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FOOTHILL-DEANZA COMMUNITY COLLEGE DISTRICT
INSURANCE INFORMATION, CONSENT & RELEASE FORM
Each Student-Athlete must read, complete, sign and submit this form to the Athletic Trainer. This Form must be received by the Athletic Training
Department prior to participation in any intercollegiate sport activities.
Important Information
As you (or your son or daughter) prepares to participate in athletics at Foothill-DeAnza Community College
District (“FHDA”), it is important that you understand the following information.
Injury Reporting Requirements
When an injury occurs, you must immediately inform the Athletic Training Department and the team Coach even if the
injury may be minor at the time. The Athletic Trainer and Coach must obtain the details of the accident for the
reporting required by FHDA, and will direct the student for medical evaluation or treatment.
Insurance Coverage for Accidental Injury-related Medical Expenses
FHDA is not responsible for medical related expenses that result in participation of an intercollegiate sport
.
However, FHDA carries an Accident/Injury Insurance Plan to assist in the payment of covered medical services that
are medically necessary. The Accident/Injury Insurance Plan is "Excess” insurance coverage and pays secondary
over any personal medical insurance coverage of the student/student athlete and/or parents/guardian
. This plan
will then consider the remaining eligible charges subject to its limitations only after the student’s personal medical
insurance has considered benefits. The Accident/Injury Insurance Plan will be herein referred to as the “Excess
Accident Medical Insurance Plan”. This plan contains limitations, including (but not limited to) the following:
It is for Medically Necessary expenses as a result of an “accidental injury” only and does not cover sickness or illness.
The accidental injury must be a result of participation in events and activities that are authorized by, organized by and directly
supervised by an official representative of FHDA.
Camps, clinics, pickup games, recreational and other events unrelated to intercollegiate sports are NOT covered.
$25,000 per injury is the maximum amount payable on an Excess basis
The first expense must be incurred within 90 days from the date of the covered injury
Additional benefits MAY be available for covered accident medical expenses that exceed $25,000 per injury.
There is a $100 deductible per accidental injury
This is the student-athlete’s responsibility (not FHDA).
The Benefit Period (duration in which coverage is provided) is up to 52 weeks from the date of the accident causing the injury.
All medical treatment must be obtained during this time in order for benefits to be considered.
If the student-athlete has NO PRIMARY personal medical insurance, medical services must be obtained by a participating network
provider of the insurance company.
For students with Primary Medical insurance, certain services obtained by non-network providers may result in a reduction of
benefits under the Accident/Injury Insurance Plan carried by FHDA.
Coinsurance differences are the student-athlete’s responsibility (not FHDA).
There is no coverage for the cost of eyeglasses, contact lenses or examinations for either
There is no coverage for the cost of dental treatment, except as specifically provided for Injuries to sound, natural teeth.
Pre-existing conditions and/or genetic problems may not be covered by this insurance
Additional limitations, exclusions and coverage conditions apply.
The Excess Accident Medical Insurance Plan carried by FHDA also provides additional benefits for Accidental Death
and other Accidental Specific Losses that may occur as a result of an accident while on travel that is directly to or
from play or practice of an intercollegiate sport, as a team or member of a group, which is sponsored and authorized
by FHDA.
Further information about FHDA’s Excess Accident Medical Insurance Plan can be provided upon request. Please
contact the Athletic Training Department.
DISCLAIMER
The foregoing summary does not take the place of or alter any of the conditions, exclusions, and other terms of the insurance policy. It is
merely a short description to the policies in force, for convenient reference. If there is any discrepancy between this information and the actual
insurance policy(ies), the insurance policy(ies) shall control.
Page 1 of 3 Form Version: August 2013
FOOTHILL-DEANZA COMMUNITY COLLEGE DISTRICT
INSURANCE INFORMATION, CONSENT & RELEASE FORM
Each Student-Athlete must read, complete, sign and submit this form to the Athletic Trainer. This Form must be received by the Athletic Training
Department prior to participation in any intercollegiate sport activities.
Excess / Secondary Insurance Claims Process:
Insurance information is necessary to expedite treatment and payment of all medical claims incurred from injuries from
participation in intercollegiate sport activities.
If the student-athlete has any other insurance coverage, this primary
coverage must pay its normal
benefit before Foothill-DeAnza Community College District’s (“FHDA”) Excess
Accident Medical Insurance Plan will consider benefits on an secondary basis. It is the student-athlete’s
responsibility to file his/her own claim with his/her personal medical insurance company. If you are covered under a
Health Maintenance Organization (HMO) or Preferred Provider Organization (PPO), you must follow the rules of your
plan including using specific facilities when appropriate. FHDA’s Excess Accident Medical Insurance Plan may
reduce benefits or not pay for charges incurred by student athletes who do not follow the terms and conditions of their
HMO or PPO primary insurance.
In order for FHDA’s Excess Accident Insurance Plan to consider benefits and where medical referral is
necessary for additional treatment, an insurance claim form must be completed. You must contact the
Athletic Training Department to assist with the process. All claim submissions require the following:
Completed Claim Form
The claim form must be completed in full and signed by the student and appropriate school official.
A separate claim form is required for each injury.
Please have the student sign and date the portion of the claim form indicating "Medical information authorization Assignment of
benefits".
Description of incident (if not provided elsewhere), Athletic Trainer notes, etc.
Operative notes for any and all surgeries or visits
Itemized Medical bills (industry standard forms referred to as HCFA1500 or UB92/UB04)
Attach itemized copies of all applicable bills, including those bills under any deductible your plan may have. Also, include those
bills paid partially or in full by other insurance. Bills showing only "Balance forward" or "Balance due" are not sufficient.
