UC Irvine Sports Medicine - Amazon S3€¦ · UC Irvine Sports Medicine The “Screen and Clearance” will be performed by the UC Irvine Intercollegiate Athletic Team Physicians

UC Irvine Sports Medicine

The “Screen and Clearance” will be performed by the UC Irvine Intercollegiate Athletic Team Physicians. Each sport

has been assigned a date and time for their “Screen and Clearance” which corresponds to their fall practice start

date (see chart below). Prior to obtaining your Athletic Medical Screen and Clearance, you MUST HAVE ALL

PAPERWORK COMPLETED AND TURNED IN!!! Medical clearance to participate will not be scheduled

with our Team Physician if paperwork is incomplete!

*** If you have a complex medical history or if you have had a recent orthopedic problem, you must bring

in a copy of medical records documenting any prior athletic injury for your physicians to review before

you will be cleared to participate***

Freshman and Transfers MUST have the following complete prior to Team Medical Clearance Date:

Physical Examination Record (completed by your physician between May 1st -July 29th*)

- Your entrance physical may be obtained by your personal physician, health care network,

or UCI Student Health Services.

- The physical must be completed by a MD, DO, or PA. It will not be accepted by any

other medical professional.

- Please schedule your physical examination TODAY.

Athletic Participation History

Incoming Student Health Form (UCI Student Health now requires all Incoming students

to submit their health forms/immunizations online, please include a copy)

Emergency Contact/Insurance Form (Completed and signed by parent and athlete,

attach copy of insurance cards)

Sickle Cell Consent Form -The NCAA Mandates that all incoming Division I student-

athletes must be tested for the sickle cell trait

- If born in CA, fax release form to 510-412-1559 as soon as possible.

- If born outside of California, request your personal physician complete the test as part of

your physical

Medical Release Forms (4)

- Authorization for Release of Health Information to Student Health

- Authorization for Release of Health Information to Sports Medicine

- Authorization for Release of Health Information to Media

- Authorization for Medical Treatment of a Minor

ADHD Documentation (*if applicable)

UC Student Health Insurance Information

Send ALL medical paperwork to: UC Irvine Sports Medicine Re: Student-Athlete Clearance Forms 103 Intercollegiate Athletics Building Irvine, CA 92697-4500

Or fax to: (949) 824-1091 (include Athlete's Name & Sport on Cover Sheet)

If you have any questions regarding this information, please call UC Irvine Sports Medicine at (949) 824-

2876 OR (949) 824-1041

University of California Irvine Sports Medicine Physical Examination Record

2.Physical Examination Record

Name: _______________________________ Sex: ____ Date of Birth:__________ Sport:_____________

Height

Weight BMI B/P Pulse

Vision R20_______/ L20________/ B/20___ contacts glasses none

Sickle Cell Trait Status __________________________ (Required by the NCAA)

Must attach a copy of the sickle cell test results document. This document must be in the official blood test results.

Tetanus Booster (REQUIRED WITHIN 10 YEARS) Date of last booster ____________________

REGULAR MEDICATION / DOSAGE

Marfan’s Screen Indicated? Yes No NORMAL COMMENTS OR ABNORMAL FINDINGS

Head, neck, face, scalp

Nose

Sinuses

Mouth and throat

Ears/ drums

Eyes / pupils / ocular motility

Opthalmoscopic

Chest and lungs

Breasts (male and female)

Heart (thrust size, rhythm, sounds)

Vascular system (pulses and varicosity)

Abdomen and viscera (hernias)

G-U system

Anus and rectum

Endocrine system

Upper extremities

Lower extremities

Spine, other musculoskeletal

Skin / lymphatics

Neurological

Psychiatric

Pelvic and sexual maturation (Circle Tanner Stage) 1 2 3 4 5

Other (indicate)

Health Assessment Summary

Student Cleared for Participation in ________________ Sport , club or activity

No Significant Health Concern

Student Not Cleared for Participation in ____________________ (Explained Below)

Significant Health Concern Found (Explained Below)

_____________________________________________________________________________________________________

___________________________________________________________________________________ ___________________________________________________________________________________

Print Name: __________________________________________________Medical Professional Title: __________________ Address: _____________________________________________________ Phone #: _______________________________ Signature: ______________________________________________Date of Exam: _______________ License #__________

I have reviewed the history form

UC Irvine Sports Medicine Athletics Participation History

Name:__________________________________________ Date of Birth:___________________Sport:____________________

Permanent

Address: ____________________________________________________City, State, Zip:_______________________________

Home Phone:____________________________________ Cell Phone: _________________________________________

The following questions are to be answered by either YES or NO, Please offer a written explanation of each YES on page 2.

Have you had or do you now have: Yes No Have you had or do you now have: Yes No

Seasonal allergies? Very bad (impaired) vision in one eye? Asthma (wheezing)? Used an Inhaler? Missing vision in one eye? Hay Fever? Pollens? Temporary loss of vision? Hives or Rash (With or Without exercise)? Do you wear glasses or contacts? Bee-sting allergy? Have you had or do you now have: Reaction to medicine? Hearing Loss? Food allergies? Perforated eardrum? Have you been under a doctor’s care since you

last physical? Chronic discharge from the ear(s)?

Recurrent ear(s) infection(s)?

