Northern Arizona University Student-Athlete
Insurance Check-Off Sheet
1) _____ Student-athlete and/or parent, guardian, primary policy holder have read the insurance policies and
requirements for participation?
2) _____ The policy holder has contacted their insurance carrier and verified coverage for Coconino County (this
may require switching to a guest or out-of-network status)
3) _____ Policy holder has verified that the current policy is in good standing, and the student-athlete is still
eligible for benefits from July 1, 2012 thru June 30, 2013
4) _____ Policy holder has verified or made changes to the plan to ensure that the plan’s deductible is between
$0.00 and $2,500.00
5) _____ Policy holder has obtained and attached proof of plan’s deductible (maximum amount of $2,500.00) to
the insurance forms to be submitted to the Medical Coordinator at NAU or provided letter of responsibility for
deductible in excess of the $2500.00 limit.
6) _____ Policy holder has ensured that all ACCCHS plans are under Health Choice and not Phoenix Health
Plan
7) _____ Primary policy holder has completed all areas on the insurance forms, excluding the athlete info at the
top of page 1 and the athletes signature lines
8) _____ Primary policy holder has signed the top line of each signature line on all four (4) pages
9) _____ Student-athlete has signed the bottom signature line on all four (4) pages
10) _____ A photocopy of the insurance cards (front and back) have been attached to the insurance forms to be
submitted to the Medical Coordinator at NAU. This includes primary carrier, any secondary carrier, and dental
11) _____ Policy holder and student-athlete have submitted completed, required materials to the Medical
Coordinator prior to the designated due date for the student-athletes sport (see bottom of insurance form pg 1)
Northern Arizona University Athletic Training
Insurance Requirements and Policies
Physician and Billing Procedures:
Student athletes who sustain injuries while participating in an organized team practice and/or competition have the right to see a
physician of their choice and/or our team physicians. All billing is subjective to insurance provider and policy
coverage/deductibles. Prior to seeing a non-team physician, consultation with the Head Team Physician and Head Athletic
Trainer must occur, per NAU policy. Before returning to team activity, the following must be provided prior to clearance of
participation:
-
dictations from office visit of attending physician
dictations from pre and post-operative procedures/visits of attending physician
restrictions of limitation
clearance to participate
rehabilitation protocol
copies of any diagnostic testing
This information allows the medical staff at NAU to adhere to attending physicians orders, maintains an open communication line
with the outside physician, and ensures quality care for the athlete.
Student athletes will only be covered by Northern Arizona University’s secondary insurance for injuries that occur while
participating in organized team activities (camps are not considered team activities). Medical expenses for any pre-existing
injuries / conditions or illness are the sole responsibility of the student athlete for their duration at NAU. Any medical / diagnostic
testing, ordered by a team physician, for participation clearance during physicals is the sole responsibility of the student athlete. If
it is determined that the student athlete did not disclose a pre-existing injury or condition during their physical, any injury
associated with that pre-existing injury or condition will not be covered by the secondary insurance policy. Any payments made
by the secondary insurance will be considered payment in full by the secondary insurance policy and any remaining costs becomes
the responsibility of the policy holder.
Policyholder signature: __________________________
Date: __________
Student Athlete signature: ________________________
Date: __________
International Student Athletes:
International student athletes are required to carry personal health insurance by the State of Arizona and NAU. The following is
a list of their requirements: 1) insurance provide $50,000 per accident or illness, 2) The insurance must cover hospitalization or
inpatient care, outpatient care, doctor visits, and outpatient surgery, 3) insurance provides $7,500 for repatriation of remains, 4)
insurance provide $10,000 for medical evacuation to home country, and 5) The deductible cannot exceed $100 per accident or
illness. Along with these requirements, NAU athletics requires that the policy provides coverage for intercollegiate athletics.
As an international student-athlete, you may purchase your health insurance prior to attending NAU or complete the application
process for insurance through our recommended umbrella policy. The cost for the umbrella policy is $165.00. These dollar
amounts will cover the cost of the policy for 3 months, with NAU paying for the other 9 months. The cost of $165.00 is owed the
day of your scheduled NAU physical. Lack of payment will result in not being eligible for participation until payment is received.
If you purchase the insurance on your own, verification by the Medical Service Coordinator will be required. If the policy does
not meet the State of Arizona’s requirements and NAU athletics, you will not be allowed to participate in any team associated
activity.
