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SPORTS MEDICINE MEDICAL COVERAGE AND INSURANCE INFORMATION
We are very excited your son/daughter has chosen UNC Charlotte to continue their athletic career and receive a great education. We would like to take this opportunity to make you aware of a few points in regards to the medical care and coverage your child will receive as a Charlotte 49er. Athletic Trainer Coverage Sports Medicine is overseen by our Director of Athletic Training, with a staff of five full time Associate Trainers and six Assistant Athletic Trainers. All of our Athletic Trainers are certified by the National Athletic Trainer’s Association and licensed by the North Carolina Board of Athletic Trainer Examiners. An ATC will be on site for all home practices and competitions. In most sports, the assigned athletic trainer will travel with the team for away competitions. When an athletic trainer does not travel with the team, arrangements will be made with the host school to provide medical coverage at the competition site. The athletic training staff works extremely hard to provide quality and consistent care to the student athletes who participate in the program. Your student athlete must report any injury to his/her assigned team athletic trainer. Medical Team The Sports Medical Team that assists the 49ers is made up of our family practice physician and team orthopedists. The team orthopedists are associated with OrthoCarolina, the largest orthopedic group in Charlotte. With offices across the region, OrthoCarolina is one of the nation’s leaders in orthopedic care. Their group consists of experts in the areas of foot and ankle, hand, hip and knee, shoulder and elbow, spine and sports medicine. They also provide our team physical therapy. All of our team physicians come to our athletic training rooms several times per week for onsite injury, illness, evaluation, diagnosis, and any office treatments that can be done outside of their offices. Insurance Each student‐athlete is required to carry primary medical insurance. The student‐athlete’s primary insurance will be filed for medical appointments and prescription medications. Please make sure your son/daughter provides their insurance information to all medical providers at the time of treatment. They will be expected to pay any applicable co‐payment or deductible at the time of treatment. Athletic Department policy does not permit reimbursement for these charges. In the event that your son/daughter is in need of medical coverage, there is a student policy that the University offers through the Student Health Center for purchase. The UNC System has selected Student Blue as the Student Health Insurance carrier for the 2014‐15 academic year. Student Blue is underwritten by Blue Cross Blue Shield of North Carolina. If you have questions about this coverage, please contact 704‐687‐6070 or visit www.bcbsnc.com/student. The deadline to waive or activate insurance is September 11, 2014. The Athletic Department serves as a secondary payer for some medical expenses. We also carry excess insurance, which is only accessed after certain deductibles are met. Our department employs an insurance specialist who works with our physician offices to expedite the payment process and to assist our student athletes with all medical claims and bills. It is important that all Explanation of Benefits (EOBs), and bills related to an athletic injury be forwarded to the insurance specialist in a timely manner by you or your
student athlete. Any questions concerning our policy may be forwarded to our insurance specialist Heather Nance at 704‐687‐0408 or [email protected]. Please note that the Athletic Department will not be able to reimburse or pay any charges incurred for a “second opinion”. These charges will be the sole responsibility of the student‐athlete and /or their parent/guardian. Summarized below are questions that we often receive about our insurance policy. What is covered by the Athletic Department’s Policy?
Co‐insurance payments (portion of bill determined by insurance after co‐pay and deductible has been met) for athletic related injuries
Physical therapy services provided to injured athletes (post‐operative and chronic injuries) provided by a licensed Physical Therapist. These services are provided at the discretion of the Team Physicians and/ or Certified Athletic Trainer. The student‐athlete’s primary insurance will be filed (the student‐athlete will not incur any out of pocket expenses for in‐house physical therapy)
Approved expenses related to bodily injury incurred during participation during primary competitive season and off season supervised conditioning with the strength and conditioning staff
Approved medication expenses related to athletic injuries
Approved vision screening expenses (one visit per year) as well as two boxes of contacts for use in‐season
Approved referrals related to athletic injuries
Approved orthopedic devices related to athletic injuries ‐must have a prescription from physician
Approved diagnostic or surgical procedures related to athletic injuries
Minor illnesses that occur during your primary competitive season (cold, flu or virus)
What is NOT covered (this is not an inclusive list)
Personal deductibles and co‐pays are NOT covered by the athletic department For example, if Joe tears an Anterior Cruciate Ligament (ACL) while playing soccer and must have an MRI the Athletic Department WILL NOT pay the co‐pay for any doctor office visits. Nor will the Athletic Department pay for the deductible from Joe’s primary insurance. The Athletic Department will pay for the remainder (co‐insurance) of the balance of the bill once Joe’s primary insurance pays its portion of the bill.
