WagnerCollegeSportsMedicine1CampusRoad٠StatenIsland,NY10301

Phone:(718)390-3302٠Fax:(718)390-3302

DearParents/GuardiansofWagnerCollegeAthletes,Wearepleasedtohaveyourchild/dependentasamemberofoneofourfineathleticteams.Wearehopefulthathe/shewillfindsuccessandenjoymentinbothathleticsandacademicswhilehereatWagnerCollege.Theenclosedpacketcontainsformsthatwillberequiredtobecompletedbeforeyourchild/dependentwillbeallowedtoparticipateinintercollegiateathleticshereatWagnerCollege.Thepurposeoftheseformsistoensurethatyourchild/dependentisfittoparticipateinintercollegiateathletics.*NOTE:TheseformsareseparatefromtheformsrequiredbytheCenterforHealthandWellness.Enclosedforyourconvenienceisachecklisttohelpensurethatallitemsarecompleted.Completedformsmaybesentviamail,scannedandemail,orfaxtotheaddresslistedbelow.WAGNERCOLLEGEDEPARTMENTOFSPORTSMEDICINEMUSTRECEIVEALL

FORMSNOLATERTHANJULY15th!Ifyouhaveanyquestionsconcerningtheencloseddocumentation,pleasecontactmeatat(718)390-3220orviaemailatalexander.lipcius@wagner.edu.Respectfully,AlexanderLipcius,MS,ATCHeadAthleticTrainerWagnerCollege1CampusRoadStatenIsland,NY10301718-390-3220(office)718-390-3302(fax)alexander.lipcius@wagner.edu

WagnerCollegeSportsMedicine1CampusRoad ٠ StatenIsland,NY10301 Phone:(718)390-3220٠Fax(718)390-3302

MEDICALFORMCHECKLIST

YOUWILLNOTBECLEAREDFORACTIVITYUNLESSTHISPACKETISCOMPLETE

� Student-AthletePersonalInformation� Student-AthleteMedicalHistorySurvey� Student-AthleteAssumptionofRisk/ConsentforTreatment� Student-AthleteProtectedHealthInformation� SickleCellTraitEducationAcknowledgement/Waiver� ConcussionEducationAcknowledgement� ConcussionSymptomBaseline� Pre-participationPhysicalExamination� OrthopedicPre-ParticipationExamination(OnlyrequiredforFOOTBALLstudent-

athletes)� HealthInsuranceInformationandAcknowledgement� Copyofthefrontandbackofyourhealthinsurancecard

ALLNEWSTUDENT-ATHLETES(FRESHMEN/TRANSFERS)MUSTHAVEAPHYSICALEXAMCOMPLETEDBEFOREARRIVINGONCAMPUS.Wepreferallreturningathleteshavethiscompletedbeforereportingtocampus,asitgivestimetocompleteanyadditionaltestingthatmayberequired.Pleasealsonotethatifanyfurthertesting(i.e.bloodwork,EKG,MRI,etc.)isneededbeyondthephysicalexamination,yourpersonalinsurancewillbebilledforthechargesofthesetestsandwillnotbetheresponsibilityofthecollege.

RETURNINGATHLETES:

PhysicalExaminationsforReturningAthletesunabletoobtainoneathomewillbeprovidedoncampusonJuly31,2019foranyfallsportathletesoncampusthatday,andduringthefirstweekofclassesforwinterandspringsportathletes.

NEWATHLETES:

ThispacketisNOTthesameaswhatisrequiredfortheWagnerCollegeHealthCenter.Youmustcompletetheirpacketasdirectedandfollowinstructionsforsubmission.IfyouhavealreadyreceivedaphysicalusingtheHealthCenter’sform,thisissufficientformedicalclearance,howeveritMUSTbeattachedtothispacket.ALLFORMSMUSTBESUBMITTED(viamail,email,orfax)NO

LATERTHANJULY15,2019

Reviewed:May,2019

Student-AthletePersonalInformation

Name(Last,First,M.I.): Sport: DateofBirth: SSN/StudentID: Sex:MFCampusAddress:__HarborView__Guild__Towers__FoundationRoom#: Year:FrSoJrSrGradHomeAddress: Street City/StateZipCodeCellphone: Homephone: *******************************************************************************************EMERGENCYCONTACTSListtwopeople(oneparent/guardianandoneofadifferentresidence)tocontactintheeventofanemergency.1.Nameofparent/guardian: Relation: Address: Homephone: Cellphone: Workphone:

