Dear Student Athlete and Parent, Welcome to Morningside College and Morningside Athletics.

We are excited to have you participating in intercollegiate athletics at Morningside College. We have placed the athletic forms needed for the Athletic Training Room Staff online. You will find these forms under the student insurance link on the Athletics website. This is need strictly for your participation in athletics; it is separate from the student health paperwork. Included in this packet are as follows: Personal Data Health History or Health Status Review Proof of Insurance Assumption of Risk Pre-existing Conditions Release & Waiver Substance Abuse Testing Insurance Coverage Information Referral Policy Sports Medicine Provider Information All the forms need to be filled out entirely, signed, and returned to the Athletic Training Room Staff by July 16, 2010, via mail or hand delivery, email submission will not be accepted. Please send the completed forms to: Morningside College Athletic Training 1501 Morningside Ave. Sioux City, IA 51106 If you have any questions about these forms, the insurance coverage information or the referral policy information please contact the Athletic Training Room Staff at 712-2745314 (Greg). We look forward to working with you during your intercollegiate athletic career at Morningside College. Sincerely, Greg Seier Head Athletic Trainer

) Please Fill In As Completely As Possible: Year of Last Tetanus Shot ____________________ TB Skin Test ________________________________ Sickle Test Index ____________________ When You Participate In Sports. (Include Birth Control. Please Name The Prescribing Physician Below (Name) (City) (State) (Phone #) Describe The Type Of Contacts Worn (Soft.INTERCOLLEGIATE ATHLETICS PERSONAL DATA MORNINGSIDE COLLEGE ATHLETIC TRAINING 2010-2011 Student Athlete Information: Name Parent/Guardian Information: ________________________ Name(s) __________________ First MI Last SS# ________________________ Relationship __________________ Date of Birth ________________________ Home Address __________________ Local Phone # ( )____________________ City. Hard. Crowns) ____________________________________________ . Zip __________________ Cell Phone # ________________________ Home Phone # Sport(s) ________________________ Work Phone # ( ( )_____________ )_____________ ________________________ Emergency Contact __________________ Year in School 1st 2nd 3rd 4th 5th (Circle One) Emergency Phone # ( Family Physician ________________________________________( Name City State )_____________ )_____________ Phone # Are You Allergic To: Type Circle One Explanation PENICILLIN YES NO SULFA DRUGS YES NO OTHER DRUGS YES NO INSECTS / FOODS YES NO Do You Take Any Medications Regularly? YES NO If Yes. Gas Permeable. Allergy Medication/Shots. Do You Wear Eyeglasses? __________ And/Or Contacts? __________ (Yes/No) (Yes/No) If Yes To The Above Question. Bridges. Etc. State. Please List And Explain. Extended Wear) __________________ Contact Brand __________________ Contact Prescription R _____________ L _________________ Eyeglass Prescription R _____________ L _________________ List All Dental Appliances (Caps.


Please note that the school’s general insurance policy for students does not cover athletic injuries. Zip Code Home Telephone # ___________________________ Work Telephone # ________________________ Insurance Company ___________________________________ Policy # _______________________ IS YOUR DEPENDENT SON/DAUGHTER COVERED UNDER THE ABOVE POLICY? Yes ____ No ____ Does your insurance require: A second opinion for surgery? Yes ____ No ____ Pre-Authorization for service? Yes ____ No ____ Check Appropriate: HMO _____ PPO _____ Co-Pay Required _________ I verify that the above statement of insurance is true. In the event that our insurance denies the claim for whatever reason the remaining balance is considered your responsibility. State.INTERCOLLEGIATE ATHLETICS PROOF OF INSURANCE 2010-2011 Student Athlete Social Security Number Date of Birth MORNINGSIDE COLLEGE ATHLETIC TRAINING Sport Dear Parent Parent/Guardian Information Our athletic accident policy which provides insurance for your son or daughter for injuries occurring while participating in the play or practice of intercollegiate sports is “SECONDARY” to any other collectible insurance company providing coverage to your son or daughter through your employer or your spouse’s employer. Keep in mind that our insurance will not consider a claim until a $500 deductible has been met be either you and/or your insurance. we can file the claim with our athletic insurance company upon your specific request. complete and correct to the best of my knowledge Signature of Parent/Guardian: Date: . Primary Policy Holder’s Name: ___________________________ SS#: _________________ Date of Birth: _________ Home Address: ______________________________________________________________________ Street City. Zip Code Employer’s Name: ___________________________________________________________________ Street City. Requests for filling must come within 180 days of the initial athletic injury. State. Zip Code Home Telephone # ___________________________ Work Telephone # ________________________ Insurance Company ___________________________________ Policy # _______________________ IS YOUR DEPENDENT SON/DAUGHTER COVERED UNDER THE ABOVE POLICY? Yes ____ No ____ Does your insurance require: A second opinion for surgery? Yes ____ No ____ Pre-Authorization for service? Yes ____ No ____ Check Appropriate: HMO _____ PPO _____ Co-Pay Required _________ Secondary Policy Holder’s Name: ___________________________ SS#: _________________ Date of Birth: _________ Home Address: ______________________________________________________________________ Street City. State. State. Zip Code Employer’s Name: ___________________________________________________________________ Street City. After your primary insurance has paid all available benefits.

