William & Mary
Division of Sports Medicine
Entering Student Athlete 2023-2024
We are pleased to welcome you to the Tribe Athletics family. There are a few items that must be completed and
returned no later than June 1, 2023 so that we can establish your personal, confidential file with the Division of
Sports Medicine. These items are necessary in medically clearing you for participation in intercollegiate athletics at
William & Mary and establishing your eligibility for coverage under our secondary insurance policy. Incomplete
forms will delay the process. This process must be complete before you will be allowed to participate in any
athletic activity.
_____ Medical Forms
• Please schedule an appointment as soon as possible with a physician for a physical examination
and sickle cell screening. NCAA requirements mandate that your last physical be within the
last 6 months for completion of our physical form.
• You must print the following forms for you and your physician to complete at your appointment.
o Student Health Center Health Evaluation Form (electronic via Student Health Center Portal)
▪ https://www.wm.edu/offices/wellness/healthcenter/student-
requirements/index.php
▪ Please note the due date of this form. There is a $100 late fee for failure to
submit the form by June 1, 2023.
o Athletic Participation Physical Form (included in this packet)
_____ Health Insurance Form
• Please note that you must include a copy of the FRONT and BACK of your insurance card in the
space provided.
• You are also required to provide proof of insurance to the Student Health Center. Please
understand that this is separate from what Sports Medicine is asking you to do. Please do both.
• TriCare Special Notes:
o If you have TriCare, you MUST specify Prime or Select.
o If you are enrolled in TriCare Standard, be aware that it has transitioned into TriCare Select
as of January 2019. Please enroll into the East Region, which will put you into TriCare
Humana. You will have to select a Primary Care Physician (PCP) such as Elizabeth Smith, NP,
out of VCU Health.
o If you are enrolled in TriCare Prime, know that your coverage from William & Mary Team
Physicians will be limited. The scope of this plan requires you to see a physician at Fort Eustis
in Newport News (40 minutes from campus).
o If you would like to switch plans, a change of address qualifies as a life event to enroll outside
of the normal enrollment period.
_____ Waive OR Enroll in the School’s Insurance
• If you have existing health care coverage for your child and DO NOT wish to purchase the
health insurance coverage offered through the Student Health Center, you need to visit
www.wm.edu/health/insurance to submit a waiver request. YOU MUST SUBMIT THIS ONLINE.
However, if you have existing health care but do not have coverage in the state of Virginia, you
may want to consider purchasing the health insurance policy offered through the Student Health
Center. You will need to submit an enrollment request for this. Please see item below regarding
lack of insurance coverage.
o If you do not submit this request by the deadline on the website, you will be automatically
billed for coverage under the student insurance administered by United Healthcare Student
Resources. The opening & closing dates are available on the website at the above link.
o Denying the student health insurance DOES NOT affect your ability to be seen at the Student
Health center or the Athletic Department’s secondary insurance coverage.
• If you do not have existing insurance coverage, you should purchase the health insurance
policy offered through the Student Health Center. Please visit www.wm.edu/health/insurance
to submit an enrollment request. YOU MUST SUBMIT THIS ONLINE.
o The opening & closing dates are available on the website at the above link.
_____ ADHD Medication Exemption Information Form (if applicable)
• The National Collegiate Athletic Association (NCAA) bans certain classes of drugs because they
can harm student-athletes and/or create an unfair advantage in competition. The NCAA will
grant medical exceptions if adequate documentation showing the student-athlete has undergone
a diagnostic evaluation for a type of drug. Exceptions may be granted for substances included in
the following classes of banned drugs: anabolic agents, stimulants, beta blockers, diuretics, anti-
estrogens, and peptide hormone. If you are on these medications, print the ADHD Medication
Exemption Information Form at the end of this packet and give to your doctor to obtain the
proper documentation for your medication so that we have it on file in the Athletic Training
Facility. Your physician needs to complete the form and include the necessary documentation
required in the form. The NCAA now requires us to have this information on file.
Submitting your forms
Please mail the completed forms to the appropriate addresses shown below by June 1st. If you mail forms to the
incorrect location, it will delay the processing of your paperwork.
Please keep pages 9-14 for your records.
Please mail the Athletic Participation Physical Form, Health Insurance Form, and ADHD Medication
Exemption Information Form (if applicable) to:
William & Mary
Division of Sports Medicine
PO Box 399
Williamsburg, VA 23187-0399
If you have questions regarding these forms or have trouble downloading these forms, please email Melanie Eley at
[email protected]u or call (757) 221-3407.
