Non-Funded Injured Athlete Intake Form

Please complete this form to the best of your ability, the more detailed you can be the better. All personal information provided is private protected information and will not be shared with any outside source. The provided information regarding your injury, medical process, and wellbeing will be used to work directly with your insurance company and medical bills.

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Before we get started, we just need to start with who is filling out this form so we know who to contact about this submission.

Who is filling out this form? *

What is your relationship to the athlete? *

Your Phone Number: *

Your Email Address: *

1. Injured Athlete / Patient Information

A. PATIENT INFORMATION

Patient Name: *

Phone Number: *

Email:

Date of Birth:

Last 4 of Social Security Number:

Today's Date: *

B. AUTHORIZATION OF RELEASE OF PROTECTED HEALTH INFORMATION

2. Authorization to Release and Disclose Injured Athlete /Patient Information The Road 2 Recovery Foundation

Are you the legal guardian of the Injured Athlete / Patient? *

Yes

Relationship to Athlete: *

Parent or Legal Guardian Full Name: *

Signature of Parent/Guardian: *

By typing your name, you are certifying this is a legal signature.

Parent/Guardian Home Address: *

City: *

State / Province / Region *

Zip / Postal Code: *

Country: *

Injured Athlete / Patient Home Address: *

City: *

State / Province / Region *

Zip / Postal Code: *

Country: *

Full Access Expiration Date:

Signature: *

By typing your name you are certifying this is a legal signature.

Today's Date: *

C. REVOCATION

D. NOT RESTRICTION ON TREATMENT

E. FURTHER DISCLOSURES

F. ROAD 2 RECOVERY HOLD BACK

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ATHLETE INSURANCE INFORMATION

Insurance Company Name:

Member ID:

Group #:

Provider Phone Number:

Primary Policy Holder Name:

EMERGENCY CONTACT INFORMATION

Primary Policy Holder Relationship to Athlete:

Primary Policy Holder Phone - If different from above:

Primary Policy Holder Email - If different from above:

HOSPITAL INFORMATION

Hospital / Facility Name:

Case Worker / Social Worker Name:

Hospital / Facility Name Phone:

City:

State:

Athlete Injury Information and Questionnaire

Date of Injury:

Please upload front and back of insurance card:

Choose File

Accepted file types: jpg, png, pdf, jpeg, Max. file size: 50 MB.

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Non-Funded Injured Athlete Intake Form

Before we get started, we just need to start with who is filling out this form so we know who to contact about this submission.

1. Injured Athlete / Patient Information

A. PATIENT INFORMATION

B. AUTHORIZATION OF RELEASE OF PROTECTED HEALTH INFORMATION

2. Authorization to Release and Disclose Injured Athlete /Patient Information The Road 2 Recovery Foundation

C. REVOCATION

D. NOT RESTRICTION ON TREATMENT

E. FURTHER DISCLOSURES

F. ROAD 2 RECOVERY HOLD BACK

3. Injured Athlete / Patient Insurance Information

ATHLETE INSURANCE INFORMATION

EMERGENCY CONTACT INFORMATION

HOSPITAL INFORMATION

Athlete Injury Information and Questionnaire

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Events
Docuseries
Mental Health Initiative

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The Foundation
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Partners

Non-Funded Injured Athlete Intake Form

Before we get started, we just need to start with who is filling out this form so we know who to contact about this submission.

1. Injured Athlete / Patient Information

A. PATIENT INFORMATION

B. AUTHORIZATION OF RELEASE OF PROTECTED HEALTH INFORMATION

2. Authorization to Release and Disclose Injured Athlete /Patient Information The Road 2 Recovery Foundation

C. REVOCATION

D. NOT RESTRICTION ON TREATMENT

E. FURTHER DISCLOSURES

F. ROAD 2 RECOVERY HOLD BACK

3. Injured Athlete / Patient Insurance Information

ATHLETE INSURANCE INFORMATION

EMERGENCY CONTACT INFORMATION

HOSPITAL INFORMATION

Athlete Injury Information and Questionnaire

Donate Causes Events Docuseries Mental Health Initiative

Shop The Foundation Board Members Partners

Donate
Causes
Events
Docuseries
Mental Health Initiative

Shop
The Foundation
Board Members
Partners