MedFlight Indiana - Request Flight

If you would like to request a flight for you or someone you are helping, please complete the following form. If an escort is medically necessary, the escort’s information is required as well. Please note: Medflight of Indiana will fly one parent/guardian for children 18 years old and younger. All other escort requests will be considered on a case-by-case basis

All flight requests are reviewed by the chief flight coordinator. If Medflight of Indiana is unable to assist you, the Flight Coordinator will contact you a minimum of one week prior after you have submitted your form. The completion of any flight is dependant on the response of volunteer pilots.

*Patient First Name

*Patient Last Name

*Patient Address

*Patient City

*Patient State

*Zip Code

*Patient Best Phone

(000-000-0000)

Best Time to Call

(HH:MM am/pm)

*Patient Email

Patient Date of Birth

(MM-DD-YY)

Patient Weight

(000 lbs.)

Purpose of Flight

Medical Condition

Parent or Escort Name

Parent or Escort Weight

(000 lbs.)

Name of Destination Facility

Facility Address

Facility City

Facility State

Zip Code

Facility Phone

(000-000-0000)

Duration of Appointment

Name of Referring Doctor

Referring Doctor Phone

Fax

Referring Doctor Email

Name of Destination Doctor

Destination Doctor Phone

Fax

Destination Doctor Email

Please list any special
needs (oxygen, wheelchair)
or other important information.

Verification Code

* Please Enter Code

Once a flight request is approved, Medflight of Indiana will:

Call the patient's doctor to obtain medical clearance for the patient to fly
Call the treatment facility to confirm the date, time and duration of the appointment
Arrange the flights through one of Medflight of Indiana's flight programs

Before traveling, please remember:

You will need to carry all appropriate documentation (e.g. identification, passport and/or birth certificate)
To have Medflight of Indiana's phone number with you at all times
If your flight is booked on a commercial airline, contact the airline prior to leaving for the airport to confirm your flight schedule
To check in at the appropriate airline ticket counter at least 90 minutes prior to departure (your tickets will be waiting at the airport)

Be sure to call Medflight of Indiana 3-4 days prior to the travel date to confirm the flight arrangements. When flights are arranged through the Volunteer Pilot Program, the pilot will call the patient directly to provide him/her with the flight details.

If your flight is booked on a corporate aircraft:

Corporate flights depart and arrive at terminals separate from commercial airlines. These details will be given to you when you call Medflight of Indiana to confirm your flight information
Washroom facilities are not usually available on corporate aircraft
Passengers on corporate aircraft are allowed one small piece of luggage

If your flight is booked on a private aircraft:

Private aircraft depart and arrive at terminals separate from commercial airlines. Your pilot will give you these details when he or she calls you to confirm your flight information
Washroom facilities are generally not available on private aircraft
Private aircraft have baggage restrictions (your pilot will give you these details)
You will be asked to sign a release of liability waiver prior to boarding the aircraft