Have you been in the hospital since your last physical? Have you had or do you now have:

Loss of or absence of a testicle (men)?

Have you ever had any type of surgery? If yes,

list below: Loss of Spleen or any other Organ?

Kidney problem or loss of a kidney?

Have you or anyone in you immediate family Yes

ever had: Self

Yes

Family NO Hernia? Painful bulge in the abdominal area?

Persistent cough?

Headaches (severe, frequent, migraine)? Diabetes (high sugar in blood or urine)? Heart trouble, murmur, racing heart? History of Mono? High Blood Pressure / Cholesterol?

Sickle cell trait or disease?

Tendency to bleed or bruise easily?

Anemia (“tired blood”)?

Marfan’s Syndrome / Kawasaki Disease? Unusual Fatigue? Heart Cardiomyopathy or Arrhythmia?

Seizure disorders or near drowning?

Have you had or do you now have:

Sinus infections?

Family history of a disabling heart / lung condition? Dental plate/dentures?

Has anyone in your family, under the age of 50, died

suddenly? Orthodontics (teeth straightened)

Do you have a Bridge of False Teeth?


Chest pain, tightness or discomfort with exercise? Have you had or do you now have:

Recurrent rash?

Ever passed out or nearly passed out DURING

or AFTER exercise or working out?

Fungus infection?

Athlete’s foot?

Shortness of breath while playing or exercising?

Dizziness or Faintness with exercise?

Recurrent boils (skin infections)?

A history of Staph Infection?

Ever become ill from working out in the heat? History

of heat stroke, heat exhaustion, or heat cramps? MRSA or herpes skin infection?


Brain concussion / Knocked out?

Any history of Attention Deficit Disorder (ADD) or

ADHD?

A hit or blow to the head that caused confusion,

prolonged headache or memory problems? Taking Medication for ADD/ADHD?

Head injury or facial/skull fracture? Any history of Learning Disabilities?

History of Migraines?

Number of previous Concussions

________

Do you want to talk to a doctor about a health

problem or an injury?

Date of most recent concussion:

Number of days missed after Concussion Health Hx Form 2013

________

________

Do you wish to discuss an emotional problem with

the doctor?

Yes No

Yes No

Do you smoke?

Family history of smoking? Any problems with Alcohol or Drug Abuse?

If yes, past or present?

Family history of drug or alcohol abuse?

________

Do you eat three meals a day?

Do you drink at least (8) 12 oz glasses of

water/day?

Any history of Disordered Eating?

Are you trying or has someone recommended that

you gain weight?

At you trying or has someone recommended that

you lose weight?

Take any medicine regularly (Over The Counter,

prescription or for emergencies)? Have you ever tried to lose weight by:

If Yes, name medication(s): Do you avoid certain types of foods? ___________________________________________ Dieting? Special Diets? ___________________________________________

___________________________________________

Cleansing Diets? Purging? Vomiting?

Using Diuretics? Laxatives?

Take any vitamins, herbal or nutritional supplements?

If yes, list below: Any History of Stress Fracture?

___________________________________________

___________________________________________ Had a sprain, strain or swelling after injury that has

kept you from participation in practices/games?

Have you ever been seen by a Heart Specialist?

If Yes: Who: ______________________________

When: _____________________________

Identify below any location(s) with history of pain or swelling in

muscles, tendons, bones or joints? If yes, check the appropriate boxes

corresponding to the body part and explain below:

Have you ever had an EKG/ECG? Echocardiogram? Head Elbow Hip Have you ever had a stress (heart) test? Neck Forearm Thigh Have you been advised to give up sports because of a

health problem? Back Wrist

Chest Hand

Knee

Shin/Calf Have you had or do you have any other medical

problems or injuries not listed on this form? Shoulder Finger /Thumb

Upper Arm Ankle

Foot /Toes

If Yes: ____________________________________ Had a pinched nerve, stinger or burner?

Had numbness/tingling in arms, hands, legs or feet? Are there any additional health problems you would

prefer to discuss privately with our Team Physician? You or your family a history of Juvenile arthritis or

a connective tissue disease?

Do you use special protective or corrective

equipment or devices? Knee sleeves, Knee braces,

orthotics, etc. If Yes: ________________________

If you have answered YES to any of the questions (page 1 & 2), please EXPLAIN below:

Women Only:

Do you experience cramps?

How old were you when you had your 1st period? ____________ Have you been diagnosed or treated for anemia?

How long do your periods last? ____________ Do you have trouble with heavy bleeding?

How often do you have your periods? ____________ Do you take birth control pills or hormones?

How many periods have you had in the past 12 mo.? ____________ Have you ever had an abnormal PAP smear?

When was your last pelvic exam? ____________ Do you have frequent urinary tract infections?

Additional comments, information or questions?

_______________________________________________________________________________________

_______________________________________________________________________________________ I hereby certify that I have completed this questionnaire completely and correctly to the best of my ability and knowledge. I certify that

there are no illnesses or injuries, current or previous, that I have incurred, other than those I have listed on the preceding pages.