Routine dental care: dental appliances (excluding protective mouth guards).
Non‐athletic related accidents or injuries (injuries that occur outside of your primary competitive season or unsupervised off season conditioning)
Medication or surgery for treatment of non‐athletic related injuries
Pre‐existing conditions, illness, or injuries.
Sexually transmitted diseases and treatment or AIDS counseling
Contraceptives
Over the counter drugs
Maternity care
Unorthodox medical care
Self or coach prescribed treatment or devices
Any treatment, consultation or medication without prior approval from the Charlotte Athletic Training Staff
Medical expenses beyond limitations and exclusions not covered by the Charlotte Athletics accident insurance policy
Injuries sustained after the completion of student‐athletes eligibility
Medical expenses incurred due to disease excluding diagnostic testing to determine nature of illness
Second opinions from outside physicians
When is my student‐athlete covered?
Coverage extends through the playing season, including the off season conditioning conducted by the strength and conditioning staff and individual workouts with the coaching staff
My child does not have primary medical insurance, what do I do?
The University mandates that all students carry a health insurance policy. There is a student policy that the University offers through the health center for purchase. If you have questions about the student health insurance policy, please contact 704 687‐6070 or visit www.bcbsnc.com/student
My insurance is an HMO, what do I do?
If you are not from Charlotte, your child may be considered “out of network” by your insurance carrier. Please contact your insurance provider and let them know your child is attending school in Charlotte, NC. Many of them will extend their coverage to this area. Please make sure that your child has FULL medical coverage and not just emergency care coverage
We hope that you find this information useful. Our goal is to provide the best possible healthcare for our student athletes. If you have any questions, please feel free to contact Heather Nance, Insurance Specialist at 704‐687‐0408.
In this package you will find forms which require your attention. Several of these forms need your signature along with your student‐athletes signature. Please take a few moments to gather this important information and go over with your son/daughter. There is a postage paid envelope provided for your convenience. Please return all these necessary forms along with a copy or your primary medical insurance card (front and back) as soon as possible. Thank you and Go Niners! Heather Nance, Insurance Specialist AJ Lukjanczuk, Director of Athletic Training
SPORTS MEDICINE MEDICAL COVERAGE AND INSURANCE INFORMATION
Student‐Athlete’s Name Sport(s) Student ID # 800 Date of Birth
Please read carefully and initial all that are applicable:
My personal health insurance is a: PPO HMO OTHER
If other please explain:
I do not need to purchase the student health insurance and I have completed the insurance waiver on‐line at
www.bcbsnc.com/student. This waiver is my verification that my child has adequate major medical coverage while participating in
athletics and attending classes while at Charlotte.
I have notified my medical insurance carrier that my child will be attending UNC Charlotte in the fall to ensure that my
coverage will extend to my student‐athlete while they are away from home. This would apply to any student‐athletes whose
parent’s primary residence is outside the Charlotte area or those not enrolled in the student insurance program.
Student‐athlete does not have personal health insurance and I have voluntarily enrolled him or her with the student
health insurance plan provided by Blue Cross and BlueShield at www.bcbsnc.com/student
I understand I will be responsible for paying any applicable co‐payments and/or deductible that is required by my
insurance carrier for any treatment that my child may need while participating in athletics at Charlotte.
I have read and understand the “Medical Coverage/Insurance” letter and do not have any questions about the UNC
Charlotte Athletic Department medical policies and procedures.
I have read the Medical Care and Insurance Coverage Information letter, and have questions regarding: (Please attach your
questions to this form along with the email and/or phone number at which you would like to be contacted and we will get back with
you as soon as possible.)