2.Name: Relation: Address: Homephone: Cellphone: Workphone:

*******************************************************************************************INSURANCEINFORMATION(Pleaseprovideacopyofthefrontandbackcopyofyourhealthinsurancecard)InsuranceCompany: Isyourinsurancea/an:(circle)HMO?PPO?Address: Phone: Policy#: Group#: ID#: PrimaryCarePhysician(PCP)Name: PCPAddress: PCPPhone: NameofInsurancePolicyHolder: PolicyHolderAddress: DateofBirth: RelationtoInsured: Phone:

*YouwillnotbeclearedforathleticparticipationuntiltheSportsMedicineDepartmenthasreceivedallrequiredinsuranceinformation*

*******************************************************************************************GENERALINFORMATIONListanyallergiestomedications: Listanymedicationstakenonaregularbasisandexplainwhy AreyoucurrentlybeingtreatedforAttentionDeficit/HyperactivityDisorder(ADHD)? YES NODoyouwearcontactlensesonaregularbasis? YES NO IfYES,pleasecircle: Hard SoftTheinformationthatIhaveprovidediscompleteandcorrecttothebestofmyknowledge.Student’sSignature: Date: Parent/Guardian’sSignature: Date: (Requiredifstudent-athleteisunder18yearsofage)

Reviewed:May,2009

NewStudent-AthleteMedicalHistorySurvey

Name Sport Date

StudentID DOB Phone Thefollowingisarecordofyourpersonalmedicalhistory.Youarerequiredtoprovideaccurateinformationwithregardtoallquestions.ThisformwillbekeptonfileintheSportsMedicineOffice,andwillremainstrictlyconfidential.IGeneralHealth:

1.Haveyoueverhad,orbeendiagnosedwithanyofthefollowingillnesses:___Hepatitis ___Tuberculosis ___Mononucleosis ___Pneumonia___Tonsillitis ___ScarletFever ___RheumaticFever ___ChickenPox___SmallPox ___Measles ___Mumps

Yes/No2.Doyouhaveanyallergies?Yes/No3.Areyoutakinganymedication?Yes/No4.Haveyoueverexperiencedarashorhivesafterphysicalactivity?Yes/No5.Haveyoufeltdizzy,faintorpassedoutduringorafterphysicalactivity?Yes/No6.Haveyoueverexperiencedchestpainduringorafterphysicalactivity?Yes/No7.Doyouhavehighbloodpressureorhighcholesterol?Yes/No8.Doyouhaveaheartmurmurorheartdisease?Yes/No9.Doesyourheartraceorskipbeats?Yes/No10.Doyouhaveafamilyhistoryofheartdisease?Yes/No11.Hasanyoneinyourfamilydiedsuddenlyforunexplainedreasons?Yes/No12.Doyouhavetroublebreathing?(Asthma,wheezing,etc.)Yes/No13.Doyouhaveskininfections,suchasringworm?Yes/No14.Doyouhaveanycommunicablediseases?Yes/No15.Doyoubleedorbruiseeasily(Anemic)?Yes/No16.Doyouabusealcohol?Yes/No17.Doyousmokecigarettes?Yes/No18.Doyouparticipateintheuseofstreetdrugs?(Heroin,LSD,Cocaine,Steroids,etc.)Yes/No19.Doyouhaveaweightproblem?(Anorexia,Bulimia,Obesity,etc.)Yes/No20.Doyouhaveweightcontrollingproblems?(binge,purge,laxativeuse)Yes/No21.Doyouhaveanimpairmentofanyorgan?Orhaveyouhadanorganremoved?Yes/No22.HaveyouoranyoneinyourfamilybeendiagnosedwithDiabetes?Yes/No23.Haveyoueverhadaseizure?Yes/No24.Hasanyoneinyourfamilypassedawayat50oryoungerofheartattackorstroke?

25.Ifyouanswered“yes”toanyoftheabovequestionspleaselistandexplainallincidents,treatmentreceivedandspecialmedicalneeds:

Reviewed:May,2009

NewStudent-AthleteMedicalHistorySurvey

IIEyes,Ears,andDental:Yes/No1.Doyouhaveanyproblemswithyourvision?Yes/No2.Doyouwearcorrectivelenses?(glasses,contacts,etc)Yes/No3.Doyouhaveanyhearingimpairments?Yes/No4.Doyouneedahearingaid?Yes/No5.Doyouhaveanydentalimplants?(bridges,crowns,etc)Yes/No6.Haveyoueverhadatoothknockedoutorremoved?

