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