Student‐Athlete’s Signature Date
Print Name Parent/Guardian
Parent/Guardian Signature Date
2014‐2015 ATHLETE CONTACT INFORMATION SHEET
Student ID# 800 Social Security #
Sport: Gender: Male/Female Date of Birth
Name (Last) (First) (Middle Initial)
Permanent/Home Address , , Street City State Zip
UNCC Address , , (If Known) Street Dorm City State Zip
Home Phone Cell Phone
E‐mail UNCC E‐mail (If Known)
Parent/Guardian Contact Information
Name Name Mother/Guardian 1 Father/Guardian 2
Address if Different from Athletes Address if Different from Athletes:
Email Email
Home Phone Home Phone
Cell Phone Cell Phone
Work Phone Work Phone
In case of emergency, and parent’s/guardians cannot be contacted, please notify:
Name OR Name
Relationship Relationship
Home Phone Home Phone
Cell Phone Cell Phone
Work Phone Work Phone
2014‐2015 STUDENT‐ATHLETE HEALTH HISTORY QUESTIONNAIRE
Student ID# 800 Gender: Male/Female Date of Birth
Sport(s):
Name (Last) (First) (Middle Initial)
Have you or are you experiencing … YES NO Comments (Dates and Explanations)
1 Dizziness or fainting spells
2 Frequent or severe headaches
3 How many meals do you eat each day? How many snacks?
4 Chronic or persistent cough
5 Shortness of breath during or after mild exertion
6 Chest pain after exertion
7 Frequent leg cramps
8 Unexplained tiredness or fatigue
9 Heat exhaustion or stroke
10 Head injury which requires x‐rays
11 Back injury or recurrent low back pain
12 Neck injury (whiplash or pinch nerve)
13 What have you eaten in the last 24 hours?
14 Broken bone
15 Injury of shoulder, elbow, wrist, hip, knee, ankle
16 What is your present weight?
17 Are you happy with this weight? If not, what would you like to weigh …
18 Epilepsy or convulsions
19 Have you ever been diagnosed with a concussion?
20 Asthma/Allergies (medication, etc)
21 Have you ever been diagnosed with Anemia?
22 Diabetes or low blood sugar
23 Rheumatic Fever
Have you or are you experiencing … YES NO Comments (Dates and Explanations)
24 Are there certain food groups that you refuse to eat?
25 Heart Murmur or Heart Disease
26 Hepatitis
27 Mononucleosis
28 Has a Doctor ever told you that you have Sickle Cell Anemia?
29 Do you have Sickle Cell Trait?
30 Have you ever had Exertional Rhabdomyolysis Kidney Failure or Endocrine Disorders?
31 Have you or are currently taking any recreational drugs, prescribed drugs, supplements, performance enhancers?
32 Hernia
33 Have you ever had high blood pressure, high cholesterol?
34 Have you ever had racing of your heart or skipped heart beats?
35
Has anyone in your family died of heart problems or sudden cardiac deaths (SCD) before age 50? Does anyone in your family have a heart problem?
36 Has a physician ever denied your participation in sports for cardiac reasons?
37 Have you ever passed out or nearly passed out during or after exercise?
38 Has a doctor ever ordered a test for your heart (e.g., electrocardiography, echocardiography)
39 Has anyone in your family died for no apparent reason?
40 Does anyone in your family have Marfan Syndrome?
41 Been knocked unconscious
42 Bled excessively after an injury or tooth extraction
43 Been diagnosed as having an eating disorder
44 Wear contact lenses during participation in athletics
45 Wear dental appliances
46 Wear a corrective brace or other equipment
47 Take medications daily for a chronic disease
48 Been on a diet
Have you or are you experiencing … YES NO Comments (Dates and Explanations)
49 Have you ever been advised to have surgery?
50 Have you ever had surgery?
51 Are you now under the care of a physician?
52 Tried to control your weight by vomiting, using laxatives, diuretics, or pills
53 Has any physician ever advised you not to participate in contact or collision sports?
54 Do you have any questions about healthy ways to control your weight?
55 Do you have any other medical problems not mentioned above?
56
Do you know of or do you believe there is any reason why you should not participate in the Charlotte 49ers Athletic Program at this time?