7.Ifyouanswered“yes”toanyoftheabovequestionspleaselistandexplainallincidents,treatmentreceivedandspecialmedicalneeds:

IIIHeadandNeck:Yes/No1.Haveyoueverhadaheadorneckinjury?Yes/No2.Haveyoueverbeenknockedunconsciousorhadaconcussion?Yes/No3.Doyousufferfromsevereorfrequentheadaches,ormigraines?Yes/No4.Haveyoueverhadabrachialplexusinjury?(stinger,burner,pinchednerve,numbness,etc.)Yes/No5.Haveyoueverhadacervicalherniation?Yes/No6.Haveyoueverhadanyotherinjurytoyourneck?

7.Ifyouanswered“yes”toanyoftheabovequestionspleaselistandexplainallincidents,treatmentreceivedandspecialmedicalneeds:

Reviewed:May,2009

NewStudent-AthleteMedicalHistorySurvey

IVMusculoskeletalInjuries:

1.Haveyoueversprained,strained,dislocated,fractured,orhadchronicswelling,and/orpaininanyofthefollowingareas? ___Fingers ___Wrist ___Hand ___Forearm ___Elbow ___Shoulder ___Shoulder ___Face ___Skull ___Neck ___Chest ___Abdomen ___Back ___Pelvis ___Hip ___Thigh ___Knee ___Shin ___Calf ___Ankle ___Foot ___Toes ___other2.Ifyoucheckedanyoftheabove,listthedateandseverityofeachinjury: 3.Haveyoueverbeenhospitalizedforanyoftheaboveinjuries?Ifyespleaseexplain: 4.DoyouhaveanyspecialrestrictionsorrequirespecialequipmentforparticipationinIntercollegiateAthletics?Ifyespleaseexplain:

*****************************************************************************************************VWomenOnly:Yes/No1.Doyouhaveirregularmenstrualperiods?Yes/No2.Haveyouevermissedacycleorperiod?Ifsohowlong?__________________Yes/No3.Doyouexperienceabnormallypainfulmenstrualcramps?Yes/No4.Areyoucurrentlytakinganymedicationtoregulateyourmenstrualcycle?Yes/No5.HaveyoueverbeendiagnosedwithAmenorrhea?*****************************************************************************************************

Reviewed:May,2009

NewStudent-AthleteMedicalHistorySurvey

VISickleCellTesting:(pleaserefertotheattachedInformationpage.)Yes/No1.Areyouinthehighriskcategory?Yes/No2.HaveyoubeentestedfortheSickleCelltrait?

IfYes,Pleaseprovideproofoftestingaccompaniedbyaletterfromyourphysician. **IfNo,thereisanattachedwaiverformtobesignedandreturnedwithyourpacket.**

**ALLINCOMINGFRESHMENANDTRANSFERSMUSTHAVETHISTESTINGCOMPLETEDORTHEWAIVERSIGNED****YOUWILLNOTBECLEAREDFORPARTICIPATIONIFTHISTHISISNOTCOMPLETED**

VIIAdditionalNeeds:

Iacknowledgethatalloftheinformationthathasbeenprovidedisaccurateandcompletetothebestofmyknowledge.Therehasbeennoattempttowithholdanypertinentinformationthatmayadverselyaffectmyhealthandperformanceasastudent-athlete. SignatureofStudent-Athlete Date SignatureofParent/Guardian(ifStudent-Athleteisaminor) Date

Reviewed:May,2019

Student-AthleteAssumptionofRisk/ConsentforTreatment

Name Sport Date

StudentID DOB Phone

STATEMENTOFASSUMPTIONOFRISKANDCONSENTFORTREATMENT

Iunderstandthatthereisaninherentriskofinjuryassociatedwithparticipationofintercollegiateathletics.Iunderstandthatthisinjurymayresultseriousphysicalinjury;temporaryorpermanentdisability;death;seriousneckandspinalinjuriesthatmayresultincompleteorpartialparalysis;braindamage;seriousinjurytovirtuallyallinternalorgans;seriousinjurytovirtuallyallbones,joints,ligaments,muscles,tendons,andotheraspectsofthemusculoskeletalsystem;andseriousinjuryorimpairmenttootheraspectsofthebody.Intheeventthatthereisaneedforroutineoremergencymedicalcarethatistheresultofanathleticinjuryand/orillness,IgivepermissiontotheWagnerCollegeteamphysicians,athletictrainingstaffandassociatedmedicalprofessionals,toadministertreatmentasdeemednecessary. Student-AthleteName(print) Date SignatureofStudent-Athlete NameofParent/Guardian(requiredifunder18) Date SignatureofParent/Guardian(requiredifunder18) AdditionalInformation:(Ifnecessary)

