ACL

Waiver forms must be submitted directly to the Controller’s Office (1st Floor, Howard Bldg) with copies of the front and back of your insurance card.  Documents may be sent via scan/email to health@ju.edu or faxed to 904-256-7206. Your student health insurance charge will not be removed unless all documents are received by the Controller’s Office by August 30, 2013.

The forms listed above are for student athlete medical records and are required for all Jacksonville University athletes prior to their participation. These forms are to be completed and turned in to the Jacksonville University Sports Medicine Department by July 16. Those potential walk-on or tryout students can turn in their respective New Student-Athlete Form prior to their tryout date. Faxes are not accepted.

Insurance/Personal Info - Read and complete all information needed and then sign. If a student-athlete's primary insurance coverage is through an HMO or managed care, the JU Sports Medicine Department strongly encourages the student-athlete and/or his/her parent(s) / guardian(s) to change the primary care physician (PCP) to a JU team physician or a local physician in the Jacksonville, FL area. Changing your son's / daughter's PCP to an Jacksonville area physician will allow your son / daughter to have a network of physicians in the Jacksonville area, as well as avoid likely delays and/or an inability to receive medical care for athletic and non-athletic related injuries.

OTHER IMPORTANT INFORMATION

Copy of Front and Back of Insurance Card - Needs to be a clear and legible copy

Copy of Student ID - Needs to be a clear copy

Health Questionnaire - Please fill out completely and sign. Explain all yes answers.

Pre-Participation Physical - Must be completed by U.S. Licensed MD/DO. Physicals from Nurses or Physicians Assistants are not accepted unless they accompany a signature from an MD/DO. Physicals from a Chiropractor are not accepted, no exceptions.

Orthopedic History - Explain all yes answers completely also including dates of injuries. If the injury required diagnostic tests, physician referral, and/or surgery, please include all office notes, surgical notes, and/or diagnostic reports.

 

Consent to Treat - Read and sign.

Release of Information - Read and sign.

Injury Reporting/Bill Payment Policy - Read and sign.