Langston University Returning Athlete Screening Form Name: Address: Social Security #: : Phone: Sport: DOB: M / D / Y 1. Have you had any injury since your last athletic screening here? Yes: No: If yes, please explain: 2. Have you had any symptoms or conditions that you would like to discuss with the physician before you participate in athletics? Yes: No: If yes, please explain: 3. Have you consulted an outside physician or dentist since your last athletic screening here? Yes: No: If yes, please explain: 4. Do you have any problems that only bother you when you are participating in athletics? Yes: No: If yes, please explain: 5. Do you know of any reason you should NOT participate in any sport? Yes: No: If yes, please explain: I certify the above information is accurate and correct and a true reflection of my present physical condition and I feel that I do not need to go through the complete screening. Signature of Athlete: STOP Do Not Write Below This Line STOP Review of recent Injury/Illness: Weight: Blood Pressure: Pulse: Reviewed by: : Recommendations: Ok for unrestricted activity? Yes: No: Signature of LU Physician:
Langston University Athletics Medical Services Program -Signature Required- Please read the following information carefully, discuss these procedures with your studentathlete, sign your name at the bottom indicating that you have read these procedures, and return this form to: Langston University Athletics, Attn: Head Athletic Trainer, Langston University, P.O. Box 175 Langston, OK 73050 or Fax to 405-466-3627. The Medical Services Program is a self-contained program that uses a network of providers and specialists. In the event of an athletically related injury, our sports medicine staff evaluates and recommends a treatment plan. When services are pre-authorized, our program covers any expense with the LU network that the family s insurance does not cover (i.e., co-payments, and deductibles). Our program is secondary or excess support to the family s insurance, which means that the family s insurance is primary and will be billed in every circumstance. Outside services will be authorized at the discretion of the Director of Athletic Training, but are covered only if they are unavailable within the LU Network. Langston University Athletic Training staff makes every effort to create the safest environment possible for athletic participation, unfortunately, injuries do occur. As a result, Langston has purchased a secondary insurance policy for all student-athletes. Please note that our insurance policy only covers injuries sustained during supervised participation in intercollegiate athletics. It is mandatory that every athlete have primary insurance. Langston defines a primary insurance as insurance with no more than a $1000 deductible. (Sooner Care, Medicaid, All Military insurance including but not limited to, Champus/Tricare/Humana etc., and AFLAC are not considered primary insurance). Langston Athletics will cover only those injuries, which are a direct result of or will affect intercollegiate athletic practice or play. This means that non-athletically related injuries (car accidents, serious illness such as appendicitis or cardiac related illnesses) WILL NOT BE COVERED. Such injuries must be covered by other insurance. Also, Langston Athletics will not be responsible for the medical cost of previous injuries, regardless if they were or were not cared for properly, that were incurred before your child was enrolled at Langston University. Prescription medications are also not covered by Langston Athletics. If your child is injured and prescription medications are required, all incurred cost will be the sole responsibility of the student-athlete. If your child is injured while participating in intercollegiate athletic practice or play, the following procedures must be followed to ensure quick processing of the claim and prompt payment of all bills:
1) The student-athlete must report any and all injuries to the Langston Athletic Training Staff immediately. Medical expenses will only be covered if a member of Athletic Training Staff refers the athlete. Non-referred visits or expenses will not be covered by this policy and as such, will be considered the athlete s responsibility. 2) If you are a member of an HMO or PPO, you must provide us with authorized medical vendors from your list. If you choose not to use the plan s authorized medical vendors, be aware that our coverage will not pay the bills that otherwise would have been honored had you used the proper medical vendors. 3) During the course of the school year, should an athlete s insurance coverage change, the Athletic Training Department must be notified immediately. Failure to do so will terminate Langston s financial responsibility for any medical expenses incurred. 4) The student-athlete must provide the medical facility or specialist with all appropriate insurance information, which will be available in our office. 5) The LU Athletic Insurance will not process a claim until all primary insurance claim procedures have been completed. Failure to do this will result in your responsibility of unpaid bills. 6) All subsequent bills/explanation of Benefits (EOB) must be submitted to the Athletic Training Staff within 10 days from the time you receive them. If you fail to submit them during this time period, you will be responsible for the remaining balances. The Athletic Department does not receive copies of the bills. 7) Certifies that the answers given in the medical history questionnaire are correct and true. Any information intentionally withheld by the student-athlete or provided by the student-athlete and later found to be false will be grounds for dismissal from the athletic team and may result in any Langston insurance coverage for the student-athlete being voided. 8) If information is incomplete or inaccurate, the parents/identified policyholder or guardians will be responsible for bills incurred as a result of injury. I hereby certify that I have read and understand the above information and policies. Signature of Parent or Guardian (REQUIRED, regardless of age of student-athlete) Printed Name of Parent or Guardian Signature of Student-Athlete (REQUIRED) Printed Name of Student-Athlete Sport *We recommend that you make a photocopy of this signed document for your records.
