You can fill out these forms electronically on Rankonesport.com at:
or by following these instructions:
Accident Insurance Information – Same as what is in the packet above:
Please read this information carefully and thoroughly. If you have
further questions, please consult the Athletic Trainer at your high school or, for middle school student athletes, at your feeder high school. FWISD students who participate in UIL-sanctioned high school and middle school sports (practice, games and travel directly to and from) and other UIL-sanctioned activities that are school-sponsored and
supervised will be covered under the District’s supplemental accident-only medical insurance plan. This insurance coverage is excess and may cover charges in excess of your own insurance policy (such as deductibles and co-payments). If you have no other insurance, this insurance will pay first or primary. The District’s plan is a limited benefit policy and may not cover all medical bills for your child. Parents/guardians are responsible for any charges not covered by the District’s plan and for participating in the proper bill/information submission to the claims processor. The school district,
each individual school, and any district employee or volunteer is not responsible for medical expenses or legally liable for any injury which may result to your child while participating in a school activity. An injury, trauma, can be defined as it pertains to the insurance policy: Trauma is defined as a physical injury or wound that is produced by an external or internal force with sudden onset and short duration. These injuries are covered in the policy. Injuries that result from Overuse occur with repetitive dynamics of running, throwing, jumping and other such activities ARE NOT covered in this policy. If your child is injured while participating in a UIL-sanctioned high school or middle school sport
(practice, games and travel directly to and from) or other UIL-sanctioned activity that requires medical attention, notify the Athletic Trainer that the injury is a result of participation in a UIL-sanctioned activity prior to taking your injured child to a health care provider. If the Athletic Trainer is not available, contact the head coach or athletic coordinator or teacher responsible for supervising the activity. If these persons are not sought out prior to visiting a health care provider, the District Plan may not pay any benefits. When a student-athlete does incur an injury that requires a doctor/hospital visit, an insurance claim form must be filled out by the parent/guardian and the Athletic Trainer. The Athletic Trainer will complete Part A of the Student Accident Claim Form and the parent/guardian must complete every line of Part B for proper processing. All Claim Forms must be signed by a school official and a parent/guardian prior to submission to the Claim Administrator for processing. A copy of the completed and signed Claim Form should be kept by the parent/guardian and one returned to the Athletic Trainer to serve as verification of the injury. The completed and signed Claim Form should be mailed, by the parents/guardians, to the address indicated on the Claim Form or a scanned copy of the
completed and signed Claim Form may be sent electronically to email address found on the claim form. Failure to submit a completed and signed claim form is the most frequent reason why claim payments are delayed.
A Claim Form must be submitted within 90 days from the date of the injury regardless of whether you have insurance or not. Parents/guardians should keep a copy of the Claim Form for your records and present a copy of the Claim Form to the provider or facility. Do not rely on the provider or facility to submit the Claim Form. Follow the instructions on the back of the Claim Form for submitting copies of itemized bills (Form No. UB04 or HCFA 1500). Any subsequent bills received by a parent/guardian that relates to the injury must be sent by the parent/guardians immediately to the Claim Administrator indicating 1) name of injured person, 2) name of the school and Fort Worth ISD, and 3) the date of the
accident. If you have other insurance, you must comply with the provisions of your primary insurance. File all bills with your primary insurance first and forward copies of itemized bills and EOBs to the Claim Administrator as you receive them indicating 1) name of injured person, 2) name of the school and Fort Worth ISD, and 3) the date of the accident.
The District Plan is an accident-only plan which does not cover health issues such as heart conditions, asthma, diabetes, hernia, etc and pre-existing conditions as defined below: Pre-existing Condition: A disease or physical condition for which the Insured received medical advice or treatment during the three months before the Insured’s Effective Date of Coverage. A schedule of benefits for the FWISD plan is available upon request from the Athletic Trainers at the high schools.
Additionally, students who have an injury or any medical condition that required a doctor visit, or have a change in their medical condition from the last athletic physical evaluation must obtain a medical release prior to returning to any type of athletic participation. Some hospital stays and illnesses may require documentation as well. A district wide form is available from the Athletic Trainer to prevent any confusion that may arise from notes from doctor’s offices. Specific information and instructions will be available at preseason parent meetings, upon request, when a claim form is issued and online at address listed on claim form.
If your son/daughter needs to go to doctor and you are unsure what that doctors office may have in form of a note, please feel free to print off the form below and take with you.