Athletic Participation Physical Form 2023 1
Athletic Participation Physical Form William & Mary
Division of Sports Medicine
I. Contact Information
Student’s Name: ____________________________________ ______________________________________ __________
Last First MI
What is your legal gender? _________________________ What is your pronoun (circle)? He/Him She/Her They/Them
SSN _______________________________ Student ID # ________________________________
Sport _____________________________ Birthdate __________________________ Age ________________
Entering Status (circle): Fr. So. Jr. Sr. Grad Expected year of Graduation: __________________
Athlete’s Email: ____________________________________________ Athlete’s Cell Phone ( ) ________________________
(W&M account)
Parents’ Names ___________________________________________ Parent’s Email: ______________________________________
___________________________________________
Home Address ____________________________________________________________________________________________________________
(Parents) Street City State Zip
Parents’ Home Phone ( ) ____________________ Parent’s Cell Phone ( ) _____________________________ (Mother)
( ) _____________________________ (Father)
CONSENT FOR TREATMENT
I give authorization to the William & Mary Sports Medicine staff to evaluate and treat any injuries that occur during my athletic
participation at the university. This includes immediate first aid and treatment, physical exam, follow-up, and
rehabilitation/treatment in the athletic training facility as well as at the Student Health Center. I understand that the team
physician has the authority to prohibit me from further participation because of injury and/or because of an undue liability risk
to William & Mary.
Student-athlete Signature ____________________________________________________________________________ Date _______________
Parent’s Signature (if athlete is under 18 years of age) ____________________________________________ Date _______________
Athletic Participation Physical Form 2023 2
_____________________________________________________ (NAME)
THE NEXT TWO PAGES TO BE COMPLETED BY THE STUDENT-ATHLETE OR PARENT/GUARDIAN:
Omitting or providing fraudulent information may result in dismissal from a team or a cancellation in
athletic aid (scholarship).
II. Personal History - Please answer ALL questions. Leave no blank spaces.
Childhood diseases _________________________________________________________________________________________________________________________
Do you have any drug allergies? ________ If yes, please list drug & reaction _____________________________________________________________
Do you have any food or insect allergies? ________ If yes, please list food & reaction __________________________________________________
Significant medical conditions (dates & diagnoses) ______________________________________________________________________________________
Surgeries not related to an athletic injury _________________________________________________________________________________________________
Current medications and reasons for use _________________________________________________________________________________________________
Check either Yes (Y) or No (N) to indicate whether you have (or had in the past) diagnosed with any of these
problems. Provide details below.
Y
N
Y
N
Y
N
Details_________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
Check either Yes (Y) or No (N) to indicate whether you have (or had in the past) these problems. Provide details
below.
Y
N
Chest pain/discomfort/tightness/pressure related to exertion
Unexplained syncope/near-syncope (temporary loss of consciousness or fainting)
Excessive exertional and unexplained dyspnea (difficult of labored breathing), fatigue, or palpitations associated with exercise
Prior recognition of a heart murmur
Elevated blood pressure
Prior restriction from participation in sports
Prior testing for the heart, ordered by a physician
Details_________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
Athletic Participation Physical Form 2023 3
_____________________________________________________ (NAME)
III. Family History – Check either Yes (Y) or No (N) to indicate if condition exists in your family (immediate family,
grandparents, aunts, uncles). Please provide details below.
Y
N
Y
N
Y
N
Y
N
Allergies
Cancer
Lung Disease
Ulcer
Anemia
Diabetes
Psychiatric Disorder
Other
Asthma
Eye Disorder
Stroke
Bleeding Disorder
High Blood Pressure
Tuberculosis
Details_________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
Check either Yes (Y) or No (N) to indicate if condition exists in your family (immediate family, grandparents, aunts,
uncles). Please provide details below.
Y
N
Premature death (sudden and unexpected, or otherwise) before age 50 attributable to heart disease in ≥ 1 relative
Disability from heart disease in close relative < 50 years of age
Hypertrophic cardiomyopathy OR dilated cardiomyopathy
Long QT-syndrome
Arrhythmias
Other specific cardiac conditions (please indicate):
Details_________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
Is there a history of heart disease in your family (immediate family, grandparents, aunts, uncles)? Yes or No
Please explain:________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
Athletic Participation Physical Form 2023 4
_____________________________________________________ (NAME)
IV. Injury History – Please read and answer ALL questions!
Have you ever been found to have only one of the following paired organs, and if so, which one is missing?