57 Have you ever wished that you were dead?
58 Have you ever wanted to hurt yourself?
For Females Only …
1 How old were you when you had your first menstrual cycle?
2 How often do you have a period?
3 How long do your periods last?
4 How many periods have you had in the last 12 months?
5 When was your last period?
6 Do you ever have trouble with heavy bleeding?
7 Do you have questions about tampon use?
8 Do you ever experience cramps during your period?
9 If so, how often do you treat them?
10 Do you take birth control pills or hormones?
11 Do you have any unusual discharge from your vagina?
12 When was your last pelvic examination?
13 Have you ever had an abnormal PAP Smear?
14 How many urinary tract infections (bladder or kidney) have you had?
The undersigned, hereby;
1. Affirms that all answers and information contained within this document is correct and true, and that no answers or information have been withheld.
2. Understands his/her having passed the physician examination does not necessarily mean he/she is physically qualified to engage in athletics, but only that the examiner did not find any medical reason to disqualify him/her.
Student‐Athlete Printed Name Student‐Athlete Signature Date Did you include your MRI’s, X‐rays, EKG’s, Medical notes, and prescriptions with your packet?
Yes No The undersigned, hereby;
1. Affirms that all answers and information contained within this document has been reviewed and is correct and true, and that no answers or information have been withheld.
Parent/Guardian Printed Name (REQUIRED) Parent/Guardian Signature (REQUIRED) Date ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ For Internal UNCC Review (Do not write below) The undersigned, hereby; Affirms that the information has been reviewed UNCC Athletic Trainer Printed Name UNCC Athletic Trainer Signature Date
STUDENT‐ATHLETE INSURANCE INFORMATION
The information you provide will be held strictly confidential. Please complete all pages of this form and return UNC Charlotte ID# 800 Sport(s) DOB Athlete , , Male/Female (Last Name) (First Name) (Middle Initial) Information for (Primary Insurance) Policy Holder
All Areas Must be Completed, If any of these areas are unknown please call your customer service number located on the back of your card for accurate information.
Policy Holder Name:
Relationship to Athlete Mother Father Guardian Stepmother Stepfather Spouse Self
Date of Birth of Policy Holder
Home Address (Street)
City, State, Zip
Home Phone: Work / Cell #( ) ( ) Email:
Name of Insurance Company Deductible Amount Office Visit Co‐Pay $ $
Insurance Company Street Address
City, State, Zip
Phone ( )
ID/Policy Number Group Number
Name of employer of Policy Holder (only if this insurance is a group plan through employer)
This policy is an HMO Yes No If yes, Please see second page PPO Yes No If yes, Please see second page
This policy requires pre‐authorization for treatment Yes NoIf yes please list phone number
I have informed this policy that my child will be attending UNC Charlotte and asked if they will cover my child for any athletic related injuries YES NO I certify to the best of my knowledge the above information is accurate and will notify the Sport Medicine Department of any changes if they occur
during the upcoming academic school year. Front and back copy of all insurance cards must be included with this form.
Signature of Parent/Guardian Date Signature of Athlete Date
STUDENT‐ATHLETE INSURANCE INFORMATION
PLEASE COMPLETE THIS SHEET IF THE STUDENT‐ATHLETE IS COVERED UNDER A GROUP INSURANCE AND IT IS AN HMO OR PPO. Please provide the name, address and phone numbers of Athlete’s primary care physician within the required network. Their office will control the approval of all necessary “referrals” to specialist(s) if they are needed. To make things more effective it is strongly suggested that all primary care physicians be changed to included UNC Charlotte’s own team physicians.
Primary Insurance Secondary Insurance
Physician’s Name
Physician’s Name
Address
Address
City, State, Zip
City, State, Zip
Phone:
Phone:
Fax:
Fax:
Yes, I have seen my primary care physician and am an established patient in his/her office (as noted above) I have informed my physician of my son/daughters participation in intercollegiate sports at UNC Charlotte. No, I have NEVER seen my primary care physician. I know that I must see him/her before I come to UNC Charlotte for my insurance to be valid. I will make an appointment to establish myself as a ‘valid” patient in his/her office prior to coming to UNC Charlotte and make him/her aware of my “out of town” residency in Charlotte, North Carolina while attending school. This will only be allowed if NO restrictions/limitations are on ability to receive services in Charlotte. No, I have NEVER seen my primary care physician and will be choosing a primary care physician in Charlotte, North Carolina. I will make an appointment with a network primary care physician 30 days prior to arriving in Charlotte and will notify the Athletic Trainer of who that physician actually is. This will only be allowed if NO restriction/limitations are on ability to receive services in Charlotte. Other – Please Explain
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ For Athletic Trainers only: Received copy of Insurance Card: Front Back Pell Grant Eligibility Updates/Changes Scholarship YES / NO Full / Part
STUDENT‐ATHLETE SECONDARY INSURANCE INFORMATION
Athlete’s Name Sport(s) Student ID # 800 Date of Birth
Yes I do have a Secondary Health Insurance Policy. If you do not have a secondary health insurance policy you can skip this page. Information for (Secondary Insurance) Policy Holder If Applicable
All Areas Must be Completed, If any of these areas are unknown please call your customer service number located on the back of your card for accurate information.