I will notify the athletic training staff in the event my coverage has ended or has changed. Initial ________ 7. Initial ________ _____________________________ ________ Student-Athlete Signature Date _____________________________ ________ Student-Athlete’s Spouse Signature Date ________________________________ _______ Parent/Guardian Signature Date . Morningside college’s Athletic Department has provided a policy which explains to the parent(s)/guardian(s) and the student-athlete that the initial claim must be filed with the parent’s or student-athlete’s private health insurance company before Morningside College’s athletic health insurance may be utilized. I hereby authorize Morningside College and EIIA (athletic insurance). and Summit to inspect or secure copies of case history records. I understand that all student-athletes must maintain primary insurance coverage while participating in athletics at Morningside College.INTERCOLLEGIATE ATHLETICS PROOF OF INSURANCE 2010-2011 MORNINGSIDE COLLEGE ATHLETIC TRAINING PROOF OFINSURANCE ADDENDUM PLEASE READ CAREFULLY AND PROVIDE INITIALS AFTER EACH STATEMENT 1. I understand that coverage denied by my primary policy and Morningside’s Accident Plan will be my responsibility. I understand that if my primary insurance lapses during the course of the school year I will be responsible for any bills generated after that point. been encouraged to secure adequate insurance protection prior to participation. I hereby authorize permission to Morningside College. and that the student-athletes or their primary insurance plan must cover at least the first $500 of each claim. and/or athletic trainers to render first aid. Initial ________ 6. Futhermore. Initial ________ 4. Thus. I will retain the copy provided to me for future reference. its team physician. laboratory reports. x-rays. A photocopy of this authorization shall be deemed as effective and valid as the original. Initial ________ 5. the undersigned has. The undersigned hereby acknowledges that he/she understands that many activities of intercollegiate athletics involves substantial risk of injury. accordingly. I have read and agree to the statements of the “Athletic Injury and Referral Policies” (Separate Page). Initial _______ 2. that it is my responsible to maintain a primary policy in which I have coverage while participating at Morningside College. Initial ________ 3. emergency medical or surgical care deemed necessary for my health and well being. Morningside College will assume no responsibility for paying denied claims. treatment. and any other data covering this and/or previous confinements and/or disabilities.


have read and agree to comply with the Athletic Injury and Medical Referral policies as put forth by the Morningside College Athletic Department. illness. dictations. or other medical /psychological /personal conditions that may affect my participation in any way with Morningside College Intercollegiate Athletics sanctioned practices. I understand that this information will be shared for referrals and correspondence with physicians and medical professionals who are directly involved with my care. I understand that in order for the Educational and Institutional Insurance Administrations. ______________________ (Student – Athlete) ______________________ (Parent/Guardian/Spouse) _________ Date _________ Date INFORMED CONSENT FOR RELEASE OF MEDICAL INFORMATION I. understand and have been provided with a copy of these policies. Signature of student-athlete _______________________ Date ________________ PLEASE ATTACH COPIES OF YOUR INSURANCE CARD BELOW FRONT BACK .INTERCOLLEGIATE ATHLETICS PROOF OF INSURANCE 2010-2011 Student Athlete Social Security Number Date of Birth MORNINGSIDE COLLEGE ATHLETIC TRAINING Sport Acknowledgment of Athletic Injury and Medical Referral Policies I. and events. contests. and follow up notes which are provided through the certified athletic trainers./Summit (Morningside College’s excess Athletic Accident Plan administrator) to process claims they must be provided with injury reports. ____________________. permission to share medical and insurance information with the Team Physicians and or other medical professionals regarding injuries. ____________________. Furthermore. My signature below verifies that I have read. give the certified athletic trainers employed by Morningside College and CNOS Sports Medicine. team functions. Inc.