Eyes
Yes
No
Right
Left
Kidneys
Yes
No
Right
Left
Ovaries
Yes
No
Right
Left
Testicles
Yes
No
Right
Left
1. Have you or a family member been diagnosed with Marfan’s Syndrome? YES (If yes, who?) ____________ NO
2. Have you or a family member been diagnosed with the Sickle Cell Trait? YES (If yes, who?) ____________ NO
3. Do you have any other medical illness or injury, past or present, that we should know about for your own protection?
YES NO
If yes, please explain: _______________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
Have you had any of the following problems that may have limited your performance and/or caused prolonged
pain/discomfort? If YES, please provide details below (date of onset and side, left or right).
Problem
Yes
No
Date of Onset
Left
Right
Explain (further details at bottom)
Knocked Unconscious
Concussion
Neck Injury
“Burner, Stinger”
Back Pain
Shoulder
Knee
Ankle
Foot
Lower Leg
Hip
Elbow
Wrist
Arm
Hand
Surgery
Physical Therapy
Details/Other: ________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
Athletic Participation Physical Form 2023 5
_____________________________________________________ (NAME)
V. Physical Examination
TO THE LICENSED HEALTH PROFESSIONAL (D.O., M.D., P.A., N.P.) PERFORMING THIS EVALUATION:
• Please review the student’s health history and provide additional details as needed.
• Please complete the physical examination and comment on all positive findings.
• All sections of examination must be filled out.
Height __________ inches Weight ___________ lbs. BP ______________ Pulse ____________ Vision R 20/_____ L 20/_____
Sickle Cell Solubility Test - Date: _____________________ Result:__________________________________________
(This testing is REQUIRED by the NCAA for ALL Student-Athletes regardless of ethnicity, family history, etc.)
Covid-19
Positive test: Yes_____ Date_____________ No______
Vaccination: Yes____ Manufacturer__________ 1
st
Dose Date______________ 2
nd
Dose Date________________ Booster Date_______________
No____ If no, are you interested in receiving it?__________
Cardiac Exam – Please complete ALL sections. Leave no areas blank.
Heart, including murmur: _________________________________________________________________________________________________________________
Lung: __________________________________________________________________________________________________________________________________________
Peripheral Pulses for Coarctation: _______________________________________________________________________________________________________
Please record examination findings below. If abnormal, please elaborate.
Normal
Abnormal
Explanation
Normal
Abnormal
Explanation
HEENT
Genitourinary
Eyes
Back
Breasts
Extremities
Gastrointestinal
Skin
Hernia
Surgical Scars
Neuropsychiatric
Endocrine
Yes
No
Yes
No
Yes
No
Shortness of breath
Dyspnea on Exertion
Chest Pain
Palpitations
Dizziness
Syncope
Are there any physical stigmata of Marfan syndrome? _______________________________________________________________________________
Physical Examination: Are there any conditions of which we should be aware? Describe fully. Use an additional sheet if
necessary.
_________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
I have reviewed the information above and make the following recommendations for his/her participation in athletics:
_______ Cleared _______ Not Cleared _______ Cleared – f/u needed (explain below)
F/U Recommendations: _____________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
Examiner’s Signature (not typed) Street City State Zip
_________________________________________________________________________________________________________________________________________________
Examiner’s Name (PRINTED) Telephone Date
Athletic Participation Physical Form 2023 6
_____________________________________________________ (NAME)
ACCEPTANCE OF RISK/LIABILITY WAIVER
Please read completely and carefully, and sign below:
a. The undersigned hereby certifies that the answers to questions on the Athletic Participation Physical Form and physical
examination are correct, true, and honest.
b. We understand that having passed the pre-participation medical/physical examination does not necessarily mean that
the student-athlete is physically qualified to engage in athletics, but only that the examiner did not find a medical reason
to disqualify them.
c. We understand and accept the risks of injury, the possibilities of permanent disability, and death inherent to the
relevant sport. By signing below the student-athlete pledges to do their best to reduce these risks by keeping in the
best physical condition and following the advice of the team physician, attending physician, athletic trainer, and
coaching staff concerning the prevention, treatment, and rehabilitation of athletic injuries.
d. We grant permission to the Sports Medicine staff to hospitalize and/or secure treatment for me for any athletic injury.
