Medical Paper Forms

In addition to filling out your contact, physician and insurance information on MyChart, there are also several medical paper forms that need to be filled out and returned to us by fax.

If a form asks for a signature, please fill out the rest of the information on your computer first, print off the form and then sign & date it.  We suggest that you make 2 copies -- one for your own records and one to send to us.

The sooner that we receive your completed online information & faxed medical forms, the sooner we can begin processing your information and making sure everything will be in place when your son or daughter arrives on campus.  Please do not wait till the due date to return your medical forms.

When your son/daughter arrives on campus, it is very important that you provide them with a copy of each of their insurance cards (medical, prescription, dental and/or vision) to carry with them at all times to present to Athletic Training Services, the Sports Medicine Clinic, University of Iowa Hospitals & Clinics, for medical appointments, treatments, and when picking up prescriptions at the pharmacy. Your son or daughter can be helped much faster if they can present their current & active insurance card.

You are responsible for filling in ALL of the information asked for on MyChart as well as the medical forms listed below.  Obtaining all of this information is vital to our department in allowing us to guarantee a smooth transition for the injured student-athlete through our exceptional health care system made up of our primary care physicians, orthopedic physicians and specialists at the University of Iowa Hospitals and Clinics.
 
Please fill out completely each of the forms listed below on your computer, print off, sign & date if needed and fax to Christine Slauson, Medical Insurance Coordinator, Athletic Training Services at 319-335-9398.  The sooner we receive your online information and your faxed forms, the sooner we can begin processing your information in preparation of your son/daughter's arrival on campus for their pre-participation physical.
 
Christine Slauson
Medical Insurance Coordinator
Athletic Training Services
S181 CHA
The University of Iowa
Iowa City, IA  52242
Phone #:  319-335-9393
Email:  christine-slauson@uiowa.edu
 
In order to open, view and fill out the medical forms listed below on your computer, please make sure you have the most recent version of the free Adobe Reader or you can download it for free at www.adobe.com/reader.
 
We thank you for your time and assistance in maintaining current demographic and insurance information allowing us to provide exceptional health care services to our student-athletes. If you have any questions feel free to call me at 319-384-1748.
 
Sincerely,
 
Terry Noonan
Director of Athletic Training Services
University of Iowa

 Please Note:   For the "UIHC Authorization for Release of Information and Payment" form below:

  1. If your son/daughter has turned 18 years old, they must sign the form;
  2. If your son/daughter has not turned 18 years old, you, his/her parents or guardians, must sign the form.
  3. If you sign this form for your son/daughter and they have turned 18 years of age or older or if your son/daughter signs this form and they are just 17 years of age, we will need to resend you the form to ask that you or your son/daughter resign and return it.

 

Forms: