3161 Donald Douglas Loop South ¨ Santa Monica, CA 90405

Phone (888) 426-2643 ¨ (Fax) (310) 397-9636

Requester Cover Sheet

For Alaska Airlines Flights

To: Fax:

Agency: Tel:

From: AFW Date:

Regarding: ______

Number of pages including cover page: 5

Please read and fill out the following documents carefully. When all information is complete, please fax to Angel Flight West at: 310 397-9636. Included are the following:

1. Agency/Requester Information Sheet

2. AFW Alaska Airlines Request Form

3. Financial Need Form

4. AFW Medical Approval for Commercial Transportation

VERY IMPORTANT NOTE REGARDING CHECKED BAGGAGE:

Alaska Airlines or Horizon Air passengers traveling on tickets purchased on or after May 1, 2009, will be charged $15 for the first checked bag* and $25 for the second checked bag. Each bag must weigh 50 pounds or less and have a maximum dimension of 62 linear inches (length + height + width) to avoid additional charges. To view a list of the exceptions visit AlaskaAirlines’ website.

Passengers checking in with one of Alaska Airlines partners may be subject to additional checked baggage restrictions or charges. Please check with the operating carrier for more information regarding their baggage policies.

1st / 2nd / 3rd / 4th / 5th or more each
Regular Traveler / $15 / $25 / $50 / $100 / $100
Military personnel on orders / Free / Free / Free / $50 / $100

Please complete and fax to 310 397-9636

Angel Flight West Requester/Agency Intake Sheet

Your Agency’s Name: ______

Street Address: ______

City: ______State: ______Zip: ______

Agency Phone: ______Fax :______

Your Full Name: ______

Job Title: ______

Your Office Address: (If different from above)______

Your Phone: (If different from above)______

Your Pager: ______

Your E-Mail: ______This is very helpful!

How did you hear about AFW: ______

Patient’s Name (if applicable) ______Appt. Date______

Angel Flight West Alaska Airlines Request Form

Please Fax completed form to 310 397-9636

Patient’s Name: ______Middle Name ______Last Name: ______

DOB: ______(Date of Birth - VERY IMPORTANT) Male q Female q Weight: ______

Mailing address: City/ST/ZIP: ______

Home telephone: (______) ______Cell (_____) ______

E-mail Address: ______

Emergency contact info: ______Tel. ______

Purpose for the trip: ______

Medical diagnosis: ______

Special medical equipment or special needs (i.e. wheelchair, portable oxygen, etc.) Yes p No p

Please list/explain i.e. Is the wheelchair collapsible? Weight of equipment, etc.:______

______

Releasing Physician: ______Phone #: ______Fax: ______

Treating Physician: ______Phone #: ______Fax: ______

Treatment Facility Name: ______Phone #: ______

_

Lodging Name: ______Phone #: ______

(If the patient will be staying overnight or for a period of time, state name of accommodation)

*Date of travel: ______Date of appt./surgery: ______Appt. time: ______

*Return date: Preferred (am or pm) for flights: ______

Departure City ______Arriving City ______

Will the patient travel with a support person(s)? Yes p No p Relationship: ______

Name: ______Middle Name ______Last Name: ______

DOB: ______Male q Female q Weight: ______Phone: (_____) ______

(Date of Birth - VERY IMPORTANT)

*Patients can have only one support person (unless for a child under the age of two). Additional parent as a support person:

Name: ______Middle Name ______Last Name: ______

DOB: ______Male q Female q Weight: ______Phone: (_____) ______

(Date of Birth - VERY IMPORTANT)

How did you hear about Angel Flight? ______

* Please DO NOT submit this form if you don’t have the travel dates

If you have any questions, please call us at 888-426-2643

Or email to:

Angel Flight West

Financial Need Verification Form Commercial Flight

Phone 888-426-2643 ¨ Fax 310 397-9636

3161 Donald Douglas Loop South, Santa Monica, CA 90405

IMPORTANT! PLEASE READ. Angel Flight does offer free air travel, however we do require written verification that the patient and family cannot afford other means of commercial transportation. Angel Flight cannot accept any patient, nor schedule any mission, until this form is completed, signed and faxed to our national office at FAX (310 397-9636)

We ask that this form be completed by a professional person, such as a social or case worker, clergyman, physician, accountant, attorney, employer or staff person of a charitable organization, ie. American Cancer Society.

Generally we need to know that insurance won't cover travel expenses, that the family doesn't have savings or credit cards to use for this purpose or that their income is insufficient to bear the cost of a plane ticket(s).

Please remember that the costs of these flights are contributed by Alaska Airlines. Their resources are very valuable. They are glad to make this contribution for those patients who are truly in need.

------

Please complete the following:

Patient's Name: ______

Give a thorough and specific explanation as to why the individual cannot afford transportation. Include important information that supports their case of financial need. Insufficient information or too brief of an explanation may result in the individual not being accepted or the form returned to you to be re-done. An additional page may be used.

Signature: ______Date: ______

Title: ______Phone #: ______

Angel Flight West

Medical Approval For Commercial Transportation

3161 Donald Douglas Loop South, Santa Monica, CA 90405

Phone 888-426-2643 ¨ Fax 310 397-9636

IMPORTANT: Angel Flight cannot coordinate free commercial tickets until this form is completed, signed, and mailed or faxed to our office at the above address.

Patient's Name: ______

Doctor's Name: ______

Doctor’s phone and on-call #: ______

Doctor’s fax #: ______

Facility/Agency Requesting Transportation: ______

Facility Phone Number: ______

Does the patient currently have a contagious or communicable disease? If so, please explain.

Yes p Nop Comments: ______

______

Is the patient medically stable to fly on a commercial flight?

Yes p Nop

Is the patient able to walk, embark, and disembark the aircraft with little or no assistance? If no, please explain.

Yes p Nop Comments: ______

______

I have carefully read and completed the above information and approve this patient for a flight on a commercial aircraft.

______

Doctor's Signature Medical License # Date