Have you ever participated in athletics against the advice of a medial professional? Yes No Males Only 27. mononucleosis)Yes No within the last month? 22. wheeze. or testicle? Yes No 21. How much time do you usually have from the start of one period to the start of another? ____________ 32. Are you missing an eye. Have you ever used steroids or other performance enhancing agents Yes No 15. Other than heat related. Have you ever passed out during or after exercise? Yes No 14. or severely strained Yes No or pulled a muscle? 26. When was your first menstrual period? ___________________________________________________ 30. sprain. Has any family member or relative died of heart problems or of sudden Yes No death before age 50? 8. 23. When was your most recent menstrual period? _____________________________________________ 31. Have you ever had a broken or fractured bone. myocarditis. Have you ever had a head injury or concussion? Yes No 11. Social Security Number Date of Birth MORNINGSIDE COLLEGE ATHLETIC TRAINING Sport Do you have asthma? Yes No 2. Do you cough. ovary. kidney. Do you get tired more quickly than your peers do during exercise? Yes No 16. shoulder. Have you ever been diagnosed with an eating disorder of any type? Yes No 25. arm. Have you ever had high blood pressure or high cholesterol? Yes No 5. Have you ever had a hernia? No 28. Have you ever had a stinger/burner in your neck. Do you have two functioning testicles? No Yes Yes Females Only 29. Do you lose or gain weight regularly to meet weight requirements for your sport? Yes No 24. Do you want to weight more or less than you do now? (Circle One) List Goal Weight _______ lb. or have trouble breathing during or after activity? Yes No 3. become unconscious. Do you have a history of diabetes? Yes No 20. Have you had a severe viral infection (for example. Have you ever been knocked out. Have you ever become ill from exercising in the heat? Yes No 17. have you ever been dizzy during or after exercise? Yes No 18. or lost your memory? Yes No 12.INTERCOLLEGIATE ATHLETICS HEALTH HISTORY 2010-2011 Student Athlete 1. Have you ever had racing of your heart or skipped heartbeats? Yes No 4. or hand due to Yes No participation in athletics? 13. Have you ever had any chest pain during or after exercise? Yes No 9. Do you have seasonal allergies? Yes No 19. Have you ever been told you have a heart murmur? Yes No 6. How many periods have you had in the last year? __________________________________________ . Has a physician ever denied or restricted your participation in sports for any Yes No heart problems? 10. Do you have a family member with a history of Marfans Syndrome? Yes No 7.

______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Student Athlete Signature ______________________Parent/Guardian Signature_____________________ .33. What was the longest time between periods? ______________________________________________ Please elaborate on any questions to which you answered yes.

illness. its Athletic Department. financial or otherwise. By signing. _____________________ Student-Athlete Signature _______ Date _____________________ Parent/Guardian/Spouse ________ Date . athletic training staff member. illness.INTERCOLLEGIATE ATHLETICS PRE-EXISTING CONDITIONS MORNINGSIDE COLLEGE ATHLETIC TRAINING 2010-2011 Student Athlete Social Security Number Date of Birth Sport It is the policy of Morningside College. or condition incurred while not engaging in intercollegiate athletic activity. I. and Morningside College Athletic Training that we (stated above) will not assume responsibility. It is noted that the National Association of Intercollegiate Athletics (NAIA) prohibits the college from being financially or otherwise responsible for any injury. _________________ (student-athlete name) understand that I can be restricted or eliminated from participation in intercollegiate athletics due to a pre-existing condition if deemed appropriate by a Morningside College team physician. for injury. It is required that the student-athlete have proper documentation from their previous physician(s) or health care providers about significant injuries or conditions prior to arrival at Morningside College. or other qualified medical personal acting in the best interest of myself and/or Morningside College. or medical conditions occurring and/or existing prior to the first official day of participation in intercollegiate athletics at Morningside College. so that proper evaluation can occur prior to beginning participation as well as appropriate follow-up care if the condition or injury is aggravated or re-injured. I agree that I have read this policy and agree to the terms described within it.