Reviewed:May,2009

Student-AthleteProtectedHealthInformation

Name Sport Date

StudentID DOB Phone

STUDENT-ATHLETEAUTHORIZATION/CONSENTFORDISCLOSUREOFPROTECTEDHEALTHINFORMATION

Iauthorizethephysicians,athletictrainers,sportsmedicinestaffandotherhealthcarepersonnelrepresentingWagnerCollegetoreleaseinformationregardingthestudent-athlete’sprotectedhealthinformationandrelatedinformationregardinganyinjuryorillnessduringthestudent-athlete’strainingforandparticipationinathleticsatWagnerCollege.Ifurtherunderstandthatitisatmyrequesttocomplywiththerequirementsoftheschoolandthereleaseofprotectedhealthinformationtoacoach,athleticdirectororschoolofficialinconnectionwithparticipation in intercollegiateathletics. Thisprotectedhealth informationmayconcern thestudent-athlete’smedical status, medical condition, injuries, prognosis, diagnosis, athletic participation status, and relatedpersonally identifiablehealth information. Thisprotectedhealth informationmaybereleasedtootherhealthcare providers, hospital, and/or medical clinics and laboratories, athletic coaches, medical insurancecoordinators,athleticand/orschooladministratorsassociatedwithWagnerCollege. Student-Athlete’sName(Print) Date SignatureofStudent-Athlete Parent/Guardian’sName(ifStudent-Athleteisaminor) Date SignatureofParent/Guardian(ifStudent-Athleteisaminor)

Reviewed:May,2019

SickleCellTraitEducationAcknowledgmentandWaiver

Name Sport Date

StudentID DOB Phone AboutSickleCellTrait:

• Sicklecelltraitisaninheritedconditionoftheoxygen-carryingprotein,hemoglobin,intheredbloodcells.• Sicklecelltraitisacommoncondition(>threemillionAmericans).• AlthoughsicklecelltraitismostpredominantinAfrican-AmericansandthoseofMediterranean,MiddleEastern

Indian,Caribbean,andSouthandCentralAmericanancestry,personsofallracesandancestrymaytestpositiveforsicklecelltrait.

• Sicklecelltraithasbeenassociatedwithaconditionknownasexertionalrhabdomyolysis,renalfailureanddeath.Complicatingfactorsincludeextremeexertion,increasedheat,altitudeanddehydration.

• Sicklecelltraitisusuallybenign,butduringintense,sustainedexercise,hypoxia(lackofoxygen)inthemusclesmaycausesicklingofredbloodcells(redbloodcellschangingfromanormaldiscshapetoacrescentor“sickle”shape),whichcanaccumulateinthebloodstreamand“logjam”bloodvessels,leadingtoacollapsefromtherapidbreakdownofmusclestarvedofblood.

• ReadtheattachedSickleCellTraitFactsheetfromtheNCAAformoreinformation.Ihavereadandunderstandtheabovematerial,andIhavereceived,read,andunderstandtheNCAASickleCellTraitFactSheet. Signature Date SignatureofParent/Guardian(ifStudent-Athleteisaminor) Date

PleaseattachSickleCellTraittestingresultsORsignthewaiverbelow

WAIVERI,____________________________understandandacknowledgethattheNCAAandWagnerCollegeDepartmentof(PrintName)Athleticsrecommendsthatallstudent-athleteshaveknowledgeoftheirsicklecelltraitstatus.Additionally,Ihavereadandfullyunderstandtheaforementionedfactsaboutsicklecelltraittesting.Ichoosenottoreceiveascreeningtestforthesicklecelltrait.IacknowledgetheriskofparticipatinginWagnerathleticswithoutbeingtestedforthesicklecelltrait.Iassumeallresponsibilityforanyconditionsthatariseduetosicklecellandparticipationinathleticsinthefuture.________________________________________________ _____________________SignatureofStudent-Athlete Date________________________________________________ _____________________SignatureofParent/Guardian(ifunder18) Date