Policy Holder Name:
Relationship to Athlete Mother Father Guardian Stepmother Stepfather Spouse Self
Date of Birth of Policy Holder
Home Address (Street)
City, State, Zip
Home Phone: Work / Cell #( ) ( ) Email:
Name of Insurance Company Deductible Amount Office Visit Co‐Pay $ $
Insurance Company Street Address
City, State, Zip
Phone ( )
ID/Policy Number Group Number
Name of employer of Policy Holder (only if this insurance is a group plan through employer)
This policy is an HMO Yes No If yes, Please see second page PPO Yes No If yes, Please see second page
This policy requires pre‐authorization for treatment Yes NoIf yes please list phone number
I have informed this policy that my child will be attending UNC Charlotte and asked if they will cover my child for any athletic related injuries YES NO I certify to the best of my knowledge the above information is accurate and will notify the Sport Medicine Department of any changes if they occur
during the upcoming academic school year. Front and back copy of all insurance cards must be included with this form.
Signature of Parent/Guardian Date Signature of Athlete Date
STUDENT‐ATHLETE PHARMACY/PRESCRIPTION PLAN INFORMATION
Athlete’s Name Sport(s) Student ID # 800 Date of Birth
Yes, I do have a prescription benefit covered by insurance. I can use any pharmacy of my choice and only pay designated copay per my plan. I have to go to a “Network Participating Pharmacy” I pay a copay and the pharmacy files my claim. My Network Pharmacies are: Wal‐Mart / CVS / Eckerd’s / Kerr Drugs / Walgreens Other ‐ I have to pay for all prescriptions then submit my pharmacy charges for reimbursement. No, I do not have ANY prescription benefits through insurance. Please submit a copy (front & back) of your prescription card if it is separate from your Primary Health Insurance Policy.
SECONDARY POLICY INFORMATION FOR STUDENT-ATHLETES
In preparation for the upcoming athletic season, we want to provide you with information about the accident medical insurance our institution carries for your student‐athlete. UNC Charlotte Athletics purchases an excess basic accident insurance policy through Mutual of Omaha. The policy covers medical expenses arising from athletic injuries up to a $75,000 limit and excess of any other available accident/health insurance (such as through your insurer). The NCAA also provides a “catastrophic” medical policy, also excess of other insurance, with much higher limits in the event of serious injury. This coverage is paid for by Charlotte Athletics and in order for it to remain affordable we require all student‐athletes to maintain a primary insurance to participate. The accident medical insurance we carry applies only to covered athletic injuries and is not a replacement for primary accident/health insurance. All student‐athletes must provide the school with primary insurance by giving a copy of the card for their policy. Front and back copy of this card is to be kept on file by the Athletic Trainer and Insurance Specialist. If at any time this coverage expires during the school year, the athletic department must be notified. We know employment situations can change, and we need to know what coverage is in place in order to provide the best care to student‐athletes and help manage the claims process efficiently. Our trainers will carry all insurance information with them when teams and athletes travel. Our policy carries a deductible of $3000.00. This deductible will be reduced as payments are made by the primary insurance company. Once the primary insurance company has made payments equal to or greater than our deductible, our excess policy deductible will be satisfied. If any portion of the deductible is not satisfied by the primary insurance company this amount will be the responsibility of the student‐athlete and/or parent/ guardian. Also, our policy does have certain limits and may not pay all charges in full. Please note most primary insurance plans offered through employers have requirements for dependents over the age of 18, and it is important to comply with such requirements in order for coverage to continue to apply to your son/daughter. One requirement may be to provide a schedule proving that your student‐athlete is a full‐time student. If you are a member of an HMO or PPO, we recommend that you contact them and make sure you understand their policies with regard to dependent students who are going to school out of the network area. In some cases, the company will set up a “guest membership” for dependents in the area of temporary residence. If this is the case, you should attempt to have this set up for your student‐athlete prior to their leaving for school.