International student-athletes are subject to the same requirement as US citizen athletes as it pertains to current and in good
standing health insurance for the entirety of the academic year. Any lapses in payments or temporary cancellations of coverage
will affect your eligibility to compete, may limit your health coverage when another policy is purchased and any medical expenses
accrued during the lapse in coverage is the athletes sole responsibility.
Insurance Coverage:
It is a requirement that the primary health insurance provide in-network coverage for Coconino County and includes the
following minimal coverage: 1) Coverage of all athletic injuries. 2) Coverage of all body parts (no exclusions), 3) 80% pay after
deductible for major medical costs and 4) $100,000.00 minimum for major medical coverage. Northern Arizona University will
not be responsible for injuries excluded by your primary health insurance policy. As of May 1, 2010 ALL Student Athletes are
required to provide written verification that their policy has a deductible no higher than $2,500.00 (a $500.00 deductible is highly
recommended). Policies that have deductibles higher than $2,500.00 will require a letter from the policyholder accepting
responsibility for any portion exceeding the $2500.00 limit.
Student athletes covered under out of state HMO policies and out of area insurance plans are highly recommended to purchase a
supplemental health insurance policy accepted by Coconino county medical providers for medical services and athletic injury
coverage. Otherwise, any surgery related to an athletic injury will need to be performed in the contracted HMO network. Please
contact the Medical services coordinator in the NAU Athletic Department at 928-523-9817 for further questions.
Policies and/or carriers that are unfamiliar to the Medical Services Coordinator/Athletic Training Department or obtained through
the internet are subject for review. While under review, the student-athlete will be required to provide a letter from the insurance
provider stating that they are covered under the policy and that the policy is compliant with NAU athletics insurance
requirements. During the review period, the student-athlete will not be allowed to participate in any team associated activity.
We strongly encourage the policy holder to verify, with their insurance provider, that there is available coverage in Coconino
County. The policy holder needs to be aware of costs associated with in-network and out-of-network providers, physicians
associated with their policy, and the potential for additional costs associated with referrals. It is not the responsibility of the
Medical Service Coordinator to obtain pre-authorization of services prior to referrals or appointments. It is the responsibility of
the policy holder to ensure that the student-athlete has the ability to obtain medical services in Coconino County and by signing
the required proof of insurance documents; they understand the policies of NAU athletics and are responsible for any costs that
fall outside of that policy. Medical expenses that are either denied because of being out-of-network may not be covered by
NAU’s secondary insurance and are subject to review on a case by case situation.
If the student athlete sees a physician approved by the head athletic trainer and/or team physician for an intercollegiate sports
injury, the student athlete’s primary insurance is billed first. All remaining costs are covered under the University’s policy.
Medical bills are sent to the patient, not to us. In order to pay the balance of your medical bills, the original medical bill and your
primary insurance’s explanation of benefits (EOB) must be submitted to the athletic training room within 45 days of receipt.
Student Athletes must submit any bills received to Medical Services to assure payment.
Any athlete who is utilizing AHCCCS for their primary insurance needs to ensure that they are under the Health Choice Plan and
not the Phoenix Health Plan. Phoenix Health Plans will not be accepted and the student-athlete will not be cleared for
participation until verification of being the Health Choice Plan.
As of July 1st, 2011 AHCCCS benefits may be affected by state budget cuts and no longer be a viable option for coverage.
It is the sole responsibility of the student-athlete and the policy holder to ensure and maintain current and continuous
health insurance coverage. If a policy is cancelled or lapses, it is the responsibility of the student-athlete and/or policy
holder to notify the Medical Services Coordinator. If an injury occurs during a policy cancellation or lapse, NAU
athletics and their secondary insurance is not responsible for any medical costs associated with that injury (per NAU
policy). Once the Medical Insurance Coordinator or athletic trainer is made aware of a policy cancellation or lapse, the
student-athlete will be removed from any team associated activity, including team travel.
Policyholder signature: ___________________________
Date: __________
Student Athlete signature: ________________________
Date: __________
2012-2013 NORTHERN ARIZONA UNIVERSITY ATHLETICS DEPARTMENT
PRIMARY HEALTH INSURANCE INFORMATION
(Please type or clearly print all information) (The policyholder must sign both sides of this form.)
Student Athlete__________________________Soc.Sec.Number__________________Birthdate__________
Student Phone number_______________________
Sport(s) _____________________________
Year of eligibility (Fr, So, Jr, Sr) ______________________
********************************************************************************************************************************
ATTACH A PHOTOCOPY OF THE FRONT AND BACK OF THE INSURANCE CARD FOR THIS POLICY
Any changes in the insurance coverage must be reported immediately. All spaces must be completely filled in!