Reviewed:May,2019

SickleCellTraitEducationAcknowledgmentandWaiver

Source:https://www.ncaa.org/sites/default/files/NCAASickleCellTraitforSA.pdf

Reviewed:April2019

NCAAStudent-AthleteConcussionFactSheet

Reviewed:April2019

NCAAStudent-AthleteConcussionFactSheet

Reviewed:April,2019

Student-AthleteConcussionEducationAcknowledgementStatement

InitialIunderstandthatitismyresponsibilitytoreportallinjuriesandillnessestomyathletictrainerand/orteamphysiciantohelpexpeditemyhealthcare.

Initial

IhavereadandunderstandtheNCAAConcussionFactSheet.

AfterreadingtheNCAAConcussionFactSheet,Iamawareofthefollowinginformation:

Initial

Aconcussionisabraininjury,whichIamresponsibleforreportingtomyteamphysicianorathletictrainerimmediately.

Initial

Aconcussioncanaffectmyabilitytoperformeverydayactivities,andaffectreactiontime,balance,sleep,andclassroomperformance.

Initial

Youcannotseeaconcussion,butyoumightnoticesomeofthesymptomsrightaway.Othersymptomscanshowuphoursordaysaftertheinjury.

Initial

IfIsuspectateammatehasaconcussion,Iamresponsibleforreportingtheinjurytomyathletictrainerorteamphysician.

Initial

IwillnotreturntoplayinagameorpracticeifIhavereceivedablowtotheheadorbodythatresultsinconcussionrelatedsymptoms.

Initial

Followingaconcussion,thebrainneedstimetoheal.IammuchmorelikelytohavearepeatconcussionifIreturntoplaybeforemysymptomsresolve.

Initial

Inrarecases,repeatconcussionscancausepermanentbraindamage,andevendeath.

IagreethatifIwithholdthefactthatIhavesustainedaconcussionfromWagnerCollegeSportsMedicineIagreetoassumealltherisksandresponsibilitiessurroundinganysubsequentorrelatedinjuryorharm;andinadvanceherebyrelease,waive,foreverdischarge,andcovenantnottosueWagnerCollege,theofficers,agents,teamphysicians,andaffiliates,andemployeesofWagnerCollege(allofwhomarecollectivelycalledWagnerCollege),fromandagainstanyandallliabilityforanyharm,injury,damage,claims,demands,actions,causesofaction,costs,andexpensesofanynaturethatImanyhaveorthatmayhereafteraccruetome,arisingoutoforrelatedtoanyloss,damage,orinjury,includingbutnotlimitedtosufferinganddeath,thatmaybesustainedbyme,duetomyfailuretoreport.Itismyexpressintentthatthisassumptionofrisk,releaseandholdharmlessstatementshallbindthemembersofmyfamilyandspouse,ifIamalive,andmyestate,family,heirs,administrators,personalrepresentativesorassigns,ifIamdeceased,andshallbedeemedasa“Release,Waiver,Discharge,andCovenant”nottosueWagnerCollege. Signature Date PrintName Parent/GuardianSignature(ifunderageof18) Date PrintName Relationship

Reviewed:April,2019

BaselineConcussionSymptomEvaluation

Name_________________________ Sport________________________ Date_____________________

StudentID_____________________ DOB_________________________ Phone____________________ Thefollowingisalistofsymptomsassociatedwithconcussion.ForthisBASELINEassessment,pleaseratethefollowingsymptomsonascaleof0-6basedonhowyoutypicallyfeel.