SECONDARY POLICY INFORMATION FOR STUDENT-ATHLETES
Athlete’s Name Sport(s) Student ID # 800 Date of Birth I have received and understood the attached “Student/Parent/Guardian Insurance Notification.” I understand
that I may bear responsibility for the deductible and balances not covered by UNC Charlotte’s accident
medical policy for any expenses related to athletic injuries. I further understand that this policy is excess over
any other insurance that may apply to such injuries. I agree that if I have primary accident/health insurance
plan, I will provide UNC Charlotte Athletics with evidence of coverage and will notify the athletic department
of any material changes in coverage during the academic year.
Please check here if student‐athlete has primary insurance and attach evidence of coverage (a front
and back copy of the insurance card(s) is needed).
Please check here if student‐athlete does not have primary insurance.
Student‐Athlete Signature Date Parent Signature Date
MEDICAL RECORDS RELEASE FORM (HIPAA)
Athlete’s Name Sport(s) Student ID # 800 Date of Birth
Per the Health Insurance Portability and Accountability Act the following signature will authorize the athletic director, certified athletic trainers, student sports medicine assistants, team physicians and affiliated medical staff to communicate and view medical records pertaining to health related issues as a result of my participation in the NCAA Athletic Program at University of North Carolina at Charlotte. The following methods of communication and injury documentation may be used:
Oral, written, or electronic communication regarding health issues between the athletic trainer, the team physician and supporting medical staff.
Oral, written, or electronic communication regarding health issues between the athletic trainer, coaching staff and athletic director.
Oral, written, or electronic communication regarding health issues between the athletic trainer and the athlete’s parents, (per athlete’s request).
Oral, written, or electronic communication regarding health issues between the athletic trainer, the team physician, supporting medical staff and the Insurance Company, Carrier or TPA in which the above University purchased Secondary Student Basic Accident Medical on my behalf.
I, , Hereby authorize the release of the following information to the organization listed below Initial evaluations History/Physical exam Progress notes Correspondence notes Consultation reports Entire medical record Treatment summary Billing records Diagnostic test results ALL INFORMATION Psychological reports Other
UNC Charlotte Athletics 9201 University City Blvd, Charlotte, NC 28223 I have read and understand the means of communication and documentation that will take place regarding my health history and any injury information that may develop because of my involvement in athletics. Student‐Athlete Signature Date
Parent Signature Date (IF under 18 years of age)
ASSUMPTION OF RISK
Athlete’s Name Sport(s) Student ID # 800 Date of Birth
Participation in intercollegiate athletics involves an inherent risk of injury which may result in a permanent disability or even death. Examples include, but are not limited to:
Sudden death, heart attack, respiratory failure
Paralysis, spinal cord damage, nerve damage
Head injuries, concussions, brain damage, Chronic Traumatic Encephalopathy
Dental injuries, tooth fractures, loss of teeth, facial disfigurement
Broken bones, joint damage, arthritis
Eye injuries, vision loss
Loss or injury to vital organs
Muscle and ligament damage, sprains, ruptures
Menstrual irregularities and complications
Psychological distress, depression, anxiety Reasonable precautions should be made by all participants, coaches, staff, and administrators to minimize this risk. Each sport has its own set of safety rules and regulations which should be adhered to at all times. To rely on officials to enforce compliance with the rulebook is as insufficient as to rely on warning labels to produce compliance with safety guidelines. As a student‐athlete, it is your responsibility to take appropriate steps to prevent injuries when possible by following the rules for the game and wearing all recommended and required protective equipment and braces. Additionally, it is your responsibility to provide timely and accurate information regarding all injuries and illness (whether the injury pertains to yourself or a teammate) to the appropriate Sports Medicine staff member and coaches and to comply with their directions. By signing below, I acknowledge that I fully understand and appreciate the RISKS associated with my participation in athletics. If I have any questions regarding the risks inherent to my sport, I understand that it is my responsibility to ask a member of the UNCC Sports Medicine Staff. In consideration for the opportunity to participate in athletics, I voluntarily agree to assume all RISKS, including death, serious bodily injury, illness or property damage. To minimize my risk, I agree to follow and play within the rules of this sport. I agree to report all injuries/illnesses in a timely manner to the Sports medicine Staff. Additionally, I have provided and accurate medical history and I will update my records as needed. I understand that having passed a physical examination does not necessarily mean that I am physically qualified to engage in athletics, but only that the evaluator did not find a medical reason to disqualify me at the time of the evaluation. Student‐Athlete Signature Date
