Treatment Site Verification Form

Treatment Site Medical Appointment Verification Form
This is a REQUIRED form for all Miracle Flights applications. This form should be completed and submitted by a healthcare professional at the treatment site facility to verify the appointment(s) and other medical details regarding the applicant's travel request.

IMPORTANT - This form shall only be completed by medical treatment site staff members, not Miracle Flights applicants. Fraudulent statements or representation shall be considered sufficient cause for denial of service.

A RN, LPN, LCSW, or any other medical administrative staff may complete this form on behalf of the patient's treating M.D., D.O., or PA-C as long as all fields are completed below and the signature block bears the name and credentials of the M.D., D.O., or PA-C.

This form may also be completed by service dog retrieval/training team members (trainers, administrators, etc.) for all service dog retrieval/training flights.

NOTE - This form should also be completed and submitted to document any changes to an existing medical trip such as a cancellations, changes in appointment dates, or release dates.
Are you submitting this form to document a change to a current medical trip?
Appointment cancellations, changes in appointment date(s), or a change in release date(s).
If this is a change, which of the following best describes the change to the current medical trip?
Appointment cancellations, changes in appointment date(s), or a change in release date(s).
Describe the change to the existing medical trip and provide any relevant details.
*** PLEASE BE SURE TO LIST THE UPDATED APPOINTMENT AND RELEASE DATES HERE ***
First and last name of person completing this form
For the person completing this form, which of the following best describes your role at the treatment site?
I am completing this form on behalf of
Treatment Physician's Full Name
First and last name of patient

First NameLast Name
Patient date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Work phone number of person completing this form
Please enter a valid phone number so that we can call you and verify the appointment date.Format: (000) 000-0000.
Work email address of person completing this form
example@example.com
Name and address of treatment facility
Description of patient's scheduled medical treatment(s)
When is the patient's first scheduled appointment/treatment date?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
When is the estimated first available date the patient can travel home by commercial airline?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Can the patient safely board a commercial flight to travel to the treatment site and back home?
Are there any special requirements for the patient as they travel on a commercial airplane? Check all that apply.
Denial of Service
Certification
Signature (treatment site physician - M.D., D.O., or PA-C or provider representative on behalf of treatment site physician)
Name of treatment site physician (M.D., D.O., or PA-C)

First NameLast Name
Appointment Documentation (optional)

Please only provide supporting appointment documents
Cancelof
Should be Empty:

Treatment Site Medical Appointment Verification Form