None Mild Moderate SevereHeadache 0 1 2 3 4 5 6“Pressureinhead” 0 1 2 3 4 5 6NeckPain 0 1 2 3 4 5 6Nauseaorvomiting 0 1 2 3 4 5 6Dizziness 0 1 2 3 4 5 6Blurredvision 0 1 2 3 4 5 6Balanceproblems 0 1 2 3 4 5 6Sensitivitytolight 0 1 2 3 4 5 6Sensitivitytonoise 0 1 2 3 4 5 6Feelingsloweddown 0 1 2 3 4 5 6Feelinglike“inafog” 0 1 2 3 4 5 6“Don’tfeelright” 0 1 2 3 4 5 6Difficultyconcentrating 0 1 2 3 4 5 6Difficultyremembering 0 1 2 3 4 5 6Fatigueorlowenergy 0 1 2 3 4 5 6Confusion 0 1 2 3 4 5 6Drowsiness 0 1 2 3 4 5 6Moreemotional 0 1 2 3 4 5 6Irritability 0 1 2 3 4 5 6Sadness 0 1 2 3 4 5 6Nervousoranxious 0 1 2 3 4 5 6Troublefallingasleep 0 1 2 3 4 5 6Totalnumberofsymptoms: of22Symptomseverityscore: of132

Thisbaselineassessmentmustbecompletedbythestudent-athleteandreviewedbytheWagnerCollegesportsmedicinestaffbeforethestudent-athletewillbeallowedtoparticipateinANYWagnerCollegesponsoredathleticactivities.Theabovesymptomscaleisadaptedfrom:DavisGA,etal.Sportconcussionassessmenttool-5thedition.BrJSportsMed2017;0:1–8.doi:10.1136/bjsports-2017-097506SCAT5

Reviewed:May,2019

Pre-participationPhysicalExamination

ThisexaminationisrequiredbeforeyouwillbeallowedtoparticipateinintercollegiateathleticsatWagnerCollege.Thedateofexaminationmustbewithinsix(6)monthsofyourteam’sfirstdayofactivity(e.g.February1foranAugust1

startdate).Thisexaminationisrequiredyearly.

Name(Last,First,M.I.): Sport: DateofBirth: StudentID: Sex:MF*****************************************************************************************************MedicalHistory:Areyoucurrentlysufferingfromanyillnessand/orinjury? YES NOIfyes,pleasespecify: Areyoucurrentlytakinganymedicationsonashortorlong-termbasis? YES NOIfyes,pleasespecifywhatandwhy: Haveyoubeenhospitalized,includingEmergencyRoomvisitsorneededtoseeadoctorforanyinjuryorillnessduringthepastyear? YES NOIfyes,pleaseprovidedetails: *****************************************************************************************************Physician’sExamination(IndicateifexaminationisNormalbyplacingan“X”whereindicated.Ifexaminationisnotabnormal,pleasedescribewhy.)Height: Weight: B/P: Pulse: Normal Commentsifabnormal GeneralAppearance Cardio-Pulmonary Circulatory Respiratory Endocrine/Lymphatic Digestive/Urogenital Extremities Head,Neck,Spine Neurological Physician’sStatementIhaveexaminedthisindividualandhavedeterminedtheindividualis(chooseoneofthefollowing):__ClearedforALLsportsw/outrestriction__Clearedw/restrictionsand/orfollow-up__NOTCleared(unfittoparticipate)Explanation/Comments: Physician’sAddress: Physician’sPhone#: Physician’sFax#: PhysicianName(Print) Signature ExamDate

Reviewed:May,2019

OrthopedicPre-ParticipationExamination

ThisexaminationisrequiredforFOOTBALLstudent-athletes.Thisexaminationisrequiredyearly.

Name(Last,First,M.I.): Sport: DateofBirth: StudentID: Sex:MF*******************************************************************************************OrthopedicHistoryAreyoucurrentlyinjured? YES NOIfyes,pleasespecify: Haveyoueverbrokenabone? YES NOIfyes,pleasespecify: Haveyouevertornorsprainedaligament? YES NOIfyes,pleaseprovidedetails: Haveyoueverhadsurgerybecauseofaninjury? YES NOIfyes,pleasespecify: ******************************************************************************************OrthopedicPhysician’sExamination(IndicateifexaminationisNormalbyplacingan“X”whereindicated.IfexaminationisAbnormal,pleasedescribewhy.) WNLCommentsifAbnormal UpperExtremity LowerExtremity Trunk Head/CervicalSpine Spine GeneralMusculature Physician’sStatementIhaveexaminedthisindividualandhavedeterminedtheindividualis(chooseoneofthefollowing):__ClearedforALLsportsw/outrestriction__Clearedw/restrictionsand/orfollow-up__NOTCleared(unfittoparticipate)Explanation/Comments: Physician’sAddress: Physician’sPhone#: Physician’sFax#: Physician’sName(Print) Signature ExamDateAthlete’sStatementIunderstandthatImustabidebyanyandallrestrictionsofactivity,whichareplacedonmyselfbytheTeamPhysicianand/ortheHeadAthleticTrainer,duetoinjuryand/orillness.IunderstandthathavingpassedthephysicalexaminationdoesnotmeanthatIamphysicallyqualifiedtoengageinstrenuousathleticactivity.IcertifythattheinformationIhaveprovidedisaccurateandtrue. Student’sName(Print) Signature Date