Langston University Department of Athletics Athletes Primary Insurance Information Name of Student: Sport: SSN: : of Birth: M / D/ Y M / D / Y Father: Mother: Name: Name: SSN: SSN: Employed: Yes No Employed: Yes No Employer: Employer: Parent s Address: Parents Address: Street Street City State Zip City State Zip Home phone #: Home phone #: Work phone #: Work phone #: Cell phone #: Cell phone #: DO YOU HAVE GROUP ACCIDENT OR HOSPITAL INSURANCE TO COVER YOUR SON/DAUGHTER? Yes No PLEASE FILL IN THE FOLLOWING BLANKS IF YOUR SON/DAUGHTER IS COVERED UNDER A GROUP INSURANCE, IT IS VERY IMPORTANT THAT YOU COMPLETE ALL THE INFORMATION BELOW. *** Please include a copy of both sides of the insurance card. *** Insurance Company Name: Insurance Company claims address: Insurance Company phone #: Policy Holders Name: of Birth: Identification Number: Group #: Deductible: Effective of Policy: Do you have any pre-existing conditions that are excluded from this policy? If yes, Explain: Is this Military Insurance? Yes No Please check the correct response: Is this an HMO or PPO Does it require you to use a network provider? Yes No If yes, please provide following information. Primary Care Physician Name: Primary Care Physician phone #: I/WE AGREE THAT ALL INFORMATION PROVIDED IN THIS DOCUMENT IS ACCURATE AND COMPLETE TO THE BEST OF MY/OUR KNOWLEDGE. I/WE UNDERSTAND THAT ANY INCORRECT OR UNDISCLOSED INFORMATION MIGHT RESULT IN DUPLICATED PAYMENTS CREATING A SUBSTANTIAL OVERPAYMENT. THE RESPONSIBILITY OF SUCH OVERPAYMENT WILL BE THE OBLIGATION OF THE UNDERSIGNED TO REIMBURSE IN FULL, UPON REQUEST, AMOUNTS DEEMED REFUNDABLE. Signature of Mother/Guardian: : Signature of Father/Guardian: :
COPY OF INSURANCE CARDS FRONT BACK Please copy the Front and Back of your insurance card and affix it above
LANGSTON UNIVERSITY MEDICAL CONSENT I,, consent to medical treatment for athletic related injuries/ illness by the Langston University Sports Medicine Staff or Team Physician(s). I authorize treatment by such personnel in the event of any athletic related injury/illness. Signature of Student-Athlete Print Name of Student-Athlete Sport As a parent or legal guardian of, who is under the age of 18, I hereby authorize medical treatment of him/her in the event of an athletic related injury/illness by the Langston University Sports Medicine Staffer Team Physician(s). MEDICAL CARE STATEMENT: The undersigned, A. Understands that by participating in athletics, the potential of catastrophic injury to him/her exists. Following the rules and procedures set forth by coaches and using proper techniques may prevent catastrophic injury, but cannot be guaranteed to do so. B. Understands that any medical expenses incurred due to pre-existing conditions and not directly attributable to athletic participation at Langston University is their personal responsibility. C. Understands that the athlete must have primary insurance coverage and proof of insurance before he/she can participate in practice or intercollegiate play. Any falsification of insurance information will be grounds for dismissal from the team. Langston s athletic medical insurance is a secondary coverage, which will aid in the coverage of any remaining balance on an athletic related injury only. D. Understands that it is his/her responsibility to report all injuries/illnesses to an Athletic Trainer or Team Physician as soon as possible. E. Understands that he or she must refrain from practice while ill or injured, as per Athletic Trainer or Physician until he or she is discharged from treatment or is given permission to return to participation by the attending Athletic Trainer or Physician. F. Understands that having passed a physical examination does not necessarily mean that he or she is physically qualified to engage in athletics, but only the evaluator did not find a medical reason to disqualify him or her at the time of the examination. G. Certifies that the answers given in the medical history questionnaire are correct and true. Any information intentionally withheld by the student-athlete or provided by the student-athlete and later found to be false will be grounds for dismissal from the athletic team and may result in any Langston insurance coverage for the student-athlete being voided. Signature of Student-Athlete