Signature of Athlete:________________________________________________________________Date:______________________________

Signature of Parent (if Under 18 at time of Physical): ___________________________________ Date: ______________________________

UCI Team Physician________________________________________________________________Date:______________________________ Health Hx Form 2016 Physician Signature Physician Print Name

UC IRVINE SPORTS MEDICINE

ATHLETE/ PARENT EMERGENCY CONTACT & INSURANCE INFORMATION

5.Insurance Form

Athlete's Name: ______________________________________ Date of Birth: ______________ UCI Student ID #:_________________

Sport (s):___________________________ Year: 1 2 3 4 5 E-mail Address: _______________________________________

In case of emergency notify:

Name: ______________________________ Relationship:_____________________ Phone: ___________________________

Dear Parent(s)/Guardian of student athletes:

DO NOT Drop dependent coverage while your son or daughter is participating in intercollegiate athletics. Primary insurance is

MANDATORY for all UC Irvine Students while participating in athletics.

The UC Student Health Insurance Plan (UC SHIP) from UC Irvine Student Health is a secondary policy has exclusions and restrictions. It is

not superior to the personal / family plan in most all cases. An exception is with the international student-athlete. UC SHIP was initially

designed to meet the UC requirement that all students have health insurance while enrolled, for the uninsured, and not to replace personal /

family coverage.

In all injury or illness cases, UC Irvine Athletics will use the student-athlete’s primary insurance.

Our athletic accident insurance policy, is "EXCESS" or "SECONDARY" to any other collectible insurance benefits, and provides additional

coverage for injuries occurring while participating in intercollegiate sport practice or play under the direct supervision of a UCI coach. It

does not cover student-athletes participating in unsupervised sport related activities.

The policy is the most comprehensive within our resources; this secondary (excess) policy is not an all-inclusive policy. The secondary

insurance policy may have limitations that define the care that we are able to provide.

The university athletic policy is not all inclusive and will only be responsible for costs deemed reasonable and customary by our insurance

provider and authorized in writing by the Director of Sports Medicine.

UC Irvine Athletics requests that YOU DO NOT DROP your son or daughter from the personal/family insurance plan.

Most employers’ group insurance allows dependent coverage to be continued to age 26 if the dependent is a full-time student.

PLEASE COMPLETE FULLY, SIGN THE BOTTOM & RETURN TO UC IRVINE SPORTS MEDICINE

Athlete:

UCI Local Address (If known) ____________________________________ City/State _______________________ Zip ___________

School Phone # __________________________________________ Cell Phone #:________________________________________

Father/Guardian: Mother/Guardian: Name (last, first) _____________________________________ Name (last, first) _________________________________________

DOB _____________________________________________ DOB __________________________________________________

Home Address ______________________________________ Home Address __________________________________________

City/State ________________________ Zip ______________ City/State __________________________ Zip ________________

Home Phone ________________________________________ Home Phone ____________________________________________

Cell Phone _________________________________________ Cell Phone ______________________________________________

Primary Insurance: Please include a copy of Insurance Cards (front & back).

Company: __________________________________________ Insurance Address: ______________________________________

City/State : ______________________ Zip _______________ Insurance Phone: _______________________________________

Plan/Group #: ______________________________________ Policy/Member ID#: _____________________________________

Subscriber Name: ____________________________________ Subscriber ID#: _________________________________________

Subscriber’s Employer: ______________________________ Employers’ Address: __ __________________________________

City/State: ______________________ Zip:_______________ Is this insurance: HMO PPO POS EPO Indemnity

Is Student athlete covered under any DENTAL INSURANCE POLICY? YES NO

Is student-athlete covered under any VISION INSURANCE POLICY? YES NO

Have you WAIVED your enrollment in UC Student Health Insurance Plan (UC SHIP) from UC Irvine Student Health by the September 8,

2017 Deadline? You must waive out yearly at www.shs.uci.edu/, current yearly fee is $1500. YES NO

I hereby certify that the information above is true, complete and correct to the best of my knowledge. If there are changes in coverage or an

expiration of coverage, I agree to notify UCI Athletics Sports Medicine Insurance Coordinator and update the insurance information on file at

949-824-1041. I understand that if enrolled in USHIP for the fall quarter, this policy will not be active and cover any medical related costs until

after the start of the academic quarter. I agree that, should it be determined at a later date that I have not accurately informed UC Irvine of

collectible coverage, I will reimburse University of California or it’s insurance company.

__________________________________________________ ____________________________________________________

Parent/Guardian Signature and Date Student-Athlete Signature and Date

(Required Regardless of Athlete’s Age)

http://www.shs.uci.edu/

UC IRVINE SPORTS MEDICINE

ATHLETE/ PARENT EMERGENCY CONTACT & INSURANCE INFORMATION

5.Insurance Form

Information regarding Primary Care Physician(PCP) / Medical Group:

If the PRIMARY insurance policy DOES restrict the medical providers the student-athlete may use PLEASE change to a LOCAL

provider NOW. If your current PCP / Medical Group is greater than 100 miles from UC Irvine, PLEASE change to a PCP convenient to

UC Irvine NOW for the upcoming school year. For assistance in selecting a local PCP / Medical Group, Call UCI Athletics Sports

Medicine Insurance Coordinator at 949-824-1041.

The insurance plan / policy is a HMO POS EPO OTHER

The Primary Care Physician/ Medical Group is:

PCP/ Medical Group: _________________________________________________Phone #: _______________________________

Address, City, Zip Code: _____________________________________________________________________________________

Secondary Insurance: Please include copy of insurance cards (front & back).

