Unpaid Medical Expense Reimbursement Program Claim Form

WLC Athletes and Parents:

We are extremely pleased to have your student-athlete representing our college in their intercollegiate sport. It is our hope that they will achieve academic and athletic success while on our campus, using their God-given gifts to the best of their ability.

Unfortunately, injuries occur and we attempt to provide our athletes with the very best care. Medical expenses may be incurred when the athlete is treated for injuries, whether locally or while traveling. When an injury occurs, our training staff is fully prepared to respond and refer to outside resources when appropriate. ALL WLC student-athletes must carry personal health insurance in order to participate in intercollegiate sports, as mandated by the NCAA. The insurance must have a payable benefit of at least $90,000 and cover athletic related injuries. You will want to ensure that your policy meets these requirements. WLC will assume no responsibility for the payment of, or authorization to pay, medical expenses resulting from injuries that occur while participating in athletics. Should you not have adequate coverage, you will need to secure it before the beginning of your athletic season.

Alternative Insurance Options:
Covering Wisconsin

At the time outside services are provided for an injury sustained during an athletic sanctioned event or practice, your student's personal insurance card will be shared as their coverage. A copy of this card MUST be provided to the athletic department in advance of your student's athletic season. The provider will submit their bill to your insurance for payment, and based on the coverage in force, will pay the claim accordingly. In some cases this will pay the entire balance; in other cases it will not.

WLC does have an Unpaid Medical Expense Reimbursement Program ("Program") that can be utilized, upon request, to defray personal expense. Requests can be made for reimbursement for unpaid medical expenses related to athletic injuries that occur in season and which were documented by a WLC Certified Athletic Trainer. Expenses must be deemed payable under the athletes personal policy, be severe and not chronic in nature, and must be accompanied by an Explanation of Benefits ("EOB") from the personal insurance carrier. Each student athlete is limited to a total reimbursement during the academic year of $1,000. It is the responsibility of the student-athlete to make sure that claims are submitted appropriately to their insurance carrier and through the Program and that their medical bills are paid in full, whether through insurance, the Program or personal payment. Copies of the Claim Form for Unpaid Medical Expense Reimbursement Program and additional information can be found at www.wlcsports.com.

If you have questions or concerns throughout the year, please do not hesitate to contact us. We look forward to competitive athletic contests and, should the need arise, to serving the medical needs of your student.

Sincerely,

Jeremiah Hoffmann
Director of Athletics