Parent Signature Date (IF under 18 years of age)
MEDICAL EXCEPTION FOR ADD/ADHD
Athlete’s Name Sport(s)
Student ID # 800 Date of Birth
The NCAA bans performance enhancing drugs to protect student‐athletes health and safety, and ensure a level of playing field for all
athletes. The NCAA also recognizes that some of these substances may be used legitimately as medication to treat student‐athletes
with certain medical conditions. Accordingly, the NCAA allows exceptions to be made for those student‐athletes with documentation
for regular use of such medications.
The NCAA requires documentation of a comprehensive clinical evaluation in order to support the use of medications to treat
Attention Deficit Disorder (ADD), Attention Deficit Hyperactivity Disorder (ADHD), or any other medical conditions that require the
use of medications such as Adderall, Ritalin, Concerta, etc.
Please initial one of the following:
I AM NOT currently taking, or have taken within the last 12 months, any banned medications that are used to treat ADD,
ADHD, or any other medical condition. I understand that I am to immediately notify, and submit the proper documentation to a
member of the UNC Charlotte Sports Medicine Staff should I ever be prescribed any NCAA banned substance.
I AM currently taking, or have taken within the last 12 months, banned medications that are used to treat ADD, ADHA, or
any other medical condition. I understand that I must obtain and submit the appropriate documentation to the UNC Charlotte
Sports Medicine Staff from the prescribing physician.
Student‐athletes prescribed NCAA banned medications must provide the following documentation to the UNC Charlotte Sports
Medicine Staff from the prescribing physician;
Documentation that demonstrates the student‐athlete has undergone a comprehensive clinical evaluation to diagnose
ADD/ADHD.
Documentation stating that the student‐athlete is routinely monitored for the use of this medication.
Current prescription on file with the UNC Charlotte Sports Medicine Staff.
I attest that I have truthfully represented whether or not I am currently taking a NCAA banned medication. I understand, and agree,
that the proper documentation must be on file with the UNC Charlotte Sports Medicine staff in order for me to participate in
intercollegiate athletics. I understand that if I refuse to comply with this policy, I can jeopardize my eligibility to participate in
intercollegiate athletics at University of North Carolina at Charlotte or any other NCAA institution.
Student‐Athlete Signature Date
Parent Signature Date (IF under 18 years of age) Athletic Trainer Signature Date
SICKLE CELL & EKG SCREENING POLICY AND PROCEDURES
Sickle Cell Trait Assessment Student‐Athletes will not be able to participate in any workout/practice/completion until UNC Charlotte Sport Medicine has a completed sports physical (this will be done when they arrive on campus), and sickle cell trait testing results. You can have the sickle cell trait test done before they arrive on campus or if you know test has already been done a copy of your student‐athlete’s “New Born Screen” from your pediatrician/family physician or local health department may be provided. If you do not have a copy of your results, screening will take place upon arrival on campus. You will not be cleared to participate until the sickle cell trait blood test results are on file.
EKG HEART ASSESSMENT
Student‐Athletes will not be able to participate in any workout/practice/completion until UNC Charlotte Sport Medicine has an EKG completed. Charlotte Sports Medicine needs the actual EKG (copy) and the result must be signed by a qualified healthcare official (MD/Cardiologist). If any additional cardiac follow‐up is recommended as a result of the EKG this will need to be done by a Cardiologist, and results turned in before any activity will be allowed. Student‐Athletes can get this done before they arrive at Charlotte or this can be done by our Sports Medicine team on arrival. You will not be cleared to participate until you’re EKG has been cleared by our team Cardiologist.