An itemized bill indicates the provider of service's full name and mailing address, type of service, date of service, fee charged
and diagnosis. Missing information will be requested from the medical service provider.
To assure quick processing, please be sure that the bill and the insurance statements submitted are for the same item.
Explanation of Benefits (EOB) from the student athlete’s primary insurance, if applicable
Include copies of the entire document (front and back when necessary).
If any or all benefits are denied by the primary insurance, a copy of the formal denial (showing the reason charges were denied)
must be provided to us.
Generally, these items will be sufficient to complete a claim determination, but occasionally additional information will
be required on a case-by-case basis.
Page 2 of 3 Form Version: August 2013
FHDA reserves the right to void coverage should the student not report the injury in a timely manner or if the
student elects medical treatment (except in the case of an emergency) that is not approved by the Athletic
Training Department or Medical Staff. Together, the student-athlete’s Personal Medical Insurance (Primary
Insurance) and the FHDA Excess Accident Medical Insurance Plan are designed to cover the cost of medical
coverage as a result of a accidental injury caused by/during participation in intercollegiate sports. However,
certain processes must be followed, limitations apply, and gaps do exist.
Payment of balances, deductibles, copayments or other non-covered medical expenses are the
responsibility of the Student-Athlete, Parent or Guardian
.
FOOTHILL-DEANZA COMMUNITY COLLEGE DISTRICT
INSURANCE INFORMATION, CONSENT & RELEASE FORM
Each Student-Athlete must read, complete, sign and submit this form to the Athletic Trainer. This Form must be received by the Athletic Training
Department prior to participation in any intercollegiate sport activities.
Consent to Treatment
In the event of injury, which occurs during participation in or practice of athletic events or while being transported to or from the
site of the contest, I voluntarily authorize the rendering of such care, including diagnostic, testing, medical treatment and
admission to any medical facility designated and authorized by Foothill-DeAnza Community College District’s Athletic Training
Department, approved Medical Staff or their designees. I acknowledge that no guarantees have been made as to the effect of
such examination or treatment on my condition or the condition of the person for whom I am duly authorized to sign. I
understand that I have the right to make decisions concerning my health care or the health care of the person for whom I am
duly authorized to make such decisions, including the right to refuse medical and surgical procedures. I also understand the
final decision on whether I may continue to participate rests solely with Foothill-DeAnza Community College District’s Athletic
Training Department and its approved Medical Staff.
Consent to Using Personal Medical Insurance
I am aware my personal medical insurance or that of my parents or legal guardian (“Primary Insurance”) will be utilized to cover
medical expenses incurred in the diagnosis, treatment, and rehabilitation of any athletic related injury or illness. As required, I
provided the completed “Record of Other Insurance Form” containing my personal medical insurance information to
Foothill-DeAnza Community College District’s Athletic Training Department staff prior to participation of any kind in an
intercollegiate sport. Foothill-DeAnza Community College District’ is NOT responsible for any expenses or balances after my
personal medical insurance has paid. Foothill-DeAnza Community College District carries an Excess Accident Medical
Insurance Plan that is secondary insurance coverage to assist in considering medical expenses that may not covered by my
Primary Insurance plan.
Release of Information
I understand that as a student-athlete, my medical records and health information will be kept confidential in accordance with the
Family Education Records Privacy Act (20 USC 1232g) (FERPA) and Health Insurance Portability and Accountability Act of
1996 (HIPAA). I give my authorization for the Foothill-DeAnza Community College District’s Athletic Department, administrators,
coaches and staff, including Athletic Trainers, Media Relations, Public Relations, and Team Physicians and/or any of my health
care providers, to release information regarding my medical and/or psychiatric history, record of injury, surgery, rehabilitation
results and/or any other medical health information. I authorize the release this information to:
1. Any health sickness and accident insurance carrier, workman’s compensation, or agency (social welfare, governmental)
which is legally responsible, or which Foothill-DeAnza Community College District has good cause to believe is legally
responsible for all or any part of the medical charges and/or professional fees due to any athletic related injury or illness;
and
2. Physicians, health care facilities or other medical providers rendering or evaluating me/the patient for medical care.
This consent may be revoked at any time by notifying
Foothill-DeAnza Community College District in
writing
, except to the extent that action has already been taken by the patient/duly authorized agent.
Financial Responsibility & Guarantee of Payment
I have reviewed and fully understand the “Insurance Coverage for Accidental Injury-related Medical Expenses” and the “Excess
/ Secondary Claims Process” information on the “INSURANCE INFORMATION, CONSENT & RELEASE FORM”. I also fully
understand and acknowledge that certain limitations and exclusions apply to Foothill-DeAnza Community College District’s
Excess Accident Medical Insurance Plan. I understand I am responsible for any deductibles, copayments, coinsurance and/or
other non-covered medical expenses or charges resulting from medical services rendered that are not covered by my personal
medical insurance or Foothill-DeAnza Community College District’s Excess Accident Medical Insurance Plan.
ACCEPTED AND AGREED
________________________ ___________________________ _____________________
PRINT - Student-Athlete Name SIGNATURE - Student-Athlete Date
________________________ ___________________________ _____________________
PRINT - Patient Name (same as above) SIGNATURE - Patient (same as above) Date
________________________ ___________________________ _____________________
PRINT - Parent/Guardian Name SIGNATURE - Parent/Guardian Date
(if under 18 years old)
Page 3 of 3 Form Version: August 2013
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