Student Athlete Family Insurance Information And Record Release Form
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1Student Athlete Family Insurance Information and Record Release Form
15-16
Full Name of Student-Athlete: _____________________________________________________ Sport: _______________________
SIU ID #________________Social Security #____________________Date of Birth: __________Cell Phone: ___________________
Street Address: _______________________________________________________________________________________________
City: __________________________________________ State: ___________________________ Zip Code: _________________
Father’s Name: __________________________________________
Social Security #____________________________________
Father’s Address:__________________________________________________________ Date of Birth:______________________
City:__________________________________________
State:____________________________ Zip Code:_________________
Father’s Phone (H):___________________________ (C):______________________________(W):___________________________
Mother’s Name: ___________________________________________ Social Security #___________________________________
Mother’s Address: ________________________________________________________ Date of Birth________________________
City: __________________________________________
State: ___________________________ Zip Code: ________________
Mother’s Phone (H):___________________________(C):______________________________(W):___________________________
1. Do you have health coverage for your daughter/son? Yes__________
No_________
2. Does your hospitalization policy require that all in-patient confinements and all surgical procedures be pre-certified to
be eligible for full benefits? Yes_________
No_________
3. Does your policy contain a mandatory second surgical opinion requirement before a surgical procedure may be
performed?
Yes_________
No__________
4. At what age does your insurance terminate for your daughter/son? __________
P
Please Attach Copy of Insurance Card
Health Insurance Company:_____________________________________________Phone#_____________________________
R
I
Name of Employer (if group coverage):______________________________________________________________________
M
Group Policy #_____________________________________________ ID #:_______________________________________
A
Member Name:_____________________________________________ Deductible Amount/Person:_____________________
R
Insurance Co. Address:_____________________________________________________ Policy Limit:________________
Y
City:__________________________________________ State:______________________ Zip Code:____________________
Please Attach Copy of Insurance Card
S
Health Insurance Company:_____________________________________________Phone#_____________________________
E
C
Name of Employer (if group coverage):______________________________________________________________________
O
Group Policy #_____________________________________________ ID #:_______________________________________
N
Member Name:_____________________________________________ Deductible Amount/Person:_____________________
D
Insurance Co. Address:______________________________________________________Policy Limit:___________________
A
R
City:__________________________________________ State:______________________ Zip Code:____________________
Y
WE AUTHORIZE SOUTHERN ILLINOIS UNIVERSITY CARBONDALE TO RELEASE ANY AND ALL MEDICAL RECORDS, BILLS, AND MEDICAL
INFORMATION TO MY INSURANCE COMPANY(IES) AND ANY INSURANCE COMPANY UNDER WHICH I AM ENTITLED TO BENEFITS
WE UNDERSTAND THAT SOUTHERN ILLINOIS UNIVERSITY CARBONDALE STUDENT-ATHLETES MUST ALSO CARRY THE SIUC EXTENDED
MEDICAL BENEFITS PLAN, AND MAY NOT ASK FOR A REFUND ON THIS PLAN.
.
A PHOTOCOPY OF THIS AUTHORIZATION WILL BE AS VALID AS THE ORIGINAL
ATHLETE’S SIGNATURE _______________________________________________________________ DATE____________________________
PARENT SIGNATURE___________________________________________________________________DATE___________________________
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Parent category: Legal