UGA Sports Medicine / UGAAA Medical Advisory Committee Additional Medical Consultation/Opinion Request Form

For the Medical Advisory Committee to consider approval of outside providers, all medical consultations must be coordinated by UGAAA Sports Medicine Staff.

If the student-athlete chooses to utilize an outside provider without PRIOR authorization from the MAC, the student-athlete assumes full financial responsibility for the services rendered.

If the student-athlete and/or parent/guardian/advisor initiate the request for an additional medical opinion, they must submit the request in writing via this form. Please complete with as much detail as able. A member of the UGAAA Sports Medicine Staff and/or Medical Advisory Committee will inform you of a decision regarding full coverage, partial coverage, or no coverage once submission is reviewed.

Student-Athlete Name:(Required)

First Last

Student-Athlete Date of Birth:(Required)

Student-Athlete Email Address:(Required)

Student-Athlete UGA ID# (81 #):(Required)

Student-Athlete Sport:(Required)

Injury/Illness:(Required)

Outside Medical Consultant(s):(Required)

Services:(Required)

Clinic Appointment

Procedure/Surgery

Rehabilitation:

Other

Clinic Appointment Date (if known):

Clinic Appointment Details:(Required)

Procedure/Surgey Date (if known):

Procedure/Surgey Details:(Required)

Rehabilitation Date:

Rehabilitation Details:(Required)

Other Service Date (if known):

Other Service Details:(Required)

Reason for Request:(Required)

Student-Athlete Signature:(Required)

Today's Date:(Required)

Parent/Guardian Signature (if under 18):

Contact Us:

1 Selig Circle
Athens, Georgia 30602
(706) 542-9103

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UGA Compliance @ugacompliance ·

12 Sep

Yes...sports wagering violations are real.

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UGA Compliance @ugacompliance ·

25 Sep 2024

As a reminder, student-athletes may receive medical treatment and attend academic appointments on a required day off. These activities do not count toward daily or weekly hour limits (CARA).

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UGA Compliance @ugacompliance ·

11 Sep 2024

Reminder: Student-athletes may not receive payment from any source for his/her complimentary admissions and may not exchange or assign them for any item of value. Also, family members and friends who have been assigned tickets may not sell or exchange them either!

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UGA Compliance @ugacompliance ·

4 Sep 2024

With the NFL season kicking off this week, remember that all sports wagering activities are prohibited for all student-athletes and UGA Athletics Staff. This includes fantasy football, survivor pools, etc.

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