The California State University, Fullerton Department of Athletics provides outstanding care to our student-athletes in specific NCAA limitations and guidelines. The following is an explanation of the University’s procedure concerning athletic injuries and payment of medical expenses. As a student-athlete at CSUF it is extremely important that you understand the nature of the medical coverage provided for athletic injuries. Please sign at the bottom of this form indicating that you have read and understand the CSUF medical coverage procedures and policy.
1. Only those medical expenses due to injury or illness sustained by the student-athlete as a direct result ofpractice or participation in intercollegiate athletics at CSUF and cleared by the Certified Athletic Training Staff can be covered by our insurance policy. Expenses to treat a student-athlete’s injury or illness that is not a result of practice or participation in intercollegiate athletics at CSUF or is defined as a pre-existing injury CAN NOT BE COVERED. This includes off-season non-team related orthopedic injuries, medical procedures such as cardiac testing, appendectomy, tonsillectomy, hernia, etc. Therefore, it is recommended that all athletes carry health and accident insurance that will cover in the above types of situations. Also, please note that the first documented treatment or service must be within 120 days of the injury, and only expenses incurred within 104 consecutive weeks of the injury will be covered.
2. In all cases involving injury due to competition or organized practice, the Athletic Department’s coverage is considered EXCESS OR SECONDARY and the athlete’s personal or parental health insurance is considered PRIMARY. This means that the student-athlete or the parents must first submit a claim with their health insurance company. After the primary insurance has paid on the allowable charges, a copy of the Explanation of Benefits and/or a statement showing the balance needs to be submitted to the Head Athletic Trainer. The balance will then be paid by CSUF insurance. We do not want any expenses to be incurred by the student-athlete or the parents if the medical problem is due to CSUF intercollegiate sport. Therefore, if there are any deductible expenses not covered by the primary insurance, please contact us and CSUF will take care of those charges.
3. Student-athletes with HMO (Health Maintenance Organizations) insurance such as Kaiser, Maxicare, Cigna, Foundation, etc. MUST visit their HMO physician for primary evaluation, diagnostic testing and surgical procedures (unless cleared by the CSUF Athletics Director). The CSUF Athletic Training Staff will assist you in every way to expedite appointments.
4. The Department of Athletics WILL NOT be responsible for costs of medical services except those cleared through the CSUF Athletic Training Staff. Any athlete who takes it upon him or herself to seek medical services without authorization from the CSUF team physician or Athletic Training Staff does so at his or her own expense.
5. Minor injuries, minor illnesses, and other medical concerns are taken care of by the Athletic Training Staff, the CSUF Health Center medical staff, and team physicians. The student-athlete should report any injury and/or illness to the Athletic Training facility as soon as possible.
6. The complete summary of benefits for CSUF student-athletes is available in the Athletic Training Room.
I confirm that I have read and understand the above information.
The Department of Athletics at California State University, Fullerton is concerned with the health care of its’ student-athletes. The responsibility of the Athletic Training Program includes prevention, evaluation, referral, treatment and rehabilitation of injuries or illnesses sustained during practices or games while competing for CSUF. The Department of Athletics WILL NOT be responsible for medical coverage for any pre-existing injury or illness.
To insure that all student-athletes receive complete medical benefits from the Health Care Personnel, the following procedures MUST BE FOLLOWED:
1. Upon receiving ANY injury during practice or competition, regardless of severity, the student athlete MUST report immediately to the Athletic Trainer.
2. If emergency treatment is required while the student-athlete is away from the campus, it is the responsibility of the accompanying Athletic Trainer, or Head Coach in the absence of the Athletic Trainer, to contact appropriate medical assistance. Return all medical bills to the Head Athletic Trainer upon return to CSUF.
3. Referrals to the team physician can only be made by the Certified Athletic Training Staff.
4. Any outside physician seen without authorization of the Certified Athletic Training Staff may result in full payment of medical bills by the student-athlete.
5. Any medical bills received by the student-athlete that were cleared by the Certified Athletic Trainer MUST be brought immediately to the Head Athletic Trainer for payment. The first documented treatment or service must be within 120 days of the injury, and only expenses incurred within 104 consecutive weeks of the injury will be covered.
The Department of Athletics will not be responsible for ANY pre-existing injury, surgery, or illness. Any conditions identified as pre-existing will be discussed with the student-athlete upon arrival to CSUF and suggestions for care will be discussed at that time.