Company: ________________________________________________ Insurance Address: __________________________________

City/State: ________________________________ Zip: ____________ Insurance Phone: ____________________________________

Plan/Group #: ______________________________________________ Policy/Member ID#: _________________________________

Subscriber Name: __________________________________________ Subscriber ID#: ______________________________________

Subscriber’s Employer: _____________________________________ Employers Address: __________________________________

City/State: _____________________ Zip: _______________ Is this insurance: HMO PPO POS EPO Indemnity

If the Secondary insurance policy DOES restrict the medical providers the student-athlete may use, please enter the corresponding policy

information below: The Primary Care Physician/ Medical Group is:

PCP/ Medical Group: __________________________________________________________Phone #: __________________________

Address, City, Zip Code: ________________________________________________________________________________________

Dental Insurance: Please include copy of insurance cards (front & back).

Company: ________________________________________________ Insurance Address: ___________________________________

City/State: __________________________ Zip: __________________ Insurance Phone: ____________________________________

Plan/Group #: ______________________________________________ Policy/Member ID#: __________________________________

Subscriber Name: __________________________________________ Subscriber ID#: ______________________________________

Subscriber’s Employer: __ ___________________________________ Employers Address: __________________________________

City/State: _____________________ Zip: _______________ Is this insurance: HMO PPO POS EPO Indemnity

Return to:


Re: Student-Athlete Clearance Forms

103 Intercollegiate Athletics Building

Irvine, CA 92697-4500

State of California - Health and Human Services Agency California Department of Public Health - Genetic Disease Screening Program

FIRST NAME LAST NAME DATE OF BIRTH (MM/DD/YYYY)

CITY MOTHER LIVED IN AT TIME OF STUDENT'S BIRTH

DATE SIGNED (MM/DD/YYYY)

BEST PHONE NUMBER TO REACH YOU

THE UNDERSIGNED HEREBY AUTHORIZES THE RELEASE OF NEWBORN SCREENING HEMOGLOBIN TEST RESULTS FROM THE RECORDS OF THE CALIFORNIA GENETIC DISEASE SCREENING PROGRAM. MUST BE SIGNED BY STUDENT IF 18 OR OLDER. PARENT OR LEGAL GUARDIAN SHOULD SIGN ONLY IF STUDENT UNDER THE AGE OF 18.

STUDENT'S INFORMATION

GENETIC DISEASE SCREENING PROGRAM (GDSP) ● NEWBORN SCREENING BRANCH 850 MARINA BAY PARKWAY, F175 ● RICHMOND, CA 94804 ● Website: www.cdph.ca.gov/programs/nbs

E-mail questions to: [email protected] ● FAX: 510/412-1559

CDPH 4400 (ENG) (2/15)

WERE YOU PART OF A MULTIPLE BIRTH?

YESNO

(Just type in numbers, parentheses and slashes will fill in)

BIRTH HOSPITAL

BIRTH MOTHER'S INFORMATION

MAIDEN NAME

FIRST NAME LAST NAME

OTHER NAMES USED

RELEASE RESULTS TO

SIGNATURE (STUDENT IF OVER 18, PARENT/GUARDIAN IF STUDENT NOT OVER 18) PRINTED NAME

YOU HAVE THE RIGHT TO RETAIN A COPY OF THIS CONSENT. YOU HAVE THE RIGHT TO REVOKE THIS CONSENT AT ANY TIME BY WRITING TO: CHIEF, GENETIC DISEASE SCREENING PROGRAM AT 850 MARINA BAY PARKWAY, F175, RICHMOND, CA 94804. THE GENETIC DISEASE SCREENING PROGRAM IS NOT RESPONSIBLE FOR FURTHER DISCLOSURES OF THE INFORMATION BY OTHER PARTIES THAT MAY RESULT FROM COMPLYING WITH THIS CONSENT.

SIGNATURE

I understand that any person who requests or obtains any record containing personal information from the California Department of Public Health under false pretenses will be guilty of a misdemeanor and fined up to $5,000 or imprisoned up to one year or both.

AUTHORIZATION FOR THE RELEASE OF RECORDS WILL EXPIRE ON:

GENDER

MALE FEMALE

IF YES, WHERE WERE YOU IN THE BIRTH ORDER?

(in other words were you a twin, triplet or more?)(Usually A, B, C or 1, 2, 3... etc.)

The Genetic Disease Screening Program (GDSP) is defined as a health care provider under HIPAA and is a covered entity. GDSP is therefore required to distribute a Notice of Privacy Practice (NPP).

PRIVACY NOTIFICATION

NCAA STUDENT ATHLETE REQUEST FOR NEWBORN SCREENING HEMOGLOBIN RESULTSPLEASE NOTE

Required questions are underlined - enter N/A if you do not have the answer. •

•

(A default 1 year from today is given. if a different date is desired, please feel free to change.)

CITY WHERE BIRTH HOSPITAL LOCATED

DATE OF BIRTH

PROVIDE AN EMAIL ADDRESS WHERE ADDITIONAL ENCRYPTED RESULTS ARE TO BE SENT

The collection and exchange of personal health information between covered providers for the purpose of treatment, payment, or health care operations with GDSP and our agents in connection with the newborn and prenatal screening programs is permitted by HIPAA and required by state law without special authorization or Business Associates Agreements.

