Request For Charitable Transportation Assistance

  • REQUEST FOR CHARITABLE TRANSPORTATION ASSISTANCE

    Please complete this information for the Patient or Primary Passenger who has a need for transportation. It is important that you provide a follow-up contact person for us to call to respond to your request. This may be a social worker, parent, or yourself as the passenger. Required fields are marked with an asterisk. Additional information may be required to complete the mission request after we follow up.

  • Follow-up Contact (person who should be contacted)

  • Primary Passenger

    IMPORTANT: Use Full Legal Name as it appears on your ID Card.
  • Travel Information

  • Escort Information

    IMPORTANT: Use Full Legal Name as it appears on your ID Card.
  • Screening Information

  • Brief description of the financial situation that warrants a charitable flight
  • These may or may not be related to this flight (example: high blood pressure, heart condition, asthma or breathing problems, chest pain, a head cold or sinus infection)
  • Personal Physician Information

    Prior to coordinating the flight, we must obtain a medical release from your personal physician who has recently seen you in their office and is familiar with the date, location and the purpose of the medical appointment you are traveling to.
  • Income & Appointment Verification

  • Examples include a letter from you physician, a printed appointment reminder from the physician's office, or a screen shot of the appointment details from your online patient portal.

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