ATHLETIC MEDICAL AND REHABILITATION SERVICES FORMS
INCOMING STUDENT-ATHLETES
Welcome to Missouri State University! We are excited for your arrival on campus. Parents, please refer to the following PDF's financial coverage considerations for medical services and medical clearance for participation in MSU Athletics for more specific information regarding health care coverage for Missouri State athletes.
Before you can participate as a MSU student-athlete, you must pass a pre-participation physical examination (PPE) administered by an MSU team physician. Before that PPE can be scheduled, the following items must be received prior to your arrival:
• Athletic Information and Health Questionnaire
• Insurance Questionnaire along with a front and back copy of your current health insurance card.
• Mercy Hospital - Springfield Patient Registration form
• Results of Sickle Cell Testing - in accordance with the requirement of the NCAA, all student-athletes are required to show results of sickle cell testing. If you are unable to locate such results, MSU will provide that test, but will be unable to clear your PPE until those results are achieved. No student-athlete will be cleared for participation until such results are received and on record with AMR.
During your PPE, you will be asked to complete the following items that are needed for the successful completion of your PPE:
• Authorization for Disclosure of Patient Health Information (HIPAA)
• Completion of a Concussion Prescreen
• Well-Being Health Questionnaire
• MSU Treatment Authorization Agreement
• Mercy Consent and Agreement Form
• Injury/Illness Reporting Agreement
If applicable, the following information needs to be provided at or prior to your PPE:
• Copies of any pertinent medical records (i.e., any surgeries or major injuries in past 5 years)
• Failure to disclose or provide records for these situations may delay or disqualify you from participation as a MSU student-athlete.
• Copies of documentation on ADD/ADHD diagnosis and medication (if applicable)
• Failure to provide this documentation may jeopardize your eligibility per NCAA policies.
RETURNING STUDENT ATHLETES
Welcome back! Please update Athletic Medical and Rehabilitation of any changes in your personal health insurance by providing us with an updated front and back copy of your insurance card.
Also, please help us streamline your returning physical by filling out the Athletic Physical Recertification Form. You should do this when you are notified by your athletic trainer about your physical. Simply type out the form, print it and either deliver it to your athletic trainer ahead of time or bring it with you to your physical.
EXITING STUDENT ATHLETES
Please print off and return the following form to Athletic Medical and Rehabilitation in the Forsythe Athletic Training Room or to the address at the bottom of the page.
• Exit Medical Assessment Acknowledgement
POLICIES
• Athletic Medical and Rehabilitation Services Policies
Athletic Medical and Rehabilitation
901 South National
Springfield, Missouri 65897
(417) 836-5461 Office
(417) 836-6101 Fax
