                            Measles:

                                                            Chickenpox:

                   
Head / Neck

 YES     NO     26. Have you ever been "knocked out" or experienced memory loss after sustaining a concussion during the past three years?

                                           Date(s):

 YES     NO    27. If answer to question 26 is yes, have you been "knocked out" more than once?

 YES     NO    28. Have you ever had a "stinger" or "burner"? If yes, how often?    

 YES     NO    29. Have you had any fainting spells, frequent or severe headaches? If so, explain:

Eye / Dental

 YES    NO    30. Do you wear glasses or contacts? Which?

 YES    NO    31. Do you wear them during athletic competition?

 YES    NO    32. Do you have sight in both eyes?

 YES    NO    33. Do you wear any dental appliance? If answer is yes, check appropriate appliance.

                                        Permanent bridge

                                        Permanent crown

                                        Permanent Jacket

                                        Removable partial

                                        Full plate

                                        Retainer

                                        Braces   

Bone and Joint

 YES    NO    34. Have you ever had a neck or spinal injury?

 YES    NO    35. Have you ever fractured a vertebra?

                                    36. List any spinal conditions that you may have (scoliosis, herniated disc, kyphosis, etc.).
                                           

                                    37. List any surgery you have had on your neck or spine.
                                   

                                    38. Check the bone(s) that you have fractured.

                                        Hand / Fingers    Dates:                   

                                        Femur (thigh)    Dates:

                                        Ulna / Radius (forearm)    Dates:

                                        Patella (kneecap)   Dates:
                                         
                                        Humerus (upper arm)    Dates:

                                        Tibia (Lower Leg)    Dates:

                                        Clavicle (collar bone)    Dates:                                                                                          

                                        Fibula (Lower Leg    Dates:

                                        Scapula (Shoulder Blade)    Dates:                                                                                

                                        Ankle    Dates:

                                        Foot / Toes    Dates:

                                        Vertebrae    Dates:

                                        Pelvis    Dates:

                                        Ribs    Dates:

                                Comments:
                                       

 YES   NO    39. Have you ever dislocated your shoulder, acromioclavicular or sternoclavicular joint?
                                        If yes, which one and when?
                           
                                            Glenohumeral Joint    Dates:

                                            Acromioclavicular Joint    Dates:

                                            Sternoclavicular Joint    Dates:

 YES    NO    40. Have you ever dislocated any other body part? If so, which of the following and when?

                                            Toes    Dates:

                                            Ankle    Dates:

                                            Knee Cap    Dates:

                                            Knee    Dates:

                                            Hip    Dates:

                                            Elbow    Dates:

                                        Other / Comments:
                                               

 YES    NO    41. Have you ever had any significant sprains that caused you to be held out of activities or sports participation?
                                        If so, which body part and when?

                                             Ankle    Dates:

                                             Knee    Dates:   

                                             Hip    Dates:

                                             Shoulder    Dates:

                                             Elbow    Dates:

                                             Wrist    Dates:

 YES    NO    42. Have you ever had surgery?
                                        If so, please explain including the date of surgery.

                                   

Skin:

 YES     NO  43. Do you have any current skin problems? (i.e.. itching, rashes, acne, warts, fungus or blisters?)
                                        If yes, please explain:

Cardiac:

 YES     NO   44. Have you ever passed out during or after exercise?

 YES     NO   45. Have you ever been dizzy during or after exercise?

 YES     NO   46. Have you ever had chest pain during or after exercise?

 YES     NO   47. Do you get tired more quickly than your friends do during exercise?

 YES     NO   48. Have you ever had racing of your heart or skipped heartbeats?

 YES     NO   49. Have you had high blood pressure or high cholesterol?

 YES     NO   50. Have you had a severe viral infection (i.e. myocarditis or mononucleosis.) within the last month?

 YES     NO  51. Has a physician ever denied or restricted your participation in sports for any heart problems?

 YES     NO  52. Have you had a medical illness or injury since your last check up or sports physical?
                                        If so, please explain:

 YES     NO  53. Have you ever become ill from exercising in the heat?

 YES     NO  54. Do you use any special protection or corrective equipment or devices not usually used for your sport or position?
                                    (i.e. knee brace, foot orthotics, retainer for teeth, hearing aid)? If yes, please indicate:


Females Only:

1. When was your first menstrual period?

2. When was your most recent menstrual period?

3. How much time do you usually have from the start of one period to another?

4. How many periods have you had in the last year?

5. What was the longest time between periods last year?


**ADDITIONAL COMMENTS CONCERNING YOUR MEDICAL HISTORY


I hereby certify that the medical history, personal health insurance and any other information requested in this document is accurate. I understand that any incorrect information may disqualify me from participation at Edgewood College and also relieves Edgewood College Certified Athletic Trainers, Team Physicians, Student Health Services and / or other medical professionals recommended by Edgewood College Sports Medicine of all medico-legal liability. 

 

Name of individual completing form:         Relation to Student-Athlete:   
                   
Date of completion: