OLIVET COLLEGE ATHLETIC TRAINING PRE-PARTICIPATION PHYSICAL EXAMINATION, (AT FORM) Name: __ Sport(s) Date: Height: Weight: Visior Pulse: (BP: } ‘With correction ~ Without corection Orthopedic Examination Body Part/Joint Status Details Cervical Spine Thoracic Spine Lumbar Spine Shoulder Elbow Wrist Hand/Fingers Hip/Pelvis Knee ‘Ankle Foot/Toes General Flexibility General Exami Body Part Head Eyes Bars Nose Throat Chest _ Heart Lungs _ ‘Abdomen Skin [ Hernia Sickle Cell Trait Positive 0 Sickle Cell Trait Negative © Date of Sickle Cell Testing: Physician comments and/or recommendations Athlete cleared to fully participate in athletic activity? YES NO IENO, please explain: Physician Signature Date: Athletic Trainer Signature Date:OLIVET COLLEGE ADULT ADHD/ADD EVALUATION FORM Dg (AT FORM #2 ~ 2017-2018) Dg Effective August, 2009 the NCAA has required stricter documentation ofthe use of prescriation medications that contain banned substances. Such medications include those that are used to treat adult ADHD/ADD. As an NCAA institution Olivet College is required to have the following documentation on file fr student-athletes that are currently taking medications similar to Adderall and Ritalin te Name: Dos: Sport Provider: Your patient isa studentathite participating in intercollegiate athletics at Olivet College. The NCAA bans the use of some stimulant medications and requires that the following documentation be submited to support a request fr w medical exception in the case of positive drug test foe such use. tn completing tis paper work, you acknowledge tha you have reviewed the patients health history and ‘have informed them at some time ofthe safety information regarding stimulant use as well as misuse guidelines. Pease attach any consult letters or notes that may clarify their diagnosis and the need fo use stimulant medication for treatment. Thank you for taking the time to do this. We greatly appreciate your assistance as we are trying to comply with NCAA requirements! Required ADHD evaluation components: © Comprehensive clinical evaluation (using DSM-IV criteria) © Adult ADHD Rating Scale (e.g, Adult ADHD self report scale (ASRS), CONNER’s, Adult ADHD reporting scale (CAARS) Score © Monitored blood pressure and pulse; - © Alternative non-banned medications have been considered: “Please submit copies of test results for the student-athlete medical records and NCAA purposes* Reporting of ADHD symptoms by significant individuals: Other Psychological Testing: _ Physical Examination Date: J Results: Laboratory/ Testing! — Previous Documentation of ADHD Diagnosis: Other/Comments; Diagnosis: Medication and Dosage: ‘The student-athlete will follow up with me in (circle one) 3 months 6months 12 months Other Physician Name (printed): Date: Physician Signature: Specialty: Office Address: Contact Number (MD. or.) Please fel free to attach any clinical SOAP notes that may help clarify your patirt/our athlete's diagnosis of ADIILVADID and the need for stimulant medications. THANK YOU FOR YOUR TIME! Student Athletes: Please complete the followin I __ give ‘garding my treatment for ADHD tothe Olivet College Athlelio Training Department und the National Collegiate Athletic Association, This authorization wil be valid for one calendar year and must be resubmitted annually. { may revoke this authorization at any time by submiting a leer in writing to the Athletic Training Department, understanding that all information celeased prior to my revacation is excluded. My signature below indicates that Ihave read and understand the above statement. Date: permission to release all information Signature: Parenv/Guaidian Signature: Date (Funder 18 years)Assignment of Benefits, Designation of Authorized Representative & Appeal Rights |, the undersigned, consent to the use of my Protected Health Information for treatment and payment for treatment. | authorize Olivet College to bill my insurance and assign directly to Olivet College Sports Medicine all ‘medical benefit or insurance reimbursement, if any, otherwise payable to me for services, treatments, therapies ‘and supplies rendered or provided by Olivet College Sports Medicine, regardless of its managed care network participation status. ! understand that Olivet College Sports Medicine will share patient protected health Information according to the federal and state law for treatment and payment. | hereby authorize Olivet College Sports Medicine to release all information necessary to secure payment of benefits to my insurance company. | authorize the use of this signature on all insurance submissions. | authorize and name Olivet College Sports Medicine (or their designated representative) to act as my authorized representative to appeal claim denials on my behalf, and request that any insurer, plan or payer of health benefits accept appeals filed by my named, authorized representative on my behalf and to share all necessary information, including PHI, with my named, authorized representative for claims filed by Olivet College Sports Medicine. | am aware that | may submit additional information to be included with the appeal, Olivet College Sports Medicine is given the right by me to 1. Make any request including providing or receiving notice of appeal proceedings and ability to appeal on my behalf. 2. Participate in any administrative actions and pursue claims regardless of network participation status. Obtain information regarding the claim to the same extent as me. 4, Receive all medical benefits and/or insurance reimbursement, if any, otherwise payable to me for services, treatments, therapies, rendered or provided by Olivet College Sports Medicine, Unless revoked, this assignment is valid for all administrative and judicial reviews under ACA, ERISA, FERPA, Public Health Services Act, and any related or applicable federal and state laws, A photocopy of this assignment is to be considered valid, the same as fit was the original | HAVE READ AND FULLY UNDERSTAND THIS AGREEMENT. Patient Signature Printed name Date Relationship to Patient ‘and tothe degree consent is required to release personally identifiable information in these recards under the Family Education Rights ond Privocy Act, 20 USC 1232(, (collectively referred to os FERPA, this signed document signifies such consent.