University of Delaware Athletics
Forms
REQUIRED FORMS FOR CURRENT UD STUDENT-ATHLETE PHYSICALS AT SPORTS MEDICINE
· Recertification Physical Questionnaire
· Sports Medicine Exit Interview Questionnaire
· NCAA Concussion Education Fact Sheet to be Reviewed
· Supplement Notification Form
PERMISSION TO RELEASE MEDICAL RECORDS
· Authorization for Release of Protected Health Information TO UD Student Health Services
· Authorization for Release of Protected Health Information FROM UD Student Health Services
REQUIRED FORMS FOR ADD/ADHD NCAA COMPLIANCE
To be completed by physician who has diagnosed and prescribed medications for treatment of ADD/ADHD:
· ADD/ADHD NCAA Compliance Form (to be completed when student-athlete first reports taking medication for ADD/ADHD)
· ADD/ADHD NCAA Annual Compliance Form (to be completed at the beginning of each academic year)
To be completed by student-athlete:
· Authorization for Release of Protected Health Information ADD/ADHD NCAA
REQUIRED FORMS FOR PRE-PARTICIPATION PHYSICAL AT UD SPORTS MEDICINE
· UD Sports Medicine Pre-Participation Questionnaire (PDF)
· Sickle Cell Information and Consent Form (PDF)
· Supplement Notification Form (PDF)
· NCAA Concussion Education Fact Sheet to be Reviewed (PDF)
REQUIRED FORMS FOR ADD/ADHD NCAA COMPLIANCE
To be completed by physician who has diagnosed and prescribed medications for treatment of ADD/ADHD:
· ADD/ADHD NCAA Compliance Form (to be completed when student-athlete first reports taking medication for ADD/ADHD) (PDF)
· ADD/ADHD NCAA Annual Compliance Form (to be completed at the beginning of each academic year) (PDF)
To be completed by student-athlete:
· Authorization for Release of Protected Health Information ADD/ADHD NCAA (PDF)
NCAA BANNED MEDICATIONS
· Spironolactone
STUDENT-ATHLETE HEALTH INSURANCE
University of Delaware Health Insurance Policies and Procedures:
Insurance Letter to Blue Hens Parents and Families (PDF)
Student-Athlete Health Insurance Policies & Procedures (PDF)
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Confirm that your primary insurance has acted on each bill. If not, call the service provider and give them your insurance information. University of Delaware will be unable to pay any amount of balance if your primary insurance has not acted due to late filing.
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Once your primary insurance company has acted, collect all bills with a remaining balance along with the Explanation of Benefit Forms (EOBs) from your primary insurance showing that each bill has been considered.
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The EOB is the explanation provided to you by your primary insurance company, which details amounts paid, balances due and reason codes for all denied payments
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This document is required as proof that your primary benefits have been exhausted
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• Email the medical bills with a remaining balance along with the EOB directly to AG Administrators Claims Department:
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AG Administrators Claims Department email address: claims@agadm.com
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Make sure to reference in your email that you are a student-athlete at the
University of Delaware
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An administrator from AG Administrators will be in touch with you and/or your guardian if there are any outstanding questions regarding the submitted claim.
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• For questions related to claims submitted to UD Athletic Department’s secondary insurance company, please contact AG Administrators Customer Service via phone (610) 933-0800 or email customerservice@agadm.com.
| Coordination of Medical Care | Insurance Policies and Procedures | Secondary Insurance Claims |
| Sports Medicine | Athletics Business Office | AG Administrators |
| sportsmed@udel.edu | athl-businessoffice@udel.edu | customerservice@agadm.com |
| (610) 933-0800 |