Treatment of cavities or cleaning teeth will not be paid for by the Department of Athletics. Any damage to the teeth incurred during practice and/or competition must be reported to the Athletic Training Staff immediately. Any payment of medical bills for dental work resulting from such injuries must be authorized by the Head Athletic Trainer. The first documented treatment or service must be within 120 days of injury, and only expenses incurred within 104 consecutive weeks of the injury will be covered.
Athletes will be provided corrective optical lenses (glasses, contact lens, or protective eyewear) ONLY if vision problems are determined to be a result of participation in intercollegiate sports or the athlete requires visual correction to participate in intercollegiate athletics.
Please Read The Following Consent Forms Carefully
(If you are under 18 years of age, your parents or guardian must also sign) The basic content of each is:
A. Medical Consent: Allows Athletic Trainers and physicians to treat any injury you receive while at California State University, Fullerton.
Release of Injury Allows those listed to release information concerning your Information: injuries to the media.
C. Release of Information: Allows those listed to release any and all information
concerning you, including records and other items listed to professional teams, agents, scouts, etc.
D. Acceptance of Risk: Acknowledges that you are aware of inherent risks involved in intercollegiate sports and that you are willing to assumeresponsibility for such risks.
AIDS and Intercollegiate Acknowledges the possible risks of HIV transmission in
If you should choose to refuse to sign any of these, please write “Refused to Sign,” the date, and your signature.
RELEASE OF INJURY INFORMATION
This is to authorize the California State University, Fullerton Athletic Training staff, team physicians and athletic coaches to release information to the CSUF Sports Information department and various media outlets, any information concerning illness or injury relative to my past, present, or future participation in athletics at CSUF.
I hereby grant permission to California State University, Fullerton Athletic Training staff and team physicians to render any treatment or medical/surgical care that they deem reasonably necessary for my health and well-being while competing in intercollegiate sports.
Release of Medical Information
I hereby grant permission to the Student Health Center of California State University, Fullerton to release medical information to the Certified Athletic Training Staff of Department of Athletics. This information would be limited to only those conditions for which the Athletic Training Room has issued an Athletic Referral slip.
RELEASE OF INFORMATION I hereby authorize the California State University, Fullerton Athletic Training Staff (including team physicians) to furnish to all professional athletic teams, scouts, agents or representatives, any and all medical information concerning or having bearing upon my participation in athletics at CSUF. Said authorization shall include, but is not limited to, any and all information within their knowledge or contained in any medical records regarding my physical condition, illness, injuries and treatment, hospitalization, examinations, x-rays, etc.
ACCEPTANCE OF RISK Participation in sports requires an acceptance of risk of injury. Athletes rightfully assume that those who are responsible for the conduct of sport have taken reasonable precaution to minimize such risks and that their peers participating in sport will not intentionally inflict injury upon them.
I understand that by voluntarily participating in athletics at the collegiate level, I am undertaking a non-controllable risk which may result in an injury or illness that may severe in nature. Such an injury may result in permanent damage, paralysis, and/or death. I also understand that sickness and/or injuries are common in all athletics and that California State University, Fullerton will provide the most reasonable medical care in order to reduce the severity of such illness and/or injuries.
I, the undersigned, also acknowledge that the above statements of acceptance of risk were read to me and that I understand them.
AIDS AND INTERCOLLEGIATE ATHLETES The Acquired Immunodeficiency Syndrome (AIDS) is caused by a virus or Human Immunodeficiency Virus (HIV). HIV has been isolated in blood, semen, vaginal secretions, saliva, tears, cerebrospinal fluid, amniotic fluid and urine. However, available evidence has implicated only blood, semen and vaginal secretion in the transmission of HIV.
Although the precise risk of transmission during exposure of open wounds or mucous membranes to contaminated blood is not known, theoretically there is a possibility of HIV transmission by blood from one student athlete to an open wound of another student athlete.
Therefore, the Athletic Training Staff and team physicians at CSUF will employ universal precaution recommended by the Center of Disease Control in care of all student athletes, since medical history and examination cannot reliably verify HIV infected patients.
California State University, Fullerton
HEALTH HISTORY FORM NAME:______________________________________________ DATE:_________________________
SPORT:____________________ AGE:______ M:___ F:___ YEAR IN SCHOOL:_____________
SS#:_______-____-_______ DATE OF BIRTH:__________________________
PARENTS PHONE NUMBER:_____________________________
IN CASE OF EMERGENCY, NOTIFY:_____________________________________________
Street City State Zip
WORK PHONE:__________________________ HOME PHONE:________________________
IN CASE THE ABOVE PERSON CANNOT BE CONTACTED, PLEASE LIST AN ADDITIONAL PERSON TO BE CONTACTED IN CASE OF AN EMERGENCY.