Reviewed:May,2009

HealthInsuranceInformationandAcknowledgement

PrimaryHealthInsuranceALLfull-timeundergraduatestudentstaking12ormorecredithours(4units)andALLfull-timegraduatestudentstaking9ormorecredithoursarerequiredtoprovideproofofhealthinsuranceeffectiveinNewYorkannually.

WagnerCollegeprovidesallstudentswithprimaryhealthinsurancethroughEducational&InstitutionalInsuranceAdministrators(EIIA).Studentsareautomaticallyenrolledinthispolicy,andthecostofthispolicyisaddedtothestudent’suniversityfees.

StudentshavingprimaryinsurancemaywaivethemandatoryWagnerCollegestudenthealthinsurancebyvisitingthefollowinglink:www.eiia.org/institution/wagner-college(EIIA).Thislinkalsoprovidesaccesstopolicyinformation,healthinsuranceIDcard,claimforms,andphonecontactinformation.ALLstudent-athletesmustprovidetheSportsMedicinedepartmentwithproofofhealthinsurance(i.e.acopyofthefrontandbackofthestudent-athlete’sinsurancecard,orproofofenrollmentintheschoolprovidedhealthinsurancepolicy).Thestudent-athletewillnotbeclearedforparticipationuntilthisinformationisreceived.

*Pleasetakethetimetoreviewtheprovisionsofyourhealthinsurancepolicy.IfyourpolicydoesnotcovergeneralmedicalandspecialistserviceintheCityofNewYorkforthedurationoftheathleticyear,thestudent-athletewillneed

tobeenrolledinapolicythatdoes*SecondaryAthleticsHealthInsuranceTheWagnerCollegeDepartmentofAthleticsprovidesstudent-athleteswithathletic-accidentcoverage.Thispolicyissecondaryinsurancecoverage.Whenservicesarereceived,aclaimmustfirstbefiledwithyourinsurancecompanyandthenallremainingbalanceswillbebilledtothesecondaryinsurance.Thereisnocosttotheathletefortheathleticcoverage.YouwillstillneedtorespondtotheCollegeforadenialoracceptanceofthegeneralinsuranceplan.TheAthleticinsurancecoverageisunrelatedtothegeneralschoolplan.CLAIMPROCEDURE

1) TheSportsMedicineStaffmustbenotifiedofanyinjuryimmediately.Inorderfortheathleticcoveragetoapply,astaffmemberMUSTarrangeanymedicalcarereceivedbythestudent-athlete.Ifthestaffisnotproperlyinformedthestudent-athletesand/orparentswillbecomefinanciallyresponsibleforanyorallmedicalbillsincurred.

2) Thestudent-athletemustbringtheirprimaryinsurancecardtotheappointment.Theywillbegivenasecondaryinsuranceclaimformthatmustalsobesubmittedatcheck-in.

3) Thestudent-athlete’sprimaryinsurancewillbebilledfirst.Theremainingbalancewillthenbebilledtothesecondaryinsurance.

Pre-existinginjuriesandinjuriesoutsideofofficialNCAA-governedathleticevents/practiceswillnotbecovered.Illnessesandself-referralsnotrelatedtointercollegiatesportswillnotbecovered.IFYOURECEIVEABILL:YoumustsubmitittotheSportsMedicineStaffassoonaspossible.BILLSMUSTBERECEIVEDWITHIN60DAYSOFTHEINVOICEDATE.DONOTWAITUNTILYOUHAVERECEIVEDMULTIPLENOTICES.Anyadditionalfeesrelatedtolatepaymentwillnotbecoveredifthebillwasnotreceivedpromptly.Youwillalsoneedtosubmitthe“ExplanationofBenefits”youreceivedinthemailfromyourinsurancecompanythatcorrespondstothebill.Thiscanalsobeobtainedonyourinsurancecompany’swebsiteorbycallingthemdirectly.BillscannotbeprocessedwithoutanExplanationofBenefits.Duetocurrentprivacypoliciesoftheinsurancecompanies,theSportsMedicineStaffhasnowayofknowingifbillshavebeenpaidbyanathlete’sfamilyinsuranceforaspecificprovider.PromptcommunicationwiththeSportsMedicineStaffisnecessaryfortroubleshootingbillingproblems.