You must have Adobe's Acrobat Reader (http://get.adobe.com/reader/) to use this form. •

Parents cannot request results for offspring 18 years or older. •

Enter data on form, print it, sign it and mail or fax it. You can also scan or take a picture and email it (see contact information below).

•

If providing more than one address, separate addresses using a semi colon ( ; )

For more information go to www.cdph.ca.gov/programs/nbs and select NCAA Athletes.If unable to fill form out and submit electronically please: Print form, fill out with clear BLOCK PRINT, sign and return by FAX, mail or email (JPG/PDF).

It can take up to 30 days to process your request. If you need your results in less time, we recommend having a sickle cell test run by your physician.

Results are only available for California births after 2/26/1990.

****

****

BEST EMAIL ADDRESS FOR US TO SEND YOU YOUR RESULTS

(Results only on birthdates after 02/26/1990)

Enter data then...


Department of Intercollegiate Athletics

Authorization for Release of Health Information to Student Health Services I authorize UC Irvine team physicians, athletic trainers, sports information staff and athletic coaches to release my health information concerning any illness or injury relative to my participation in athletics at UC Irvine to:

University Student Health Services

501 Student Health – UC Irvine Irvine, California 92697-5200

Tel (949) 824-5301

In order to facilitate medical care related to my participation in those sports. I understand that I cannot participate in my sport(s) without signing this release. This release will be effective for the time period of my participation in intercollegiate athletics at UC Irvine.

Notice: UC Irvine Sports Medicine and many other organizations and individuals such as physicians, hospitals and health plans are required by law to keep your health information confidential. If you have authorized the disclosure of your health information to someone who is not legally required to keep it confidential, state or federal confidentiality laws may no longer protect it.

Your Rights: I understand that the treatment, payment enrollment or eligibility for benefits may not be conditioned on

signing this authorization except if the authorization is for: 1) conducting research-related treatment 2) to obtain information in connection with eligibility or enrollment in a health plan 3) to determine an entity’s obligation to pay a claim 4) to create health information to provide a third party.

I may revoke this authorization at any time. To do so I must submit a written request to Jim Pluemer Director of Sports Medicine, UC Irvine Athletics, Crawford Hall, Irvine, CA 92697-4500. The revocation will take effect when UC Irvine Sports Medicine receives it, except to the extent that UC Irvine Department of Intercollegiate Athletics or others have already relied on it.

I am entitled to receive a copy of this Authorization.

Signature:

Athlete’s Signature Date

Athlete’s Printed Name Sport

Athlete’s Parent or Legal Guardian Signature (If Athlete is under age 18) Date

Athlete’s Parent or Legal Guardian Printed Name (If Athlete is under age 18)

Witness Signature (If Athlete is unable to sign) or Interpreter Date



Authorization for Release of Health Information to Sports Medicine I authorize UC Irvine team physicians, athletic trainers, sports information staff and athletic coaches to release my health information concerning any illness or injury relative to my participation in athletics at UC Irvine to the athletic coaches, administrators, and sports information staff for legitimate educational purposes related to my participation in those sports. I understand that I cannot participate in my sport(s) without signing this release. This release will be effective for the time period of my participation in intercollegiate athletics at UC Irvine.






Signature:

Athlete’s Signature

Date

Athlete’s Printed Name

Sport

Athlete’s Parent or Legal Guardian Signature (If Athlete is under age 18)

Date


Witness Signature (If Athlete is unable to sign) or Interpreter

Date



Authorization for Release of Health Information to Media I authorize UC Irvine team physicians, athletic trainers, sports information staff and athletic coaches to release my health information concerning any illness or injury relative to my participation in athletics at UC Irvine to the medial, including TV, radio, newspapers, or magazine media outlets for news stories, health care communications stories or for: ________________________________________________________________ This release will be effective for the time period of my participation in intercollegiate athletics at UC Irvine.






Signature:

Athlete’s Signature

Date

Athlete’s Printed Name

Sport

Athlete’s Parent or Legal Guardian Signature (If Athlete is under age 18)

Date


Witness Signature (If Athlete is unable to sign) or Interpreter

Date

NCAA Medical Exception Documentation Reporting Form to Support the Diagnosis of Attention Deficit Hyperactivity Disorder (ADHD)

and Treatment with Banned Stimulant Medication

ADHD Medication exemption 2016.doc 5/1/2017

• Complete and maintain (on file in the athletics department) this form and required documentation supporting the medical need for a student-athlete to be treated for ADHD with stimulant medication. • Submit this form and required documentation to Drug Free Sport in the event the student-athlete tests positive for the banned stimulant (see Drug Testing Exceptions Procedures at www.ncaa.org/drugtesting).