illness. _________________. or emergency treatment deemed reasonably necessary to protect. and/or because of an undue liability risk to Morningside College. ________ Student-Athlete Initials ________ Parent/Guardian/Spouse Initials I. but are not limited to death. I recognize the importance of following coach’s instructions concerning playing technique. ____________________________ Student-Athlete Signature ________ Date __________________________ Parent/Guardian/Spouse ________ Date . I understand that the dangers and risks of playing or participating to play/participate in the above sport include. initial and sign. I further authorize the Athletic Training staff at the above mentioned institution who are under the direction and guidance of Morningside College’s team physicians. (student-athletes name) agree to share in confidence the perimeters of my signs and symptoms of injury/illness with the team physician. serious neck and spinal injuries which may result in complete or partial paralysis. rehabilitative techniques/reconditioning. athletic training staff. report changes on condition and take an active part in potential rehabilitative measures for my well-being. I understand that the dangers and risks of playing may result not only in serious injury. to render any preventive technique. Furthermore. ______________________. I. social. I also authorize the athletic training staff and/or other medical consultants to evaluate and treat my injuries that occur during my participation in intercollegiate athletics at Morningside College. and generally to enjoy life. brain damage. general health and well-being. parent/guardian/spouse that they have read and hereby understand the term and conditions of the Morningside College Athletic Injury and Medical Policy and will hereby return all information as requested previously. training.INTERCOLLEGIATE ATHLETICS ASSUMPTION OF RISK 2010-2011 Student Athlete Social Security Number Date of Birth MORNINGSIDE COLLEGE ATHLETIC TRAINING Sport The student-athlete and a parent/guardian. etc. Because of the dangers of participating in the above -mentioned sport(s). serious injury involving bones. (student athletes name) am aware that playing or participating to play/participate in any sport can be a dangerous activity involving many risks of injury.. I take personal responsibility to meet appointments. tendons. parent/guardian/spouse (if appropriate) are required below to signify acceptance by the said student-athlete. and to agree to obey such instructions. ligaments. must read carefully. if the student is a minor at the time of signing. maintain or promote the health well-being of the student athlete listed above. serious injury to virtually all internal organs. to engage in other business. Furthermore. I also recognize that the risk of the above mentioned injuries/conditions is present even when following coach’s instructions concerning playing technique. and recreational activities. but in a serious impairment of my future abilities to earn a living. and other aspects of my body. accepted method of injury care. joints. ________ Student Athlete Initials _________ Parent/Guardian/Spouse Initials The signature of the student athlete. and other team rules. health education counseling. training and other team rules. athletic training staff and other qualified medical personnel have the authority to eliminate me from further participation because of an injury. I understand the team physicians. medical condition. muscles. etc. to follow the advise/instructions of the team physicians and athletic training staff. and other members of the sports medicine network.

employees. personal injury or death resulting from any accident which may occur as a result of participation in the above mentioned activity. and to the same extend and scope. I. associates and officers from any and every claim. the undersigned. affirmatively swear that I am at the time of this signing of legal age (or if not of legal age will have an appropriate parent or guardian sign as well) and fully competent to and do hereby execute this Release and Waiver on behalf of myself. my heirs. in consideration for being permitted to participate in such activity. and forever discharge Morningside College. arising from any bodily harm. warrant that I am presently in good physical condition and hereby agree to assume the risk of any injury or condition that I may suffer as a result of my participation in ____________________ at Morningside College from ____________(beginning date) until ____________ (end date). or assigns. demand. its agents. waive. affiliates. I the undersigned and appropriate parent or guardian. Therefore. In witness whereof I have voluntarily and without inducement from any party executed this Release and Waiver on ______________ (date). Further. medical care or other emergency treatment rendered me in connection with my participation in such activity.INTERCOLLEGIATE ATHLETICS RELEASE & WAIVER 2010-2011 Student Athlete Social Security Number Date of Birth MORNINGSIDE COLLEGE ATHLETIC TRAINING Sport In recognition of and with knowledge of the fact that engaging in the sport of _________ involves a substantial risk of personal injury. _________________________ Student-Athlete Signature __________ Date _________________________ Parent/Guardian Signature __________ Date . I furthermore represent and warrant that I have read and fully understand the terms of this document and their legal significance. I hereby release. contracted employees. or action of whatever kind. I release said parties from any claim whatsoever which may be attributable to the receipt of first aid.

