2024-2025 Athletic Training
Carthage College Medical Consent And
Medical Insurance Agreement
Medical Consent Authorization
I hereby grant permission to the Carthage College Athletic Training Department Staff, Team Physicians and Consultants
to render myself, and/or son/daughter, any treatment or medical care deemed reasonably necessary. This includes
preventative care, first aid, diagnostic testing, rehabilitation, emergency treatment, and/or hospitalization.
________________________________ __________________________________ _________
Printed Name os Student Athlete Signature of Student Athlete Date
Medical Insurance Agreement
Carthage College provides excess athletic accident coverage for all student-athletes participating in intercollegiate
athletics. An accident is defined as an unexpected, sudden, and definable event which is the direct cause of bodily injury
independent of any illness, prior injury, or congenital disposition. Coverage is NOT provided for medical expenses
resulting from illness, disease, or conditions unrelated to accidental bodily injury. Pre-existing conditions, out-of-season
injuries, injuries that occur in-season that are not directly related to competition or supervised or routine medical care are
not covered. Students must maintain primary insurance that covers intercollegiate athletics and is applicable to
coverage in the state of Wisconsin. Government provided plans are not accepted. A copy of the insurance card (front
and back) needs to be on file.
In the event an athletic claim is filed, the procedures listed below must be followed to ensure excess coverage through
Carthage College.
● Carthage Athletic Trainer must perform initial evaluation and student-athletes must comply with treatment.
● All non-emergency injuries are to be treated on-site for 72 hrs before referral or second opinion.
● If a student-athlete is accidentally injured during competition or supervised practice and generates medical
expenses associated with the accident, all claims must first be filed with their primary insurance company.
● If a balance remains after the personal insurance company has paid its maximum, that balance can be
submitted to the school’s insurance company. It is the student athlete’s responsibility to give the Carthage
insurance information to all of his/her medical providers.
● If the expense is covered, the school’s insurance company will pay the balance of the eligible medical
expenses up to the maximum of the policy after the $500 deductible is met.
● If the primary coverage is through an HMO or PPO, it is the responsibility of the student-athlete to follow the
proper procedures required by that plan in order for the school’s insurance to satisfactorily complete its portion
of the claim.
I, the undersigned, understand the terms of this Medical Insurance Agreement.
__________________________________ ________________________________ _________
Printed Name of Student Athlete Signature of Student Athlete Date
__________________________________ ________________________________ _________
Printed Name of Policy Holder/Parent Signature of Policy Holder/Parent Date