Please return this form to the student-athlete or to the following address: Institution Name: UC Irvine Intercollegiate Athletics Sports Medicine Institution Representative Submitting Form: Jim Pluemer MS, PT, ATC, CSCS

Assistant Athletic Director - Sports Medicine 309 Crawford Hall,

Irvine CA, 92697-4500 Office: 949-824-7633 Fax: 949-824-1091

Student-Athlete Name_________________________________________________ Date of Birth_________________________

I hereby authorize and request a report associated with this visit be sent to UC Irvine Sports Medicine (fax: 949-824-1091) or by separate report via mail. Patient’s Signature: __________________________________________________________ Date: ______________________

To be completed by the Student-Athlete’s Physician:

Current Treating Physician (print name): _____________________________________________________________________

Specialty: ______________________________________________________________________________________________

Office address __________________________________________________________________________________________

Physician signature: _____________________________________________________________ Date____________________

Check off that documentation representing each of the items below is attached to this report o Diagnosis. o Medication(s) and dosage. o Blood pressure and pulse readings and comments. o Note that alternative non-banned medications have been considered, and comments. o Follow-up orders. o Date of clinical evaluation: _________________ o Attach written report summary of comprehensive clinical evaluation. Please note that this includes the original

clinical notes of the diagnostic evaluation. The evaluation should include individual and family history, address any indication of mood disorders, substance abuse, and previous history of ADHD treatment, and incorporate the DSM criteria to diagnose ADHD. Attach supporting documentation, such as completed ADHD Rating Scale(s) (e.g., Connors, ASRS, CAARS) scores. The evaluation can and should be completed by a clinician capable of meeting the requirements detailed above.

DISCLAIMER: The National Collegiate Athletic Association shall not be liable or responsible, in any way, for any diagnosis or other evaluation made, or exam performed, in connection herewith, or for any subsequent action taken, in whole or in part, in reliance upon the accuracy or veracity of the information provided hereunder.

http://www.ncaa.org/drugtesting

NCAA Guidelines to Document ADHD Treatment with Banned Stimulant Medications Addendum to the January 2009 Guidelines

Q & A March 2009

Updated July 2010 (*New Questions)

1. *What is the outcome in the case of a student-athlete who tests positive for stimulant

medication prescribed to them by a legitimate medical provider but has no documentation to support the diagnosis, and who subsequently undergoes an evaluation that determines the student-athlete does not have ADD/ADHD? • This case above will be reviewed under the drug-testing appeals process. The

outcome of that process may be not to penalize the student-athlete, but require the student-athlete to discontinue using the banned medication.

2. *Is the documentation of a diagnostic assessment required to meet the NCAA Medical Exception Policy for treatment with stimulants for ADD/ADHD the same as that required for academic accommodations through the institution’s disability resource center? • No, the diagnostic evaluation to meet the NCAA documentation criteria does not

need to include the full battery of testing for learning disabilities generally conducted for the institution’s disability resource center review. In order to meet NCAA criteria, the institution must submit documentation of the clinicians write up, to include a comprehensive history and assessment as it relates to DSM criteria for ADHD, including the measures used to rate the student-athlete’s symptoms of attention deficit. This evaluation should be accompanied by a signed letter from the prescribing physician describing the course of treatment and current prescription.

3. Why is the NCAA instituting a stricter application of the medical exception policy for the

use of banned stimulant medications to treat ADHD?

• The stricter application reflects a stronger stand on policy enforcement, protecting the student-athlete competing while using these stimulants, and the integrity of the sport. This stricter application of the medical exception policy is intended to provide clearer documentation of the student-athlete’s evaluation, and not intended to replace the clinician’s evaluation and treatment.

As experienced across campus, more and more college students-athletes are being treated with stimulant medications for ADHD. These stimulants are banned for use in NCAA competition for both performance and health reasons, and using them may result in a positive drug test and loss of eligibility, unless the student-athlete provides adequate documentation of a diagnostic evaluation for ADHD and appropriate monitoring of treatment. In recent years, the number of student-athletes testing

Addendum to January 2009 ADHD Treatment With Banned Stimulants Guidelines July 20, 2009 Page No. 2 _________

positive for these stimulant medications has increased 3 fold, and in many cases there has been inadequate documentation submitted in support of the request for a medical exception to the NCAA banned drug policy.

4. Who was consulted in the development of the guidelines?

• The NCAA sought consultation from MDs, Psychiatrists, Psychologists and others in the development of the guidelines for appropriate documentation requirements; these were then reviewed and approved by the NCAA Committee on Competitive Safeguards and Medical Aspects of Sports.

5. How was the change communicated to the membership? • Beginning in January 2008, the membership received notification of the effective date

of the stricter application -- August 2009 – in the form of NCAA News articles, notices in email communications, and the posting of a video describing the rational and expectations of the stricter application. This 18 month period of notice would allow member institutions to inform current and incoming student-athletes to be prepared to gather the necessary documentation of the diagnosis, course of treatment and current prescription.

6. Who needs to conduct the evaluation? • The initial evaluation may be conducted by clinicians with experience in assessing

ADHD; these include school psychologists, clinical psychologists, psychiatrists, other MD’s and their supervised clinicians.

7. What type of ADHD evaluation documentation needs to be submitted to support an ADHD diagnosis and treatment with banned stimulant medication? What is acceptable and what is not acceptable proof an evaluation has been conducted? • The documentation should include a comprehensive clinical evaluation, recording

observations and results from ADHD rating scales, a physical exam and any lab work, previous treatment for ADHD, and the diagnosis and recommended treatment. The physician can provide documentation of the above either with a cover letter and attachments or provide the medical record. This documentation should be kept on file in the athletics department until such time that the student-athlete tests positive for the


stimulant. A simple statement from the prescribing physician that he or she is treating the student-athlete for ADHD with said medication IS NOT adequate documentation.