Langston University Athletics DENTAL WAIVER AND RELEASE I,, have been provided the opportunity to wear a mouth-guard, custom fit or generic, for my use during all Langston University practices and games. I hereby acknowledge that not wearing a mouth-guard while participating as a player for Langston University can potentially cause dental, mouth, jaw and other related injury. I hereby accept full responsibility and all financial liability for any direct or indirect injury, medical and/or dental, any related loss of teeth or mouth function or any condition and/or complication related to not wearing a mouth-guard while participating and competing for Langston University. I hereby forever discharge and release the NAIA, Central States Football league, Red River Athletic Conference, all affiliated and associated teams, Langston University, administrators, agents, officers, directors, employees, contractors, representatives, coaches, team physicians, team dentist(s), athletic trainers and associated or affiliated medical staff. This waiver will automatically expire six years from the date signed. Printed Name of Student Athlete Sport Student Athlete Signature Parent/Guardian Signature if under age of 18
HIPAA RELEASE FOR MEDICAL RECORDS As required by the Health Insurance Portability and Accountability Act (HIPAA) of 1996, all of your medical, insurance, and health information is protected. It cannot be shared without your permission. Situations may arise during your time at Langston University that requires the medical staff to have access to your medical history, insurance information, or physicians notes. Because this information is protected you must release the information to a representative of the University. This form will serve as a release of that information. It will only be released to the person named and will not be shared with other athletic department personnel unless further permission is given. I hereby authorize any insurance company, healthcare provider or other party involved in my medical care to release my medical information to Langston University Athletic Training Department. I understand that this information will be used only to facilitate my care at Langston University and will not be released to any others without further authorization. Furthermore, I authorize Ross McCulloh or Sports Medicine Staff to speak with healthcare providers and insurance agents on my behalf. I understand that I may revoke this authorization at any time by submitting a written request to the office of the Athletic Trainer at Langston University. This authorization will expire 180 days after I am no longer a member of the institution or the athletic program unless there is prior revocation. Signature of student-athlete Signature of Parent/Guardian if under age of 18 The following release is necessary in order to allow the Athletic Training Staff to speak with coaches and administrators in the Athletic Department about your medical information. If you become injured during your time at Langston University, the Athletic Training Staff will need to discuss your participation status with these individuals. I hereby authorize members of the Athletic Training Staff to discuss my medical and health information with other members of the Athletic Department as it pertains to my athletic participation. I release this information to be discussed in order to help determine my level of participation in the athletic program at Langston University. I understand that this release allows the Athletic Training Staff to speak with sport coaches, strength coaches, and members of the Athletic Administration concerning my medical and injury information. I agree that this information will be presented in the form of an injury report and that these individuals will not have access to my personal records. Further, I agree that all members of the Athletic Training Staff may have access to my medical files kept by the Head Athletic Trainer, as it may be necessary to facilitate my care. Signature of Student-Athlete Signature of Parent/Guardian if under age 18