If the student-athlete is under the age of 18, the undersigned parent grants permission to the Sports Medicine staff to
hospitalize and secure treatment for my son/daughter or ward for any athletic injury.
e. I give permission for Certified Athletic Trainers (within the Athletic Department), the Team Physician, VCU Health
physicians, Student Health Center staff, and all consulting physicians to exchange, written or orally, any information
concerning any injuries or illness that effect my ability to participate in physical activities throughout the time in which
I am an official student athlete at William & Mary. Any change in this status must be made in writing by the student-
athlete and rendered to all parties concerned.
We, the undersigned, have read and understand the Acceptance of Risk/Liability Waiver statements and agree to follow its
policies and procedures. We also hereby release William & Mary and its agents and employees, from any liability caused by,
or arising out of the athletic participation in the university's athletic program, unless solely caused by the negligence of the
university or its agents and employees.
Athlete's signature* Parent's signature*
Date Date
*Parent's signature is needed if student-athlete is under 18 years of age.
William & Mary
Division of Sports Medicine
Insurance FAQs
What type of athletic insurance does the athletic department carry?
As a service to our student athletes, the Athletic Department provides a secondary, or supplemental, athletic accidental
insurance. The secondary policy will only be applied to medical costs incurred for services rendered by a participant
in the William & Mary Sports Medicine network and their specific written referral for further care. That care must still
be coordinated through the athletic training staff prior to the visit. The secondary policy is applicable only for athletic
injuries that are a direct result of intercollegiate activity during a required practice or competition supervised by a
coach.
The secondary insurance policy requires that the injured athlete first make a claim under their primary
medical or hospitalization insurance. Medical expenses not covered by the primary insurance will be paid under the
school's policy (subject to its limitations and conditions). Although we attempt to purchase the most comprehensive
policy within our resources, this is not an all-inclusive policy.
How does my child qualify for secondary coverage?
You must complete an annual Health Insurance Form that asks for the personal insurance information under which
your child is covered. The Understanding Your Health Insurance Coverage While Away From Home form explains the
procedures that we must follow to access your primary insurance. In addition, you must complete the Insurance Card
Form in which you must copy, paste, or otherwise attach a copy of the front and back of your insurance card. These
three forms must be on file in the athletic training facility prior to an injury.
How does the secondary insurance coverage work?
The secondary insurance policy requires that the injured student-athlete first make a claim under the primary
insurance. We send your primary insurance information when the student-athlete is referred for care. The provider
should file a claim with your insurance company for the services rendered. Your company will evaluate the claim and
either pay you or the provider directly or deny the claim. If the provider does not file with the primary insurance, the
provider may send you a bill for you to file with your insurance company.
If after 60 days of the date of injury, you have not received anything from your insurance company:
1. Call your insurance company to check the status of the claim, and/or
2. Submit the bill from the provider to your insurance company.
We will also send the providers our secondary insurance information and notify our insurance company that a claim
may be forthcoming. The provider should file a claim against our secondary insurance company after your primary
insurance has been exhausted.
• You should contact the providers directly to make sure they have filed with primary and secondary insurance
companies. You may need to file these claims yourself.
• All claims must be resolved with the secondary insurance company within 104weeks of the date of injury.
When is an athlete referred to a physician?
Whenever the team physician or the athletic trainers are of the opinion that a consultation would facilitate/improve the
care of an injury, arrangements for such a visit will be made. Coaches do not have the authority to refer an athlete to
any physician except for emergency medical care when the Sports Medicine staff is not available.
What if I belong to an HMO?
If you belong to a Health Maintenance Organization (HMO), you are limited to the HMO's physician and facilities. Send
us specific instructions, requirements, and/or limitations which may be included with the policy. This information is
necessary for the claims process to be filed correctly. Failure to follow the proper HMO procedures will void your
eligibility for coverage under the athletic department's secondary insurance.
Which physicians can an athlete see under the secondary insurance plan?
For an athlete to be covered under the Athletic Department's secondary insurance, they may be seen only by
participants in our Sports Medicine network. This network is composed of a wide range of specialists from VCU Health
and the local medical community. This group provides the best possible health care to William & Mary athletes. We
formed this network to ensure accurate and continuous communication between the physicians and the Sports
Medicine staff.