8. Will an assessment conducted more than three-five years ago be acceptable?

• Yes, in fact the expectation is that for many student-athletes, the evaluation and

initiation of treatment likely began during grade school. Documentation of that evaluation, along with the history of treatment and current prescription, should be submitted by the student-athlete to their sports medicine staff upon matriculation.

9. What is required of a student-athlete who for years has been prescribed stimulant medication to treat ADHD but has not undergone a full assessment?

• In order to obtain a medical exception, the student-athlete must undergo a full

assessment as described above. This may be conducted on campus, through a community mental health service, or by any experienced clinician.

10. Does a student-athlete need to have an updated letter from the prescribing physician on file each year of their eligibility? • Yes, an annual follow-up with the prescribing physician is the minimum standard,

and that can be reflected in a letter from the physician or a copy of the medical record, with written indication of the current treatment.

11. Do physicians have to use a certain form when performing the evaluation for ADHD?

• There is no specific form physicians need to use to perform an evaluation. The guidelines present the criteria identifying what to report, and several ADHD rating scales are listed, but it is the totality of the clinician’s evaluation that should be reflected in the documentation. This evaluation should be conducted by a clinician experienced in assessing ADHD

12. Can an institution pay for the evaluation to diagnose ADHD?

• From an interpretation: Institution paying for academic performance testing


Date Issued: October 26, 1988 Date Published: October 26, 1988 (Item Ref: g). g. Institution Paying for Academic Performance Testing: Determined that Constitution 3-1-(h)-(4)-(i) [incidental benefits -- tutoring expenses] would permit an institution to pay for tests to determine the academic performance level of enrolled student-athletes in order to identify potential academic problems, inasmuch as such a diagnostic test is considered part of the tutoring process. Recommended that this interpretation be published in LAC subsequent to review by LIC.

13. What happens if neither the school nor student-athlete can afford to pay for the testing?

• In each division, the institution can submit an incidental expense waiver. For Division I, SAOF may be used if it is approved by their conference office.

14. Some student-athletes are embarrassed and don’t reveal that they are taking medication for ADHD. How does the institution address this issue?

• The institution should be proactive in communicating the importance to all student-

athletes about reporting to sports medicine all medical issues and medications – in order to avoid loss of eligibility and to respond appropriately in any medical emergency. The need for this reporting should be expressed to the student-athlete as standard operating procedure and addressed during initial medical assessments and subsequent health histories. The NCAA is preparing a poster to remind student-athletes to report all medications.

15. Does the student-athlete need to first try non-stimulant medication to treat ADHD?

• The student-athlete does not need to be put on a trial of non-stimulant medication, but the documentation must note that a non-stimulant alternative was considered and why the stimulant medication was chosen.

16. If a student-athlete received a medical exception for the use of banned stimulant medication to treat ADHD prior to August 2009, will that student-athlete be required to meet this policy application?

• There is no ‘grandfathering’ on this issue; for any positive drug test occurring from

August 1, 2009, a medical exception for the use of banned stimulant medication must


include the required documentation, even if a student-athlete has received a medical exception for ADHD stimulant medication prior to August 2009.

17. How will the policy address a student-athlete who tests positive for a banned stimulant prescribed by their physician but has not undergone a full assessment for an ADHD diagnosis?

• If a student-athlete has not undergone an evaluation and/or cannot produce documents

at the time the positive test is confirmed with the institution, the student-athlete must be declared ineligible until 1) the documentation can be produced or 2) a drug-test appeal is heard and approved.

18. Does a student-athlete currently on stimulant medication but lacking a formal evaluation need to discontinue the medicine in order to undergo the assessment?

• If a student-athlete has been on a prescribed stimulant medication, but no evaluation

documentation is available, and the student-athlete will be referred for evaluation to document the diagnosis of ADHD, they can continue the medication if helpful and they are tolerating it. Clinicians familiar with ADHD regularly see patients who are taking ADHD medications and have no formal documentation at the time. There is no need to stop the medication and interfere with appropriate treatment of the medical condition. The evaluation is a clinical evaluation which includes taking a comprehensive history, evaluation current/past symptoms, reviewing the effects of medications (including getting information from the patient's prescription/med bottle), checklists, etc. There is no need to take the patient off the medication for evaluation especially if they are doing well.

19. How will clinical notes and testing results be secure once the institution sends these documents to the NCAA?

• The information provided by the school to the NCAA to address drug-testing issues is

covered by the Student-Athlete Statement and Drug-Testing Consent compliance forms. All subsequent use of these materials by NCAA review committees follow strict NCAA confidentiality protocols

20. How will this policy be communicated to student-athletes?


The National Collegiate Athletic Association July 20, 2010 MEW:rhb

• The institution is responsible to communicate to all student-athletes NCAA banned drug policies, including the medical exception policy. The medical exception policy information is available in the Drug-Testing Program handbook, on-line at NCAA.org and also included in the Drug-Education and Drug-Testing video (to be updated summer 2009). In addition, the NCAA will provide posters spring 2009 to all NCAA institutions that alert student-athletes to the need to report all medications.

IMPORTANT NOTICE ABOUT HEALTH INSURANCE PLEASE READ CAREFULLY TO AVOID UNNECCESARY FEES

Health insurance is mandatory for all UCI students. A fee for the University of California Student Health Insurance Plan (UC SHIP) will

be assessed each academic term as part of registration fees. Students may waive out of UC SHIP by providing proof of adequate

insurance that meets the University's minimum requirements. UC SHIP can only be waived online by the fee payment deadline for

each term. No late waivers are accepted. Read the following information to determine if your student-athlete is eligible to waive UC

SHIP.