I also understand that any and all information INCLUDING drug test results pertaining to such incidents may be reviewed by Morningside College Administration for review and possible action independent of the Athletic Department. I agree to fully accept and comply with the decision and consequences determined appropriate by the Director of Athletics and/or Associate Director of Athletics that any expenses incurred for counseling. I understand. MARIJUANA. BENZOPAIN. after appropriate appeals process if I so choose. substance abuse education or other such services are my sole responsibility. but are not limited to the following: ALCOHOL. METHADONE. competitive rules or Morningside College policy. and ANABOLIC STEROIDS. if applicable. and its affiliated organizations and programs. Drug testing may occur should just-cause or evidence beyond a reasonable doubt be presented or apparent to any member of the Morningside College coaching staff. I understand and agree with the above-mentioned penalty for a positive drug test and violation of substance abuse policy. METHAQUALONE. for violation of substance abuse policy illegal by law. BARBITUATES. or mascot constitutes an agreement to comply with all the regulations of Morningside College. Testing may also occur on a random basis terminated by the Director of Athletics. OPIATES.SUBSTANCE ABUSE TESTING VOLUNTARY SUBMISSION MORNINGSIDE COLLEGE ATHLETIC TRAINING 2010-2011 Student Athlete Social Security Number Date of Birth Sport The acceptance of membership on any athletic team bearing Morningside College name._________________. Athletic Training staff. _______ Initial The drugs TO BE TESTED for include. departmental administrative staff or other appropriate Morningside College faculty or staff. logo. AMPHETAMINES. PHENCYCLIDINE. I. rehabilitation. A voluntary consent to undergo and cooperate in drug testing is encouraged. its athletic department. PCP. I also understand that TERMINATION of team membership and recommended non-renewal of any athletic scholarship MAY occur at the time of a POSITIVE TEST. COCAINE. SIGNED: ___________________________________________ PARENT (if needed): _________________________________ DATE: ___________ DATE: ___________ . fully understand that I may be temporarily or permanently suspended from a team or there may be a recommendation made for non-renewal of my scholarship. agree to comply with and participate in Morningside College Athletic Department voluntary substance abuse testing within the above stated guidelines.

If you are considering Short Term Major Medical plan. during. thus.or outside of athletics. Morningside College is not responsible for the remaining balance. and therefore will not meet the athletic department’s requirement for Proof of Insurance. I urge you to begin the process quickly. Please fill out All of the forms completely and return them to us as soon as possible prior to your son/daughter’s arrival on campus. recognition. and met at least the deductible ($500 minimum per claim) as described in the athletic department policy. Contact an agent you are comfortable with and share this letter with them so that you will be prepared for the upcoming school year. is an attractive value…but will not cover athletic injuries. Meis serves as our orthopaedic consultants. and after an athletic related injury or illness for those student-athletes who participate in intercollegiate athletics at Morningside College. he serves as a coordinator for the Siouxland Medical Residency Program in teaching new physicians how to be successful. rehabilitation and reconditioning. Also keep in mind that neither Morningside College nor E.Dear Morningside College Parents/Guardians and Student-Athletes. The Center for Neurosciences. the insurance policy that is maintained by the athletic department is a secondary policy. I encourage you and your son/daughter to become familiar with the mechanics of your coverage. Dr.I. Our staff’s activities include prevention. Furthermore. We are pleased to serve Morningside College and its student-athletes. managed care and referral. Go Mustangs!!! Greg Seier. Their practice. Illness is not covered at all under the athletic department’s secondary insurance policy. South Dakota. If you do not currently have a primary insurance policy that will cover your son or daughter in this provider area. be sure to verify that it will cover athletic injuries. Merle Muller serves as our Head Team Physician and oversees all care provided to our student-athletes. Please keep in mind. permission for treatment. high deductibles. often many headaches can be avoided. Also please note that if there is a remaining balance after both your and Morningside’s insurance process the claim. your primary should give you peace of mind that your son or daughter has coverage regardless of what may happen to him or her in. MSE ATC/L Athletic Trainer 712-274-5314 . the policy that is offered to all Morningside students during registration (John Rice Agency). No student-athlete will be allowed to participate in organized practice or competition until the Proof of Insurance forms. Orthopaedics. Taking that into account. etc.I. Athletes will not be allowed to participate in practice or competition until all forms are complete and they have been cleared on their on-campus physical! We look forward to the upcoming academic year and the promise it brings. notification of company. as some of them do not. it will not pay until the primary carrier has processed the claim/bills. If you have questions please do not hesitate to call on us. as it is not directly related to athletic accidents that may occur.A/Summit (our athletic insurance carrier) will pay for injuries that are not directly related to intercollegiate athletic participation. and evaluation. Dr. It is the responsibility of the Athletic Training Staff to coordinate the care provided prior to. as well as all Athletic Department forms are completed and on file in the Athletic Training Room with the Athletic Department. In addition to his duties at the Family Practice Center. education and counseling regarding athletic injuries and illnesses. & Spine (CNOS) is located at 575 Sioux Point Road in Dakota Dunes. Examples: limited # of physicians. Dr Meis is sports medicine trained orthopaedic physicians and have extensive training and experience dealing with athletic injuries. If we all are familiar with our policies.

