FAA Eval Info Sheet

Please select this link to complete an FAA Form 8065 Request for Airman Medical Records from the FAA to allow Dr. Hupp to access your records. NOTE: You may CANCEL this authorization at ANY time by sending an email to Dr. Hupp at drghupp@gmail.com.

FAA Form 8065

Please also complete this Request for Exchange of Information for ANY outside source (family member, spouse, friend, family doctor, psychiatrist, psychologist, therapist, CFI, etc). This will kept on file with Dr. Hupp and can be AMENDED, UPDATED, or CANCELLED by you at any time with an email to drghupp@gmail.com.

Standard ROI Authorization

Your Name

First NameLast Name

Your Email

example@example.com

Your Phone Number

Please enter a valid phone number.

PI Number if known

May I text you with appointment reminders and updates on your case from my perspective?

Yes (you may cancel at any time by replying STOP to a message from me)No

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Name of AME

First NameLast Name

AME Contact Information

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Most Recent Visit with AME

Date

Do you have a pending visit scheduled with your AME?

YesNo

When is your visit?

Date

Name of CFI (if applicable)

First NameLast Name

Include CFI Phone Number or Email (how you contact them)

Select ALL of the following conditions that apply to your situation.

You have been charged with driving while intoxicated or under the influence in any state.You've been involved in three or more motor vehicles accidents while you were operating that vehicle (include motocross, ATVs, dirt bikes, jet ski, car, truck, moped, motorcycle - basically anything with a motor).You have been referred or ordered by a court or employer for a substance abuse evaluation and / or treatment.You have had a concussion from ANY activity at ANY time in your life.You have sent Dr. Hupp a copy of your letter from the FAA stating their concerns and what type of evaluation they require for your application / file.You have a reference letter, or letters, from others you would like me to review.

Please provide a sentence or two (or three or whatever) about your thoughts / perspective of why you think the FAA is asking for this evaluation. Don't hold back - the FAA with NEVER see this statement. It helps me understand your situation better and better advocate for your desire to get (back) into the air.

FAA Evaluation Information Sheet