Langston University Athletics Authorization Form For Uses and Disclosures of Patient Protected Health Information Student-Athlete: Sport: Social Security Number: of Birth: I hereby authorize the Langston University Athletic Department to release my protected information. Protected health information may include: a. Injury or illness relevant to past, present, or future participation in intercollegiate athletics at Langston University; b. Information contained in my personal medical records unrelated to my participation in intercollegiate athletics at Langston University; c. Information concerning my medical status, medical condition, injuries, prognosis, diagnosis and other related personally identifiable health information, including but not limited to: Injury reports, test results, x-rays, progress, counseling reports, and any other documentation regarding my health status. Authorization is granted for release of my protected health information to: My parents/guardian and/or spouse for the purpose of assisting me in making healthcare decisions while I am a student-athlete. The coaches, assistant coaches, and other athletic staff so that they may make decisions regarding my athletic ability and suitability to compete while I am a studentathlete. My teammates so that they may be aware of limitations that I may be under while I am a student- athlete. Academic departments for the purpose of making decisions regarding my ability and suitability to perform academically while I am a student-athlete. The red river conference, central states football league, National Association of Intercollegiate Athletics for the purpose of making determinations regarding my eligibility status while I am a student-athlete. Applicable insurance providers for the purpose of processing insurance claims while I am a student-athlete. This authorization expires one year from the date of my signature below. The persons or entities that are authorized to receive the information above are not health care providers or health plans covered by federal health privacy laws; they may re-disclose the information and those laws would no longer protect the disclosed health information. Once you sign this authorization, we can rely on it until you revoke it or, if you have not revoked it, until it expires. Any revocation will not be effective as to information already disclosed in reliance on the authorization. You can revoke this authorization by delivering a dated and signed letter to the Director of Athletics. Printed Name of Student-Athlete Signature of Student-Athlete
Langston University Drug Testing Consent Form For and in consideration of my being permitted to participate in varsity athletics at Langston University, I hereby agree to abide by the drug-testing program that has been set forth in the Langston University Athletic Department Drug Testing Policy. By signing this form, I affirm that I am aware of the Langston University Athletic Department Drug Testing Policy, which provides in part that: 1. A student-athlete who tests positive on the drug screen test must attend mandatory counseling sessions after the first positive test. Additionally, he or she will be subject to subsequent drug tests, the student s parents/guardian will be notified of the positive test, and there will be discipline of the student-athlete directed by the head coach. There are more severe penalties for subsequent positive drug tests. 2. The penalty for missing a drug test is the same as the penalty for testing positive, unless there are extenuating circumstances. 3. I agree to allow Langston University s Athletic Department to drug test me in relation to my participation in intercollegiate athletics sanctioned by Langston University. Also, I understand that the University s Athletic Department can request a drug screen on me at any time when there is reasonable suspicion. 4. I understand that this consent and the results of my drug tests may be disclosed to my parents, the Athletic Director, the Head Coach, faculty athletic representative, my treating physician and Langston University Sports Medicine Staff. 5. I agree that the Langston University Counseling Center may discuss my drug counseling with the Athletic Director, the Head Coach, faculty athletic representative, my treating physician, and Langston University Sports Medicine Staff. 6. I voluntarily agree to follow all of the criteria outlined in the Langston University Athletic Department Drug Testing Policy. I specifically consent to have my urine collected and tested for the substances pursuant to this policy and I authorize the Langston University Athletic Department and/or the counselor to notify and discuss the results of my drug(s) with my parents or guardian. Signature of Student-Athlete Signature of Parent/Guardian (if student-athlete is under age of 18) Printed Name of Student-Athlete of birth Intercollegiate sport(s) participating in