Athletic Activity Fund Program University Health Services / Student Health Plan Office McCosh Health Center Washington

n Rd. Princeton University Princeton, New Jersey 08544 Phone: 609-258-5819 Fax: 609-258-9191

Athletic Activity Fund (AAF) Reimbursement Request Form Prior to submitting any claim for NCAA out-of-pocket expense reimbursement, claim must be processed through insurance company (Student Health Plan or Private Health Insurance) and all final statement balances paid in full by patient. Medical care or services not authorized by Team Physician or a member of the UHS Medicine Staff are not eligible for reimbursement by the AAF. For outside medical services that are authorized by a Team Physician or a UHS physician, the AAF will reimburse patients a maximum $200 medical insurance deductible, a maximum $100 prescription deductible and 20% in-network coinsurance payments. Please refer to publication Important Information for NCAA-Qualified Intercollegiate Athletes and Club/Intramural Sports for detailed program limitations. To be eligible for the AAF, all NCAA or other Qualified Intercollegiate athletic related injuries or illnesses must be reported immediately to the Team Physician/UHS Athletic Medicine Staff regardless of your health insurance plan (SHP or Private/Family Insurance). Last Name: ________________________ Date of Birth: ___ / ___/ ____ First Name: ________________ Class Year: ________

PUID#: _______________ NCAA Sport: ______________________

Name of Athletic Medicine physician or University Health Services physician who referred you for off-campus care: __________________________________ Date of visit: ____ /____ /_________

Type of treatment for which referral made and # of visits: ____________________________________________________________________________________ ____________________________________________________________________________________ Description of your injury/illness you sustained while participating in your NCAA sport: ____________________________________________________________________________________ ____________________________________________________________________________________ Documentation that is required to be attached to this AAF Reimbursement Form to be processed: 1. Bill from the medical provider/hospital showing the charges for services/treatment received. No balance due bills will be accepted. Bill must show date(s) of service, treatment type, or services rendered and itemized amounts. 2. Explanation of Benefit Statement (EOB) from your insurance carrier showing the provider/hospital charges and how much was reimbursed by your insurance carrier. 3. Receipt of payment (cancelled check, credit card receipt or statement, provider receipt). 4. Address and payee (specify if payment is to be payable to parent or student): _______________________________________ _______________________________________ _______________________________________ _______________________________________ Completion of this document in its entirety is required to process your AAF reimbursement request. Incomplete forms will be mailed back. Please allow 4-6 weeks for your request to be completed.