Reviewed:May,2009

HealthInsuranceInformationandAcknowledgement

BillsandEOBsmaybedeliveredtothestaffbythestudent-athleteorsentdirectly(mail,email,orfax)to:JulieFlantzer,AssociateAthleticTrainerWagnerCollegeAthletics1CampusRoadStatenIsland,NY10301Julie.flantzer@wagner.eduFax:(718)390-3302OUT-OF-NETWORKPROVIDERPOLICYYourprimaryinsurancecompanywillhaveproviders(physicians,physicaltherapists,etc)thatareconsidered“in-network”.Eachindividualpolicyhasdifferentcoverageforin-networkandout-of-networkproviders.Athleteswhoseekoutcarebysomeoneotherthanourteamphysicianmustfirstverifythattheproviderisin-network.IFYOUWISHTOSEEAPROVIDERWHOISOUTSIDEYOURINSURANCENETWORKTHESESERVICESWILLNOTBECOVEREDBYWAGNERCOLLEGE.Student-athleteswhodoelecttoseekcareoutsideofourteamaffiliatedphysicianswillberequiredtosignanacknowledgmentstatingtheyassumefinancialresponsibilityfor“out-of-network”care.CHANGEINPRIMARYINSURANCEDuringthecourseoftheacademicyearsomestudent-athleteshavetheirmedicalinsurancechangeorgetterminatedduetotheparents/guardianschangingorlossoftheiremployment.ItistheresponsibilityofthestudentathletetonotifytheSportsMedicineStaffandprovideacopyoftheirnewcardwhenanychangestakeplacewiththeirmedicalinsurance.Shouldthestudent-athletefailtonotifytheSportsMedicineStaffthestudent-athleteandortheirparents/guardiansmayberesponsibleforanyorallmedicalbillsincurred.REFERRALSManyinsurancecarriersrequireareferralforspecialtyservices.AtWagnerCollegewedealmainlywithspecialtyserviceswithourteamphysician,inparticularorthopedicservices.Ifbeforebeingseen,referralsarenotobtainedmanytimestheseserviceswillbedeniedbytheprimarycarrieraswellasoursecondaryinsurancecarrier.ItwouldbehelpfuliftheprimarycarephysicianisswitchedovertoalocalphysicianhereonStatenIslandsothatwecaneasilyobtainreferralsifnecessary.DENTALINSURANCECOVERAGEOnoccasionanathleticinjurywillresultininjurytotheteethormouth.Insuchcasesitishelpfultohaveacopyofthedentalinsurancecardifitisseparatefromtheprimaryinsurancecard.PleaseprovidecopiesofbothupdatedcardstotheSportsMedicineStaffatthebeginningofeachschoolyearifnecessary.Againpleasedoublechecktoseethatthecardisuptodateforcoverageofmedicalanddentalservices.Ifyouhavefurtherquestionsregardinginsurance,pleasecontactJulieFlantzer,AssociateAthleticTrainerat(718)420-4044orjulie.flantzer@wagner.edu

PLEASEKEEPTHISLETTERFORYOURRECORDS

Reviewed:May,2009

HealthInsuranceInformationandAcknowledgement

Name Sport Date

StudentID DOB Phone

Initial

IacknowledgethatIhavereadandunderstandWagnerCollegeinsurancepoliciesandprocedures.

Pleasechooseoneofthefollowingoptionsbymarkingan“X”

IhaveaprimaryhealthinsurancepolicythatprovidescoverageintheCityofNewYorkforthecompleteupcomingathleticyear.(Submitacopyofthefrontandbackofyourinsurancecardwiththispacket)

Idonothaveaprimaryhealthinsurancepolicy,ormypolicydoesnotprovidecoverageintheCityofNewYorkforthecompleteupcomingathleticyear,andwillbeenrolledintheWagnerCollegehealthinsurancepolicy.

Signature Date SignatureofParent/Guardian(ifStudent-Athleteisaminor) Date SignatureofPolicyHolder(ifnotstudent-athlete) Date PrintedNameofPolicyHolder Relation