Name of Policyholder_____________________________________________________________________
Policyholders’Social Security Number _____________________________DOB:_____________________
Policyholders' Mailing Address______________________________________________________________
City, State, Zip_______________________________________________________________
Policyholders' Phone Number (home) ______________________ (work) ____________________________
Policyholders' Employer ___________________________________________________________________
Policyholders' Employers Mailing Address ____________________________________________________
Name of Insurance Company________________________________________________________________
Group/Plan Number ______________________________________________________________________
Policy Number __________________________________________________________________________
Insurance Company MailingAddress__________________________________________________________
Insurance Company Phone Number___________________________________________________________
********************************************************************************************************************************
Is your policy an: (circle one)
HMO
PPO
Managed Care Plan
Primary Care Physician ________________________________________ Phone number_______________________
Except for emergency situations, are you required to get a referral to see any health care provider other than your Primary Care Physician or Insurance
Company Clinic? No ( ) Yes ( )
If your Primary Care Physician or Insurance Company Clinic is not located in the Flagstaff area, are there any participating physicians, clinics, or medical
facilities in the Flagstaff area? No ( ) Yes ( )
Flagstaff area Provider___________________________________ Phone Number________________________
Will a change in the athlete’s enrollment status (full -time student to part-time student) change the athlete’s insurance coverage? No ( ) Yes ( )
Is the student athlete covered by another health insurance policy? No ( ) Yes ( )
If yes, please provide the same information for the second policy as asked above.
*******************************************************************************************************************
I agree that the information provided is accurate and complete to the best of my knowledge.
I agree to notify the Northern Arizona University Athletic Training Department of any changes in insurance coverage.
I/We grant permission for medical personnel to provide treatment in emergency situations.
Signed: ______________________________________________________ Date_____________________
(Signature of Policyholder) (The policyholder must sign both sides of this form)
Signed: ______________________________________________________ Date_____________________
(Signature of Guardian if different than Policyholder and student athlete is under 18 years of age) (Must sign both sides of form)
Signed: ______________________________________________________ Date_____________________
(Signature of Student Athlete) (The athlete must sign both sides of this form)
This completed form must be approved by the Medical Services Coordinator/Athletic Training Department prior to participation in
any manner as a student athlete at NAU. Any changes in insurance coverage must be reported immediately. Failure to report
changes immediately may limit coverage by the secondary insurance. Due dates – fall sports (Football, Soccer, Volleyball and X-C)
Friday July 20th, ALL other sports Friday August 17th.
NORTHERN ARIZONA UNIVERSITY
ATHLETIC INSURANCE PARTICIPATION POLICY
******************************** Section A - Health Insurance Requirements ********************************
All athletes must have a primary insurance to participate in any tryout, conditioning workout, practice, or competition.
All student athletes participating in Northern Arizona University intercollegiate sports programs are required to have a primary medical
insurance that will cover any injuries they may receive. It is a requirement that the primary health insurance provide innetwork coverage for Coconino County and includes the following minimal coverage:
1) Coverage of all athletic injuries.
2) Coverage of all body parts (no exclusions). (Northern Arizona University will not be responsible for injuries excluded by your
primary health insurance policy).
3) Any deductible greater than $2,500.00 will not be accepted and the student athlete will not be cleared for participation.
A $500.00 deductible is highly recommended.
4) 80% pay after deductible for major medical costs.
5) $100,000.00 minimum for major medical coverage.
Any changes to the primary health insurance coverage must be reported immediately and a new insurance information form
completed including new copies of your insurance cards.
************************ Section B- Northern Arizona University Secondary Athletic Insurance *************************
Northern Arizona Universities Athletic Insurance is a secondary policy only. All athletes must have a primary insurance to
participate in any tryout, conditioning workout, practice, or competition. This policy may pay for costs not covered by your primary
health insurance. The following conditions must be met for possible coverage by the secondary insurance:
1) The injury must have occurred during participation in a supervised regularly scheduled game, practice, or workout
(Summer camps are not covered under this policy).
2) The injury was reported to the Northern Arizona University Athletic Training Room within 24 hours of the injury occurrence
As well as recorded in an injury report or on your treatment record.
3) Copies of itemized bills, with procedure codes, and insurance explanation of benefits or denial of payment forms must be
presented to the Medical Service Coordinator within sixty (60) days of the date of service (DOS).
Northern Arizona University secondary athletic insurance policy will not cover the following:
1) Any pre-existing medical conditions, injuries, surgeries, or bracing.
