Medication Permission Form 2017-2018
All medications, prescription and non-prescription, require a medication form.
Effective October 15, 2006, our school district will provide accident coverage for all students. Outlined below is important information regarding this coverage. It is intended as a brief description for reference only, and is not the policy.
Only ACCIDENTS that occur in school-sponsored and supervised activities including participants in interscholastic sports are covered.
DEFINITION OF ACCIDENT:
An unexpected, sudden and definable event which is the direct cause of a bodily injury, independent of any illness, prior injury or congenital predisposition.
Conditions that result from participating in an activity do not necessarily constitute accidents. For example, illnesses, diseases, degeneration, conditions caused by continued stress to a particular area of the body, and existing conditions aggravated by an accident are not covered.
- This plan of insurance is EXCESS ONLY. It will not duplicate benefits paid or payable by any other insurance or plan including HMO's or PPO's.
- The policy will not cover expenses payable under the insured's HMO (Health Maintenance Organization), or PPO (Preferred Provider Organization). If the insured chooses not to use an authorized medical vendor (under HMO or PPO), the policy will only cover expenses incurred that it would have honored had the insured used the proper medical vendor.
- Medical treatment for a covered accident must begin within 60 days of that accident. Only expenses incurred within 52 weeks are considered. Benefits are determined on the basis of REASONABLE AND CUSTOMARY for the geographic location where services are performed.
- Specific exclusions of the policy include, but are not limited to, sickness, disease, or hernia in any form; non-prescription drugs; fighting; and orthotics not prescribed exclusively for rehabilitation (e.g., playing brace, mouth guard).
- Any person who knowingly presents a fraudulent claim containing any false or misleading information is guilty of insurance fraud and may be subject to fines and confinement in prison.
Accidents must be reported to the school within 20 days. Proof of loss must be submitted to First Agency, Inc. within 90 days after medical treatment ends. Questions regarding claim procedures may be directed to First Agency, Inc. at 5071 West H Avenue, Kalamazoo, Michigan 49009 or 269-381-6630 or Fax 269-381-3055.
HOW TO FILE YOUR ACCIDENT CLAIM FORM:
- Pick-up claim form from your school office.
- Complete ALL blanks. If information is not applicable, indicate the reason it is not (e.g., deceased, unknown).
- Attach all ITEMIZED bills (not balance due statements) for MEDICAL EXPENSES ONLY.
- Include all worksheets, denials, and/or statements of benefits from your primary insurer. (Each charge must be processed by all other insurances/plans before they can be processed by First Agency, Inc.)
- If you are employed and no coverage is provided by your employer, A LETTER OF VERIFICATION FROM YOUR EMPLOYER STATING THAT NO COVERAGE IS PROVIDED MUST BE SUBMITTED.
- Mail within 90 days of the accident to:
First Agency, Inc.
5071 West H Avenue
Kalamazoo, MI 49009-8501
Jenison Public Schools / MI