Prior written authorization must be granted by a Sports Medicine network physician if an athlete wishes to seek medical
attention outside of the network. Authorization is granted only in cases where our consulting physicians cannot provide
the required care. If an athlete seeks a second opinion or care from an out-of-network provider, they will be medically
ineligible to participate in athletics or utilize the services of the William & Mary Sports Medicine Program until medical
records are received and reviewed by the Sports Medicine staff. The athlete has the responsibility to see that the
physician forwards all requested information. You also assume financial responsibility for any travel cost and the
services of that provider. Our secondary insurance cannot be applied to those services.
Towards which bills can the secondary insurance coverage be applied?
The Athletic Department's secondary insurance can be applied only to those bills for an athletic injury:
1. Injury is reported to the Sports Medicine staff within 24 hours of occurrence,
2. When prior approval for a referral was granted through the Sports Medicine staff,
3. When the care has been coordinated through the Sports Medicine staff,
4. For services rendered by participants in the Sports Medicine network and their specific written referral,
5. For care rendered within 104 weeks of the date of injury, and
6. Your insurance company has responded to and resolved all claims.
What types of things are not covered under secondary insurance?
• Any injury sustained in an activity that is not associated with a required intercollegiate practice or competition
supervised by a coach.
• A chronic or recurrent injury that was sustained prior to participation in athletics at William & Mary.
• Any degenerative condition as diagnosed by a physician.
• Any illness (cold, flu, infection, etc.).
• Unauthorized consultations or treatments.
• Conditions because of non-compliance with school's policies, team rules, or the advice of the team physician,
attending physicians, the athletic trainers or coach.
• Any injury that is not reported to the athletic trainers within 24 hours of occurrence or onset of symptoms.
• Costs, including travel, associated with second opinions.
What are the parent's and/or athlete's responsibilities?
It must be clearly understood that you and/or your child are financially responsible for all charges for the care of
an athletic injury and the resolution of all claims. The Athletic Department at William & Mary assumes no financial
liability for expenses generated for medical care of an athlete. We will try to relieve any financial burden that may occur
from the care of athletic injuries through the department's secondary insurance policy. However, this is not an all-
inclusive policy and benefits will be applied subject to the terms and limitations of this policy.
In addition, the parents and/or athlete have the responsibility to follow the proper procedure to access the secondary
insurance policy to seek benefits for charges that arise from an athletic injury. Again, all charges are ultimately the
responsibility of the athlete. Therefore, if the threat of collection or garnishment arises from an unpaid bill, the parents
and/or athletes are strongly urged to pay all balances to avoid harm to his or her credit rather than wait for the
insurance company to decide on benefits.
Will I have to pay for any health care costs that arise due to an athletic injury?
For all athletes--both those who receive athletic grant-in-aid and those who do not--our secondary insurance policy
currently carries a $0 deductible per injury that must be met by either a) your primary insurance or b) the athlete or
his or her parents. Further, any remaining balances or charges that are not met after all insurance benefits are
exhausted are the responsibility of the athlete.
Where can I find more information regarding secondary insurance?
Specific questions should be directed to Melanie Eley, Insurance Coordinator for Sports Medicine at (757) 221-4845 or
[email protected].
What if my primary insurance coverage changes during the year?
It is the athlete's responsibility to notify the Sports Medicine staff promptly of any changes in his or her primary
insurance coverage including changes in insurance carrier, address, benefits, primary care physician, etc. To maintain
coverage under our athletic injury policy, the student athlete must provide the following:
1. Health Insurance Form completed with the new information
2. Understanding Your Health Insurance Coverage While Away From Home completed
3. Insurance Card Form completed with new insurance card attached
What if my child does not have primary insurance?
You should purchase the health insurance policy – United Healthcare Student Resources (UHCSR) – offered through the
Student Health Center. Please visit www.wm.edu/health/insurance to submit an enrollment request. YOU MUST
SUBMIT THIS ONLINE. The opening & closing dates are available on the website at the above link.
Establishing a Primary Care Physician in Williamsburg
In an attempt to provide the best possible health care to our student-athletes, our staff is headed by Dr. Virginia Wells, MD.
If your health insurance requires a referral from a specific physician for care, we would ask that you transfer that designation
to a physician here in town, whether it be someone at the William & Mary Student Health Center or one of our local medical
clinics. When you call, please identify yourself as a William & Mary student-athlete. To make this change, you will need to
contact your insurance company. Your efforts now will help expedite care for your child in the event of an injury.
Please feel free to call upon us if we can be of assistance to you with this process.