SICKLE CELL SCREENING CONSENT FORM
Athlete’s Name Sport(s)
Student ID # 800 Date of Birth
Please read the following information and sign below
I have read the information provided in the UNC Charlotte Sickle Cell Screening Policy and Procedures, and I
understand that sickle cell screening is recommended for my participation in UNC Charlotte’s intercollegiate
athletic programs.
By my signature below, I hereby consent to sickle cell screening, and in the event of a positive test result, I
hereby consent for the release of my test results to UNC Charlotte Sports Medicine, team physicians, and
appropriate Athletic Department Staff. In the event of a positive test result, I understand that medical follow‐
up is required for athletics participation and sickle cell education and genetic counseling is strongly
encouraged.
Student‐Athlete Signature Date
Parent Signature Date (IF under 18 years of age)
ATHLETIC HEALTH CARE TEAM
OrthoCarolina Team
Dr James Fleischli –Orthopedic Physician Dr. Michael Dockery –Orthopedic Physician Dr. J. Kent Ellington – Foot and Ankle Specialist Dr. Christopher Chadderdon – Hand Specialist John Colville – Physical Therapy
Team Physician/Internal Medicine Dr. Robert Jones – Medical Director of the SHC Certified Chiropractic Dr. Luke Bennett ‐ Chiropractic Physician for TOPTEAM Fitness Chiropractic Performance Institute Dentist Drs. Joshua and Elizabeth Damesek – General Dentistry Eye Dr. Steven Eyler – University Eye Associates
49ERS Sports Medicine Staff Judy W. Rose Field House AJ Lukjanczuk – Dir. of Athletic Training / Head Football Athletic Trainer Adam Jordan – Assistant Athletic Trainer – Football Justin Walker – Assistant Athletic Trainer – Football Ethan Eanes – Graduate Assistant Athletic Trainer ‐ Baseball David Johnson SAC Athletic Training Room Jeremy MacVarish – Associate Head Athletic Trainer – Men’s Basketball Jennifer Winningham – Assistant Athletic Trainer – Women’s Basketball Stephen Digh Jr. – Graduate Assistant Athletic Trainer – Volleyball Kevin Thornton – Graduate Assistant Athletic Trainer – Men’s Soccer Katie Lambeth – OrthoCarolina Outreach ‐ Cheer Transamerica Track & Field Training Room Tara Serafino – Assistant Athletic Trainer – Track & Field TBD – Graduate Assistant Athletic Trainer – Cross Country Halton‐Wagner Tennis Complex Evan Kureczka – OrthoCarolina Outreach – Men’s & Women’s Tennis TBD – Graduate Assistant Athletic Trainer – Women’s Soccer Wells Fargo Field House Matt Hancock – Graduate Assistant Athletic Trainer ‐ Softball
Students with health insurance coverage must supply this
information online every fall and spring semester by the due date.
Failure to comply will result in automatic enrollment into the
$802 Student Health Insurance Plan for the semester.
Health Insurance Requirement
ONLINE HEALTH INSURANCE WAIVER
DUE BY SEPTEMBER 10, 2014
This requi rement appl ies to the
fo l low ing students :
Undergraduate Students
•Six or more on -campus c red i t
hours and degree - seek ing .
Graduate Students
• Three or more on -campus cred i t
hours and in a degree -seek ing or
cer t i f i ca te program.
In te rnat ional Students
• Al l s tudents wi th an F -1 or J -1
v i sa regard less o f c red i t hours .
Submitting your waiver or enrollment form online is fast and
easy. Be proactive and submit your form today. “
” Students who are currently uninsured may enroll into the
Student Health Insurance Plan by completing the Student Blue
enrollment form found on our website. Open enrollment ends
on September 10, 2014.
Need help or want more information?
Student Blue 1-888-351-8283
Student Health Center
www.studenthealth.uncc.edu
Student Insurance Office
Located at the corner of Mary Alexander and
Cameron Blvd
Building #65 on campus map
(704) 687-7435
Fall 2014
