Verification Of Health Insurance Form printable pdf download

SUNY Cobleskill Department of Sport and Exercise

VERIFICATION OF HEALTH INSURANCE

Student-Athlete Name: ________________________________Sport: _____________________

DOB: _______________ Cell Phone # ____________________ 800# _____________________

Home Address: ________________________________________________________________

Emergency Contact and Phone #: __________________________________________________

SUNY Cobleskill does not provide health / sports injury insurance for student-athletes. I

understand that I will be responsible for all medical expenses incurred with participation

in intercollegiate athletics at SUNY Cobleskill.

By signing this form I hereby certify that I have either:

Check one and initial:

______ A) Purchased the School Health Insurance Policy

______ B) I have Health insurance policy that covers athletic related injuries up to $90,000.

Please provide a copy of your insurance card in the space provided.

Paste or Tape in This Space

Copy of the Front and Back of the Insurance Card

Do not use staples

CONSENT FOR RELEASE OF INFORMATION

Name: _________________ Sport___________________ Date of Birth: __________

Do hereby grant authorization to The SUNY Cobleskill’s Sports Medicine Staff to release and /or obtain my injury

reports and/or medical records and participation status for any and all injuries /illnesses incurred as a direct result of

or affecting my participation as a member of an intercollegiate athletic team at SUNY Cobleskill. This

information, as warranted and/or appropriate would be released to one or more of the following:

Athletic Administration, Wellness Center, Appropriate athletic team coach, Team physician Family and/or

specialist physician, Hospitals / clinics / ambulance crew, Insurance providers Professional scouts, Parents.

I understand that in accordance with Federal and State laws, this release does not include permission to transmit

information specifically related to HIV (Human Immunodeficiency Virus) the causative agent of AIDS) status, and

if such information is to be released, additional specific release forms are required. I understand that this consent is

valid for 1 academic year from the date of signing and that I may rescind this consent at any time with written

notification.

__________________________ _________________________________

_________

Student Signature

Parent signature if under the age of 18

Date

Verification Of Health Insurance Form