Guidelines for the Resolution of Athletic Insurance Claims
If you receive a bill:
1. Check whether your primary policy has been billed FIRST. Please contact your primary insurance company
by phone or online to make this determination.
a. If your primary policy has been billed, please find the corresponding Explanation of Benefits (EOB)
for the date of service. A copy of this form must be sent to our secondary insurance company to
complete the billing process.
b. If your primary policy has not been billed, please follow the directions in step 2 to have an itemized
bill sent to your primary insurance company.
2. Determine if the bill is itemized – the bill should have the service(s) that were rendered and their individual
costs. A balance statement is not sufficient. Contact the medical provider and have them send an itemized
statement to yourself, or directly to the insurance policy.
If you do not receive a bill within 30 days of the date of service, or 60 days from the date of injury:
1. Contact the medical provider to determine whether or not they have filed with your primary insurance
company.
AG Contact Information
Mailing Address: AG Administrators, P.O Box 21013 Eagan, MN 55121
Fax: 610-933-4122 Phone: 610-933-0800
Please understand:
1. For the resolution of claims, the secondary policy needs an EOB from your primary policy and itemized bill
from the medical provider for each date of service.
2. The secondary policy can only be applied to those bills,
a. where services are tendered of the treatment of an athletic injury, and
b. when prior approval of that referral was granted through the athletic training staff, and
c. when the care has been coordinate through the athletic training staff, and
d. when your insurance company has responded to all claims
3. The claim for this injury expires 104 weeks from the date of injury. The secondary insurance company may
deny claims for bills after that date.
We are willing to advise you through the process, but the responsibility for the payment of all bills and the
resolution of all claims rests with you. Should you have any questions about the claims process, please feel free to
contact the Athletic Insurance Coordinator at (757) 221-4845. Should you have any questions concerning any bills
from medical providers, please contact them first before contacting the Athletic Insurance Coordinator. Thank you
for your cooperation in this matter. Please keep this sheet for your records throughout the claims process.
Notice of Privacy Practices
The Division of Sports Medicine developed this document to keep you informed as to how the Sports Medicine staff
may use and disclose your protected health information to carry out treatment, payment, or health care
operations. It describes your rights to access and control your protected health information and governs the
mechanism in which you can give your consent to the Division of Sports Medicine to release your protected health
information to other entities.
Please visit http://www.wm.edu/offices/sportsmedicine/_documents/privacy-practices.pdf to view or to
download the entire Notice of Privacy Practices.
William & Mary
Division of Sports Medicine
Health Insurance Form for 2023-2024 School Year
Athlete’s Name: ________________________________________ Gender: _________________ Pronoun: _____________ DOB: _____________
____________________________________________________ ____________________ ____________ _____________
Permanent Home Address City State ZIP
____________________________________________________ ____________________ ____________ _____________
Mailing Address if different from Permanent Address City State ZIP
__________________________________ ____________________________________ ___________________________ Sport: __________________
Home Phone Number Athlete Cell Phone Number Athlete Email
SSN: _______________________________________ WM Student ID #: ____________________________
REQUIRED REQUIRED
Policy Holder’s Information
Secondary (if applicable)
Name ____________________________________________________________
Home Address: _________________________________________________
_____________________________________________________________
Home Phone ( ) ___________________________________
Work Phone ( ) ___________________________________
Insurance Co. ___________________________________________________
Policy Holder’s ID #: ___________________________________
Policy Group #: ________________________________________
Claims Phone #: _______________________________________
Mailing Address for Claims ____________________________________
______________________________________________________________
Policy holder’s relationship to athlete: _________________________
Is your dependent son/daughter covered under this policy?
 Yes  No Policy Holder’s DOB: ________________
What type of insurance do you have?
 Traditional  HMO  PPO  POS  Other
Does your insurance cover prescriptions?  Yes  No
Name ____________________________________________________________
Home Address: _________________________________________________
_____________________________________________________________
Home Phone ( ) ___________________________________
Work Phone ( ) ___________________________________
Insurance Co. ___________________________________________________
Policy Holder’s ID #: ___________________________________
Policy Group #: ________________________________________
Claims Phone #: _______________________________________
Mailing Address for Claims ____________________________________
______________________________________________________________
Policy holder’s relationship to athlete: _________________________
Is your dependent son/daughter covered under this policy?
 Yes  No Policy Holder’s DOB: ________________
What type of insurance do you have?
 Traditional  HMO  PPO  POS  Other
Does your insurance cover prescriptions?  Yes  No
If you have more than one insurance, please make sure that you do a coordination of benefits and verify which one is primary.
