Gift of Life Air Transportation

PATIENT TRANSPORT REQUEST

Please call (281)650-1380 if THIS IS AN EMERGENCYand you have not been contacted within 2 hours of submitting application

All fields must be filled out or your request will be rejected..Place N/A if field does not apply...The following items must also be faxed/mailed to us for finale approval:
(1) A letter from the attending physician stating reason for transport and condition of patient.
(2) A copy of either W-2 or Most recent Income Tax filed.
(3) Total Number for People in Household.
(4) Insurance Information if Covered.

Part I       Patient Information

Patients Name Age Sex Medical Condition

Address Line 1

Address Line 2

City State Zip Code

Phone Number WorkPhone

Alternate Phone Fax

E-Mail Address

Pateints Weight Luggage Weight No. of Pieces
Is the Patient in a Wheel Chair
Will the Patient need any of the following?
Stretcher Oxygen
Special Medical Equipment
If Yes Please List

On Board Medical
If you answered yes to on board medical Please answer the following questions so can assure the proper medical staff is on-board
Is the Patient in Critical Condition Age Group Is This a Hospice Patient

Part II       Contact Person

Name Relation
Address
City   State Zip Code
Phone Number Alternate Phone

Part III       Family Data and Financial Information

Family Size (refers to family residing at same location)
#1. Name Age Relation to Patient
#2. Name Age Relation to Patient
#3. Name Age Relation to Patient
#4. Name Age Relation to Patient
#5. Name Age Relation to Patient
#6. Name Age Relation to Patient
Total Household Annual Income $.00
Document Proof will you provide
Is the Patient Covered by Health Insurance?
Is Medical Transportation Covered?
If the patient is covered by health insurance please fill out the following.
Insurance Carrier
Company Address
City State Zip Code
Company Phone Number Policy Number
Contact Name if known

Part IV       Referring Doctor

Doctors Name Office Number
Office Address
City State Zip Code

Part V      Appointment & Travel Information

Appointment Date:    00/00/0000         Requested Travel Date:    00/00/0000
Note: Requested Travel Date is Usually 1 or 2 days prior to Appointment Date
Departing From:
City State Airport  Closest Airport to You if Known
Destination:
Receiving Facility
Address
City State Airport  Closest to Facility if Known
Receiving Doctor    Phone Number

Returning:    00/00/0000
Note: Return Date is Usually 1 or 2 days after Appointment Date
If There are Additional Appointments Scheduled That Will Require Transport. Please List Below (Up To 6)
1.)   2.)   3.)   4.)   5.)   6.)

Part VI      Companions Traveling with Patient

Gift of Life Air Transportation has provisions for 2 people to travel with patient for support. We will Allow up to 4 additional people to travel with patient on a SPACE AVAILABLE BASIS
RETURN TRANSPORT CANNOT BE GUARANTIED.

Note: There may be a charge for each additional person traveling with patient.

Please Fill Out All Fields

Travel Companions :

#1. Name Age Phone Relation to Patient

Weight Luggage Weight Number of Peices

#2. Name Age Phone Relation to Patient

Weight Luggage Weight Number of Peices

Additional Travel Companions :

#3. Name Age Phone Relation to Patient

Weight Luggage Weight Number of Peices

#4. Name Age Phone Relation to Patient

Weight Luggage Weight Number of Peices

#5. Name Age Phone Relation to Patient

Weight Luggage Weight Number of Peices

#6. Name Age Phone Relation to Patient

Weight Luggage Weight Number of Peices

I have read and agree to the Terms and Conditions and the Disclaimer

To Review The Terms and Conditions and Disclaimer Click Here To download a printable version of the Transport Request Click Here

Copyright©2005 Gift of Life Air Transportation Corporation