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, non-specific description of the patient's diagnosis
  • Brief description of the financial situation that warrants a charitable flight
  • Brief description of passenger's illness, diagnosis, or reason for needing the 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)
  • Physician Information

    Prior to coordinating the flight, we must obtain a medical release from your personal physician. We also request that you provide information on the treating physician at your destination.
  • This field is for validation purposes and should be left unchanged.

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