2) Ordinary illnesses and general prescriptions.
3) Any lab work, diagnostic testing, stress tests, medical tests, etc. ordered by team physician during physicals
4) Injuries received outside of participation in a supervised, regularly scheduled game, practice, or workout.
5) Medical charges that are found to be over and above usual and customary for the area of service.
6) Injuries sustained while substance abuse or misuse is occurring.
7) Providers not covered by the primary insurance or that not have been preauthorized by the Athletic Training Medical Staff.
Northern Arizona University will not be responsible for:
1) Charges that are declined by any and all insurances.
2) Late charges or charges associated with noncompliance or falsification of information.
I have received and read the Northern Arizona University Athletic Insurance Participation Policy and understand the responsibility of the
athlete to maintain a primary health insurance and the responsibility of the University to a student athlete who becomes injured as a result of
participation in intercollegiate sports at Northern Arizona University. Northern Arizona University reserves the right to verify signatures and
policy information.
Signed: ______________________________________________________ Date_____________________
(Signature of Policyholder) (The policyholder must sign both sides of this form)
Signed: ______________________________________________________ Date_____________________
(Signature of Guardian if different than Policyholder and student athlete is under 18 years of age) (must sign both sides of form)
Signed: ______________________________________________________ Date_____________________
(Signature of Student Athlete) (The athlete must sign both sides of this form)
This is only a brief summary of the Northern Arizona University Athletic Insurance policy and benefits. The policy is kept on file and can be
reviewed in the Northern Arizona University Athletic Training Room. If you have questions regarding primary insurance responsibilities or
secondary insurance coverage, please contact: Athletic Training Medical Service Coordinator at NAU Dept. Athletics PO Box 15400,
Flagstaff, AZ 86011-5400. Phone 928-523-8917; fax 928-523-8464.
2012-2013 NORTHERN ARIZONA UNIVERSITY ATHLETIC DEPARTMENT
SECONDARY HEALTH and DENTAL INSURANCE INFORMATION
(Please type or clearly print all information)
Student Athlete__________________________
Sport(s) _____________________________
********************************************************************************************************************************
ATTACH A PHOTOCOPY OF THE FRONT AND BACK OF THE INSURANCE CARD FOR THIS POLICY
Secondary Health Insurance
Name of Policyholder_____________________________________________________________________
PolicyholdersSocial Security Number _____________________________DOB:_____________________
Name of Insurance Company________________________________________________________________
Group/Plan Number ______________________________________________________________________
Policy Number __________________________________________________________________________
Insurance Company MailingAddress__________________________________________________________
Insurance Company Phone Number___________________________________________________________
********************************************************************************************************************************
Is your policy an: (circle one)
HMO
PPO
Managed Care Plan
Primary Care Physician ________________________________________ Phone number_______________________
Except for emergency situations, are you required to get a referral to see any health care provider other than your Primary Care Physician or Insurance
Company Clinic? No ( ) Yes ( )
If your Primary Care Physician or Insurance Company Clinic is not located in the Flagstaff area, are there any participating physicians, clinics, or medical
facilities in the Flagstaff area? No ( ) Yes ( )
Flagstaff area Provider___________________________________ Phone Number________________________
Will a change in the athlete’s enrollment status (full -time student to part-time student) change the athlete’s insurance coverage? No ( ) Yes ( )
Is the student athlete covered by another health insurance policy? No ( ) Yes ( )
If yes, please provide the same information for the second policy as asked above.
ATTACH A PHOTOCOPY OF THE FRONT AND BACK OF THE INSURANCE CARD FOR THIS POLICY
Dental Insurance
Name of Policyholder_____________________________________________________________________
Policyholder’s Social Security Number _____________________________DOB:_____________________
Name of Insurance Company________________________________________________________________
Group/Plan Number ______________________________________________________________________
Policy Number __________________________________________________________________________
Insurance Company MailingAddress__________________________________________________________
Insurance Company Phone Number___________________________________________________________
I agree that the information provided is accurate and complete to the best of my knowledge.
I agree to notify the Northern Arizona University Athletic Training Department of any changes in insurance coverage.
I/We grant permission for medical personnel to provide treatment in emergency situations.
Signed: ______________________________________________________ Date_____________________
(Signature of Policyholder)
Signed: ______________________________________________________ Date_____________________
(Signature of Guardian if different than Policyholder and student athlete is under 18 years of age)
Signed: ______________________________________________________ Date_____________________
(Signature of Student Athlete)