Request for Charitable Transportation Assistance

Please complete this information for the Patient or Primary Passenger who has a need for transportation. It is important that you provide a follow-up contact person for us to call to respond to your request. This may be a social worker, parent, or yourself as the passenger. Required fields are marked with an asterisk. Additional information may be required to complete the mission request after we follow up.

Please note:

  • You will be asked to provide documentation of your family income. Examples include the first page of your most recent Federal tax return, social security, Medicaid or disabilty statement. Please have one electronic file with one or more of these documents ready to upload before you start this form.
  • If you have verification of your medical appointment (a letter from your physician, a printed appointment reminder, or a screen shot of your patient portal showing the appointment date), you can upload it at this time as well.

Items marked with * are required entries.

Follow-up Contact (person who should be contacted)

Primary Passenger

IMPORTANT: Use Full Legal Name as it appears on your ID Card.

Travel Information

Escort Information

IMPORTANT: Use Full Legal Name as it appears on your ID Card.

Screening Information

Patient's primary illness/condition (briefly)

  characters remaining

Financial Situation - Brief description of the financial situation that warrants a charitable flight   characters remaining

Reason for the Flight* - Brief description of passenger's illness, diagnosis, or reason for needing the flight   characters remaining

Brief description of other conditions - These may or may not be related to this flight (example: high blood pressure, heart condition, asthma or breathing problems, chest pain, a head cold or sinus infection)   characters remaining

Physician Information

Prior to coordinating the flight, we must obtain a medical release from your personal physician. We also request that you provide information on the treating physician at your destination.

Personal Physician (Your primary physician)

Income & Appointment Verification

Please upload documentation verifying that you have a medical appointment at the facility specified above. Examples include a letter from you physician, a printed appointment reminder from the physician's office, or a screen shot of the appointment details from your online patient portal.*

Please upload documentation showing your household income. Examples include income tax forms, social security statements, or W2 forms.

Please choose the income bracket from the list below that best represents the patient's total, annual, household family income.*

Please the number of people living in your household.*

Please choose the ethnicity that best describes the patient.*

IMPORTANT: I authorize Mercy Medical Angels to contact my physician through the information I have provided to obtain a medical clearance form showing proof of appointment:

 Yes  No