Fillable Insurance Information Signature Devo

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Insurance Information Signature Devo

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Insurance Information – Developmental Baseball Team
Daytona State College Sports Medicine Department
In the event that the athlete should require a visit to a health care professional off campus, his/her primary
health insurance company will be billed. It is highly advisable for your son to be knowledgeable about any
payment or physician requirements mandated by your insurance company. Daytona State College does not
provide athletic injury insurance coverage for developmental teams.
Note: Please call your insurance company (1) to let them know that your son will be attending college away
from home; (2) to find out if your son must see his/her primary care physician (PCP) before receiving care; and
(3) to ask them about the feasibility of changing to a PCP in the Daytona area. Having a PCP in the area greatly
reduces the money, time, and effort spent by the athlete trying to access health care. One of the physicians at
the Halifax Health Family Practice Clinic would be the most convenient for the athlete, as this clinic is within
walking distance of the College.
Please see the document “Procedures Regarding Athletic Injuries, Illness, and Medical Care” for details
regarding health care for members of the DSC Developmental Baseball Team. Both you and your son should
read it thoroughly, and sign and return the statement below. Also please carefully complete the insurance
information form, being sure to include all requested information. Should you have any further questions,
please call Kim Csabi, Sports Medicine Program Director, at (386) 506-3989.
SIGN AND RETURN:
I have thoroughly read the document “Procedures Regarding Athletic Injuries, Illness and Medical Care”. I
understand that failure to comply with these procedures may result in me/my son being ineligible to
participate in athletics at Daytona State College.
______________________________ ___________________________ _________
Athlete printed name Athlete signature Date
______________________________ _______
Parent signature Date
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Insurance Information Signature Devo

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Completed 1 November 2019

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