the ATC’s will assist with the proper referral in all cases. 5. All student-athletes must maintain primary insurance coverage throughout the entire school year. inform the ATC (certified athletic trainer) assigned to your team for proper follow-up. try to contact a member of the athletic training staff. This means they must be covered by a plan/policy that will pay claims should they become injured or ill during a practice or contest. you are encouraged to contact your insurance carrier prior to filling out the paperwork requested by the Athletic Training Staff. report to Mercy Medical Center (6th & Douglas) or St. The staff ATC’s will be responsible for making all initial referrals and appointments. or if urgent. In some cases a fee for missed appointments may be assessed. Prior to your return to activity after a significant injury or surgery. for care and follow-up. 8. employer changes insurance. so that the policy holder. . etc. 7. Morningside College has a special arrangement for accelerated appointment scheduling with quality physicians and medical professionals to care for the needs of our student-athletes. and dated and on file prior to clearance for participation in any Morningside College sanctioned intercollegiate athletic practice or contest. (You will not be allowed to participate in intercollegiate athletics without evidence of primary insurance. The packet with your medical history. the insured (student-athlete) and the athletic training staff all understand what is required in the event of an injury.) You must also provide Morningside College with a photocopy of your insurance card (front & back) as stated on the Proof of Insurance form as well as any other appropriate medical documentation about pertinent. report to the Athletic Training Room. If medical care is needed during a time when the Athletic Training Room is closed. dictations. Again. 2.Athletic Department ATHLETIC INJURY AND REFERRAL POLICIES THESE POLICIES ARE DESIGNED FOR THE PROTECTION OF THE STUDENT-ATHLETE PARTICIPATING IN THE MORNINGSIDE COLLEGE INTERCOLLIEGIATE ATHLETIC PROGRAM. You are encouraged to contact your insurance carrier prior to filling out the paperwork requested by the Athletic Training Staff. A claim may be made to the secondary insurance carrier upon request within the 180-day claim period set by the company. prior and/or current medical conditions. ASAP. 1.e. If you are insured by a PPO or an HMO network. waivers. contact them and obtain authorization for treatment immediately. Should the student-athlete lose or change coverage for any reason (parent changes job. and other forms as well as an on campus athletic physical conducted by a Morningside College team physician must be completed. Report all new injuries or illnesses to the supervising ATC prior to 10:00 am the following day for proper care and notification of the coaching staff. If you are not insured by a PPO/HMO network and elect to have surgery without a referral from the Morningside Athletic Department. 3. you will need a medical release from a Morningside College Team Physician Prior to returning to activity regardless of other release obtained. You will also be required to obtain the appropriate documents (i. AND FOR THE DEPARTMENT OF ATHLETICS AT MORNINGSIDE COLLEGE.) the student-athlete is responsible for notifying the athletic training staff as soon as possible. The student-athletes are furthermore responsible for restoring coverage for themselves in some manner. 9. you will be responsible for all bills/expenses incurred. signed. 6. If signs and symptoms appear away from the athletic setting. you will be responsible for the bills. our Team Physician will see you first and conduct the initial evaluation. 4. the insured (student-athlete) and the athletic training staff all understand what is required in the event of an injury. we ask that our team physician handle medical referrals and care if possible. This is an additional reason to maintain primary insurance coverage. If injured during a contest or practice. Make sure to notify your primary insurance carrier and the Athletic Training staff AS SOON AS POSSIBLE. In the interest of the college. 10. rehab prescription) explaining the care and treatment given to you outside of the Morningside College Sports Medicine Network. proof of insurance. In the event that you are injured and require surgery or other testing. so that the policy holder. NOTE: Illnesses are not covered by the Athletic Accident Plan carried by Morningside College. However. Morningside College does not assume responsibility of medical bills for any athletic related injury for any student-athlete. Luke’s Regional Medical Center (28th & Pierce). You will ultimately be responsible for keeping such appointments and making transportation arrangements. If you seek medical treatment without a referral from a staff ATC.