NAME:___________________________________ PHONE NUMBER:___________________
PERSONAL PHYSICIAN:_________________________ PHONE NUMBER:______________
Street City State Zip
This information is confidential. Please answer each question carefully.
Explain all YES answers after the question.
1. Have you had a medical illness or injury since your last physical?
2. Are you on any prescription or non-prescription medicines (including
inhalers, birth control pills, etc.)?
3. Are you allergic to any medications, foods, pollens, or insect stings?
4. Have you ever passed out during or after exercise?
YESNO 5. Do you have any history of dizziness (fainting, blackouts), chest pain, or
irregular heart rhythm at rest, during or after exercise?
6. Have you suffered any of the following during the past 3 years: head
injury, concussion, loss of consciousness, fainting, knocked out?
7. Have you ever had an injury to your ribs, rib cartilage, collarbone, or
chest wall and/or had a collapsed lung?
8. Do you have any history of heart murmur, scarlet fever, rheumatic fever?
9. Do you have any missing or broken teeth or braces/retainer? Have you
been advised to have any dental (teeth or gum) surgery, procedure (fillings, caps, crowns, or removal of teeth) that have not been completed?
10. Do you have any current skin problems (itching, blisters, rash, warts,
11. Do you have any history of a fracture, injury or pain in the face, jaw,
teeth, skull (head), or nose?
12. Do you or any of your family members have any drug or alcohol
13. Have you ever had surgery or have been advised to have any orthopedic
surgery (bones, joints, ligament, cartilage, or disc) at any rime in your life?
14. Do you have any history of mental illness (depression, manic depression,
anxiety, etc.), counseling, or psychiatric care?
15. Do you have a loss or impairment of an organ (kidneys, eyes, testicles,
lungs, ears, ovaries)?
16. Do you have any problems with diet, weight, or anemia?
YESNO 17. Do you have any problems with environmental heat illness, heat stroke,
heat cramps, heat exhaustion, or heat fatigue?
18. Do you have any history of major medical illness? (Circle the illness and
explain) Seizures, Anemia, Diabetes, Tuberculosis, Arthritis, Thyroid Disease, Hepatitis (Jaundice), Infectious Mononucleosis, Hypertension (high blood Pressure), Pneumonia, Rectal pain or bleeding, or other infectious diseases in the
past three years?
19. Have you had asthma, recurrent bronchitis, wheezing, shortness if breath
or coughing, during or after exercise?
20. Do you have a history of seizure, epilepsy “fits” or convulsions?
21. Do you have normal hearing, normal vision and can you breathe through
both sides of your nose?
22. Do you wear glasses or contacts during athletics? If yes, indicate the
type of contacts (soft/hard).
23. Do you have frequent headaches (greater than one per week) or after exercise (not related to injury during exercise)?
24. Do you have any history of injury to the nerves in your neck (burners/stingers)?
25. Have you ever had a fracture/dislocation or ligament/cartilage injury of the shoulder, elbow, wrist, hip, knee, ankle, that required evaluation by a physician or athletic trainer or prevented your participation in an event/game or practice?
26. Have you had any of the following: (circle) Stress fracture, chondromalacia, Osgood Schlater’s disease, medial epicondylitis, shoulder impingement, arthritis
Osteomyelitis, or jumper’s knee?
27. Have you experienced a severe ankle sprain in the past two years that caused you to miss practice (more than 3 days) or a game/event participation?
28. Do you know of any, or do you believe there is any health reason why you should not participate in the Cal State Fullerton intercollegiate athletic program
at this time?
29. Do you need information regarding any health issues?
ADDITIONAL FEMALE HISTORY
Have you failed to menstruate for more than three consecutive months in the past two years?
Have you ever had a gynecological exam or PAP Smear?
Do you have irregular cycles: less than 21 days or greater than 35 days?
Do you have abnormal menstrual flow: less than two days or more than seven days?
Do you have or think you have an eating disorder?
Do you have a vaginal discharge that is a concern for you?
Do you take prescription or non-prescription medication for menstrual pain?
If you are sexually active, do you use birth control? If yes, please list what