Emergency Contact (Parent) Information
Secondary Emergency Contact Person
Name(s)
Address
City ST Zip
Email(s)
Work/Cell #s
I hereby certify that I have read and understand the attached Insurance Frequently Asked Questions (FAQ).
Signature of Policy Holder or Designee ________________________________________________________________ Date____________________
PLEASE FILL OUT COMPLETELY, LEAVE NO AREAS BLANK
1
_____________________________________________________ (NAME)
*Understanding Your Health Insurance Coverage While Away From Home*
It has been our experience that it would be beneficial for you to contact your insurance company NOW, long before
your child enters school, to ensure your child has adequate, hassle-free coverage while he/she is away at school. We
have developed the following questions to help you understand the scope of your insurance coverage to determine if
it will meet the needs of your child. The coverage that you have experienced at home may not be the coverage your
son/daughter receives while away at college. In case of injury or illness while away from home, you would hope that
your son or daughter should be able to access the same level of health care in Williamsburg without difficulty. If your
insurance does not allow out-of-network coverage, your son/daughter may have to go home for care or be exposed to
higher co-pays and higher out-of-pocket expenses. Such restrictions also inevitably slow the access to comprehensive
care that will return your child to health and to competition. You may ultimately find it advantageous or necessary
for you to change your insurance plan or even insurance company to maintain the coverage at school that you have
experienced at home. Failure to provide current and complete information and/or notify us of any changes
could compromise and complicate access to the athletic department’s secondary insurance policy making you
solely responsible for all medical bills.
1. Does your son/daughter have coverage and/or out-of-network benefits in Williamsburg, VA for services
other than emergency care (i.e. diagnostic testing such as MRI or x-ray, chiropractic care, physical therapy,
etc.)?
YES NO
If no, consider switching insurance. We suggest you speak with the William & Mary Sports Medicine staff at
(757) 221-3407 to discuss your coverage needs.
2. Does your son/daughter need a referral from their PCP to access other providers (imaging, specialists, etc.?
YES NO
If YES:
PCP Name: ___________ Phone Number: _______
If so, we ask that you make either Dr. Virginia Wells, Dr. Alexander Vap. Dr. Thomas Loughran, or another
physician in Williamsburg as their PCP instead. When you call please identify yourself as a W&M student-
athlete. Please contact us at (757) 221-4845 if we can be of assistance in selecting a PCP in the local area.
3. Please circle all eligible providers within your benefits. You may check these providers by calling your
insurance company or logging into your insurance company’s website. Please search the providers and
locations listed below.
Alexander Vap, MD Robert O’Connell, MD
VCU Health @ W&M VCU Medical Center VCU Health Neuroscience, Orthopaedic,
and Wellness Center
Scott W. Sautter, Ph.D Peninsula Radiological Riverside Hospital
Associates
Sentara Regional Hospital Sentara CarePlex Hospital Velocity Urgent Care
Tidewater Diagnostics Imaging Pivot Physical Therapy VA Anesthesia & Perioperative Care
Specialist
_____________________________________________________ (NAME)
PLEASE COPY YOUR INSURANCE CARD (FRONT & BACK) BELOW
READ CAREFULLY
• I authorize payment of medical benefits to all providers for all services and materials they provide during the care
of an injury/illness.
• I agree to supply any and all information requested by my primary insurance, William & Mary, and their excess
insurance company in a timely manner in order to expedite the claims process.
• I hereby authorize William & Mary and their excess insurance company to secure and inspect copies of case
history records, lab reports, diagnoses, x-rays, and any other data pertaining to the injury/illness I am receiving
care for or previous confinements or disabilities relevant to the care of the injury/illness.
• I authorize the Sports Medicine staff at William & Mary and/or my coach to hospitalize and secure treatment for
me for any athletic injury/illness. If the athlete is under 18 years of age, the undersigned parent grants permission
to the Sports Medicine staff at the university and/or their coach to hospitalize and secure treatment for their
son/daughter for any athletic injury/illness.
• I authorize The Division of Sports Medicine at William & Mary to release medical records to other healthcare
providers in order to facilitate timely & appropriate treatment or care.
• A photostatic copy of this authorization shall be deemed as effective and valid as the original.
• I will notify the Sports Medicine staff at William & Mary immediately upon any change in the above health
insurance information.