The team physician and our athletic conference officials shall be the final authority for medical hardship and related situations. The athletic director. 12. If these are deemed inaccurate. . and team physicians will have the final say regarding the interpretation of the above-mentioned policies.11. Copies of your insurance carrier’s pay or denial statements (“explanation of benefits”) are required before any medical charge is considered by the Morningside College Athletic Accident Plan. athletic training staff. Medical bills generated by an athletic injury must be submitted to your primary insurance first. in complete confidentiality. 13. conditions or concerns that they may have with the Certified Athletic Trainers. the Athletic Training Staff can submit a claim form (completed by the studentathlete) for consideration of excess payable charges. The Morningside College Athletic Accident Plan provides coverage in excess of the studentathlete’s/parent’s coverage. 15. The athletic training staff has been specially trained to assist in these matters and has specialists at various facilities waiting to assist in any way they can. conditions (physical or psychological). These issues could include: pregnancy. 14. This is done on request only and the claim must be over the $500 deductible. any other non-athletic medical issues. The student-athletes are encouraged to share. the student-athlete may be required to pay for medical care to correct preexisting conditions or other ailments in question and jeopardize their athletic eligibility. When at least the first $500 is paid by your insurance or you. No athlete will be recommended for medical hardship unless the above procedures have been followed and a Morningside College Team Physician has been consulted. and disorders (physical or psychological). The documents provided to Morningside College Athletic training regarding medical history and physicals should be completed with accuracy.

Ryan Meis CNOS Sports Medicine 575 Sioux Point Road Dakota Dunes. SD 57049 Office: (605)-217-2667 Please feel free to contact Greg at any time with any questions about the care of your son or daughter. Our goal is provide the best possible health care for the student athletes. Merle Muller Family Practice Center 2501 Pierce Street Sioux City. MSE ATC/L Head Athletic Trainer 1501 Morningside Avenue Sioux City IA 51106 Office: (712) 274-5314 Fax: (712) 274-5578 seier@morningside. Thank Head Team Physician Dr. please allow us to coordinate all appointments and referrals when possible. Morningside College Athletic Training Staff . IA 51106 Office: (712)-294-5000 Team Orthopaedic Physicians Dr.Morningside College Sports Medicine Providers Certified Athletic Trainers Greg Seier.

Athletic Training Staff Morningside College Athletic Training 1501 Morningside Avenue Sioux City. please include all available documentation and clearance from your physician. Please make sure that all of the forms are completed entirely. cancer.). diabetes. and dated. Thank you for your assistance in getting your paperwork completed and returned by July 16th 2010 Sincerely. etc.Physical Forms Checklist □ Personal Data □ Proof of Insurance – 3 Sheets □ Copy of Insurance Card □ Health History or Health Status Review** □ Assumption of Risk □ Pre-existing Conditions □ Release & Waiver □ Substance Abuse Testing Waiver **If you have an ongoing medical condition (heart murmur. signed. IA 51106 .

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