All student-athletes who are cleared medically and declared eligible for practice/competition are covered by a secondary/excess and catastrophic insurance program provided by UC Irvine. This policy is for intercollegiate athletics injuries only. UC Irvine’s secondary insurance program is designed to cover expenses not covered by the individual or family coverage. For further details please see the student-athlete handbook. PLEASE ALSO NOTE THAT SUBMITTING THE ENCLOSED INSURANCE FORMS TO THE UCI ATHLETIC DEPARTMENT DOES NOT WAIVE

STUDENT-ATHLETES OUT OF UC SHIP.

♦ Every quarter a fee of $593.00* will be included with every student's registration fees for UC SHIP. This represents an annual

fee of $1778.00*. (Coverage includes the Summer period when insured for Spring.)

♦ UC SHIP coverage includes medical, vision, dental and prescription drug benefits.

♦ Students who have health insurance from another source may opt out of the UC SHIP program provided it meets the following

criteria*:

• Be a Medi-Cal, Medicare or Tricare/military insurance policy or a Covered California plan

• Plan has no maximum lifetime benefit limit.

• Plan provides a total out-of-pocket expense (including deductible and co-insurance) that does not exceed $7,150.00 for an

individual and $14,300 for a family per year for hospitalization, surgery and emergency care.

• Plan was purchased in the United States from a domestically owned and operated insurance company.

• Plan is not a travel insurance policy or a reimbursement program.

• Plan provides a health care facility within 50 miles of UCI that the student is eligible to use. (For example, HMO patients

from outside the Los Angeles area must transfer to a local provider.)

• Student is enrolled and eligible for benefits from the first day of the academic term throughout the academic year

• International students must be insured with a U.S. based company that provides federal-mandated levels of benefits, in

accordance with the type of visa held by the student, for medical evacuation and repatriation of remains.

♦ If your insurance coverage meets the above criteria you may waive out of UC SHIP (i.e. waive the $593.00* per quarter fee) via

an online registration formᵗᵗ.

♦ If your son or daughter is currently covered under a family policy, UCI Athletics strongly recommends maintaining that

coverage due to the UC SHIP program's policy of no coverage for injuries sustained in intercollegiate practice or play.

♦ Students are solely responsible for waiving out of UC SHIP (the Athletic Department cannot do it for them)

If you have any questions regarding the SHIP Waiver criteria, please call or email the SHC Insurance Office at 949-824-2388; or via email at [email protected]. ᵗᵗ You can read more about UC SHIP at http://www.shs.uci.edu/health_insurance_privacy/insurance.aspx#Cost * The UC SHIP waiver criteria listed above applies to the 2017-2018 academic year. Please visit www.shc.uci.edu for updates.

mailto:[email protected]

mailto:[email protected]

http://www.shs.uci.edu/health_insurance_privacy/insurance.aspx#Cost

http://www.shc.uci.edu/

UC Irvine Sports Medicine Department of Intercollegiate

Athletics

Authorization for Medical and/or Psychological Treatment of a Minor (less than 18 years of age)

Full Name:_________________________________________________________________ (Last, First) Date of Birth: ____________________ Student ID #: ____________________

I, _____________________________ am the parent or legal guardian of the student named above. I hereby authorize any healthcare provider at the University of California, Irvine Department of Intercollegiate Athletics Sports Medicine and/or Student Health Center to administer any medical and/or psychological treatment that is deemed necessary for the student named above. _______________________________________________ _______________ Signature of Parent or Legal Guardian Date

University of California, Irvine Sports Medicine

903 W. Peltason Dr. Irvine, CA 92697-4500

(949)824-2876


Department of Intercollegiate

Athletics

Important Dates for Pre-participation Physicals

ALL medical forms must be completed and turned in to UCI Sports Medicine by the following dates for the listed men’s and women’s sports programs

JULY 29th: BASKETBALL, CROSS COUNTRY, GOLF, SOCCER, VOLLEYBALL, WATER POLO, CHEER

SEPTEMBER 15st: BASEBALL, TRACK & FIELD, TENNIS

LOCATION: Gottschalk Medical Plaza located on campus (at Academy Way and Medical Plaza

Drive)

SATURDAY, AUGUST 5, 2017 SATURDAY, AUGUST 12, 2017 SATURDAY, SEPTEMBER 23, 2017

7:30am Men’s Soccer 7:30am Men’s Volleyball 7:30am Baseball

Women’s Soccer Women’s Water Polo

Women’s Volleyball

8:00am Men’s Golf 8:00am Men’s Water Polo 8:00am Track and Field

Women’s Golf

8:30am Men’s Basketball 8:30am Men’s Cross Country 8:30am Men’s Tennis

Women’s Basketball

Women’s Cross Country

Women’s Tennis

9:00am 9:00am Cheer 9:00am Women’s Basketball Scout team

Documents

UC Irvine Sports Medicine - Amazon S3€¦ · UC Irvine Sports Medicine The “Screen and Clearance” will be performed by the UC Irvine Intercollegiate Athletic Team Physicians