2 Original: Athletic Insurance Coordinator Revised 5/9/2019 trg
TERMS
• I/We agree that all information provided is accurate and complete to the best of my/our knowledge.
• I/We understand that any incorrect or undisclosed information can result in duplicate payments creating an
overpayment. The responsibility of such overpayment will be the obligation of the undersigned to reimburse in
full, upon request, all amounts deemed refundable.
• I/We understand that all medical care incurred for the primary carrier will process an athletic injury before the
athletic injury policy can be utilized.
• I/We are aware that any athletic grant-in-aid may be canceled if I give false information on any institutional
form.
• I/We certify to the best of my/our knowledge that the above information is accurate and will notify the Depart-
ment of Athletics of any changes if they occur during the upcoming academic school year. Medical expenses are
payable only for medical expenses incurred within 104 weeks after the date of the covered athletic injury.
• I/We understand that the athlete must seek medical care and treatment within 90 days of a covered accident to
be eligible for benefits. Any delinquent bills resulting in bad credit due to non-compliance with insurance com-
pany requests may be the responsibility of the student-athlete and/or his/her parent(s)/guardian(s).
Student-Athlete’s Printed Name Student-Athlete’s Signature Date
If student-athlete is under 18 years of age:
Parent’s/Guardian’s Signature Date
AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION
Patient name Bengal ID #
authorizes the release of protected health information (PHI), including insurance claims information and med-
ical information for the processing of medical claims from health care providers and student-athlete’s primary
(and, if applicable, secondary) health insurance plan(s) to the ISU Athletic Insurance Coordinator and the
Idaho State University Sports Athletic Plan.
Entity receiving the information:
Type of PHI to be disclosed: e.g., claim date of service, claim dollar amount, treating provider name, accumula-
tor information, claim type, network contractual adjustment amount, ineligible amount, co-payment amount,
deductible amount, covered expenses, payment percentage, claim payment amount.
Purpose(s) to which disclosure of PHI will be limited: e.g., claims processing for the benefit of the participant in
the form of claim status, claim payment status, claim appeal status and decision, claim processing details,
plan benefit information.
I further understand and agree:
1. This Authorization for Release of Protected Health Information will expire 2 years after the termination of
my participation in the Plan;
2. I may revoke this Authorization at any time by notifying the providing person/organization in writing;
3. I may see and copy the information described on this form if I ask for it; and
4. The information that is disclosed under this Authorization may be re-disclosed by the receiving entities.
I certify that I have read and understand this Authorization, and that the information in it is true and correct.
SIGNING THIS AUTHORIZATION IS NOT A PREREQUISITE TO YOUR PARTICIPATION IN THE IDAHO STATE UNIVER-
SITY SPORTS ATHLETIC PLAN; HOWEVER, NOT SIGNING COULD JEOPARDIZE PROCESSING OF ANY OUTSTANDING
CLAIMS.
Student-Athlete’s Printed Name Student-Athlete’s Signature Date
If student-athlete is under 18 years of age:
Parent’s/Guardian’s Signature Date
Please return completed form with the front and back copy of the insurance
card to Email: sains@isu.edu
Mail: Idaho State University
Fax: (208) 282-4063 921 S 8
th
Ave Stop 8173
Pocatello, ID 83209
Due by July 1, 2019
or prior to summer workouts.
