Medical Insurance Acknowledgement

Athletic Injury Care and Insurance
Despite the utmost focus on prevention, athletic injuries do occur. In these cases, Vincennes University Department of Athletics attempts to provide our athletes with the very best possible care.  Due to an accident or bodily injury, medical bills may be incurred when the athlete is treated, whether it be locally, during a road trip, or by a medical vendor in his/her own home area.

Claim Procedure
All medical bills incurred by the student-athlete as the result of an athletic injury in a Vincennes University Department of Athletics sanctioned activity will be sent directly to the student-athlete. In some cases, the Department of Athletics may receive a copy of the bill, but in no case will the athletic department be the primary place for the incurred bill to be sent. 

Note
If your primary insurance coverage is through a Health Maintenance Organization (HMO) or Preferred Provider Organization (PPO) you must follow the proper procedures required by your plan for the university’s insurance to satisfactorily complete its portion of the claim.  This is especially important if your plan requires pre-authorization if treatment occurs outside your plan's service area.

Step 1
Submit the bills incurred to your primary insurance plan first.  Your primary insurer will either honor the claim and pay all or a portion of the bills incurred; or not honor the claim and send you a letter of denial.

Step 2
If a balance remains after your primary insurance has contributed towards the claim, send the Explanation of Benefits (EOB) from your primary insurer, as well as a copy of any incurred itemized bills to the Vincennes University Department of Athletics.  Additionally, if you receive a letter of denial from your primary insurer, send the letter of denial, as well as a copy of any incurred itemized bills to the Vincennes University Department of Athletics.  If no primary insurance coverage is available, a letter from the employer of yourself/parent/guardian with verification will be necessary.

Step 3
If there are incurred bills not paid by primary insurance, the claim will be sent by the Vincennes University Department of Athletics to our insurance carrier’s office for processing.  If additional information is requested by our carrier or the Vincennes University Department of Athletics, please communicate in a timely fashion, as all incurred bills remain in your name.

VU Athletics Insurance Coverage
Vincennes University Department of Athletics carries an athletic accident insurance policy that provides coverage for the student-athlete for accidents while participating in an organized and/or supervised workout, practice, or competition, including sponsored and organized team travel. This policy is not responsible and does not cover any non-athletic injury or illness. This insurance policy is an ‘in excess’ policy; were the student-athlete to have health insurance coverage, either personally or through a parent/guardian, that health insurance policy will serve as primary insurance for all athletic-related injuries and illness.

HAS insurance coverage under a current, in-force insurance policy for injuries that occur while he/she is participating in intercollegiate athletics

DOES NOT HAVE insurance coverage under a current, in-force insurance policy for injuries that occur while he/she is participating in intercollegiate athletics

Insurance Coverage Updates
Were there to be a change in coverage or expiration of coverage, I agree to notify Vincennes University Department of Athletics of this development and update the insurance information I have on file with Vincennes University Department of Athletics.

Authorization for Records Access
I authorize Vincennes University Department of Athletics to inspect or secure copies of case history records, laboratory reports, diagnosis, x-rays and any other covering this and/or previous confinements or disabilities. A Photostat copy of this authorization shall be deemed as effective and valid as the original for up to two years after date of signature.

Direct Payment to Medical Vendors
 I authorize Vincennes University Department of Athletics or its insurance agent to pay the medical vendors directly for any bills incurred from intercollegiate athletic accidents after all primary insurance payments, if applicable, have been applied.

Attestation
I certify, under penalty of perjury of the laws of the State of Indiana, that I have read the contents and warning of this acknowledgement; that I fully understand this acknowledgment; that I am in agreement with the terms of this acknowledgment; that I am signing this acknowledgement voluntarily, under no compulsion; that the foregoing is true and correct; that I have had an opportunity to ask questions and seek advice regarding this acknowledgement; that I am age 18 or over or, if not, that my parents/guardians hereby make these promises on my behalf; and that I choose to participate (or to permit my child or ward to participate) in the Vincennes University activity listed below of my own accord.

I further give my permission and understand that the athletic trainer, coaching staff, team physician, administrators, or other school officials can use their own judgment in applying first aid until medical help becomes available, or to secure medical aid and ambulance service in case parents cannot be reached. I voluntarily accept their service on my behalf and grant permission for them to perform their necessary duties as described above. Moreover, I agree to hold Vincennes University, its Athletic Training Staff, and the team physician free of liability from any claims, demands, or suits for damages whatsoever that may arise from athletic participation in the Vincennes University Intercollegiate Athletics program, as well as during the course of any treatment, rehabilitation, or return to play progression.

Acknowledgment & Consent
Clicking Submit signifies that you have thoroughly read and fully understand all the information presented in this form. This consent, waiver, indemnity and release is binding on me, my heirs, executors, administrators and assigns.This action is the equivalent of providing your handwritten signature and the current date.