SIGNATURE:_________________________________________________________________________ Date:____________________________
(If under 18, parents must sign, otherwise must be signed by parent or student-athlete)
**PLEASE COMPLETE ONLINE WAIVER FORM IF APPLICABLE**
If you have existing health coverage and DO NOT wish to purchase the student health insurance coverage offered
through the Student Health Center at William & Mary, you need to visit www.wm.edu/health/insurance to submit
a waiver request. If you do not submit this waiver request online by the date on the website you will be
charged for the student insurance! Denying the student health insurance DOES NOT affect the ability to be seen
at the Student Health Center or the Athletic Department’s secondary insurance coverage.
2
3
PLEASE COPY YOUR COVID-19 VACCINATION CARD BELOW
William & Mary Athletics does not require COVID-19 vaccination to participate; however, we strongly recommend it in our
student-athletes. Non-vaccinated student-athletes will still be required to test periodically based upon department,
university, NCAA and/or CDC testing policies. Fully vaccinated student-athletes will also not be required to quarantine if
deemed a close contact to a positive case. If you have received all your doses of the vaccine, please copy your provided card
below.
Copy vaccination card here
William & Mary Division of Sports Medicine
Attention Deficit Hyperactivity Disorder (ADHD) Medication Exemption Information Form
Primary Care Physician/Health Care Provider:
The student-athlete presenting this form to you plans to
or already participates in intercollegiate athletics at the
William & Mary. Our institution is governed by the rules
and regulations of the NCAA (www.ncaa.org), thus
requiring the collection of medical records for those
student-athletes diagnosed/treated for ADHD/ADD
utilizing specific medication which may be banned by
the NCAA. In order to show compliance with this
legislation, we are asking our student-athletes to take
this letter to their primary care physician/health care
provider to fill out and to provide the following
information in order to continue/begin their NCAA
participation while also continuing to take their
ADHD/ADD medication.
Please return this form & supporting documentation
to the student-athlete or to the following address or
fax number:
William & Mary
c/o Division of Sports Medicine
PO Box 399
Williamsburg, VA 23187-0399
Phone (757) 221-3407 // Fax (757) 221-4361
I authorize the release of this information and the results
of this examination to William & Mary Division of Sports
Medicine staff.
Student Signature: ____________________________________________
Date ______ /______ /______
Student-Athlete’s Name: ________________________________________________ Date of Birth: ________________________
Date of initial evaluation: _____________________________ Date of most recent follow-up: ______________________
Physician’s Diagnosis: ____________________________________________________________________________________________________
Medication Prescribed/Follow-up Orders: _____________________________________________________________________________
(Examples of the NCAA Banned-Drug Class: Stimulants include amphetamine, atomoxetine, dexmethylphenidate,
dextroamphetamine, methamphetamine, and methylphenidate. For more information please visit www.ncaa.org/health-safetly.)
✓ Please attach a brief summary of the comprehensive clinical evaluations used to diagnose this student-
athlete with ADHD/ADD (reference DSM-IV criteria) and any supporting documentation.
✓ Please attach any ADHD Rating Scale (ex: Connors, ASRS, CAARS) scores and report summaries.
✓ Please include medication documentation, along with a copy of the script for the current medication.
The student-athlete does not have to be put on a trial of non-stimulant medication but documentation
must note that a non-stimulant alternative was considered and why the stimulant medication was
chosen instead.
✓ If available, please provide copies of the following:
o Any psychological testing results
o Laboratory/testing results helping to diagnose ADHD/ADD
Name of Physician: _____________________________________________________
Address: _________________________________________________________________
Specialty: ________________________________________________________________
Signature: _______________________________________________________________ Date: _________________________________
STAMP
William & Mary
Division of Sports Medicine
Entering Student Athlete 2023-2024
Please make sure that you have completed the following items:
Medical Forms
Student Health Center Health Evaluation Form (electronic)
Athletic Participation Physical Form
Health Insurance Form
Waived or Enrolled in the School’s Insurance online
ADHD Medication Exemption Information Form (if applicable)
Reviewed the Privacy Practices online
Submitting your forms
Please mail the completed forms to the appropriate addresses shown below by June 1
st
. If you mail forms
to the incorrect location, it will delay the processing of your paperwork.
Please keep pages 9-14 for your records.
Please mail the Athletic Participation Physical Form, Health Insurance Form, and ADHD Medication
Exemption Information Form (if applicable) to:
William & Mary
Division of Sports Medicine
PO Box 399
Williamsburg, VA 23187-0399