Menu Give

Assistance Request Form

Please be aware that flight requests can only be fulfilled with a minimum of 21 days from the appointment date to ensure adequate time to receive necessary paperwork and schedule the flight.
Please do not submit requests with less than 21 days notice as they will not be accommodated. We do not provide any flights outside the United States. Veteran status verification required. This program does not provide any compassion flights for family members without the patient present.

Veteran's Information

Branch of Service*

Status*

State*


Nature of Request & Reason for Travel*

Travel Information

One Way or Round Trip *

 One Way Round Trip

Departure Time *

Return Time *

If your request contains more than one destination, please provide details in the 'Nature of Request' section

Departure

State*

Destination

State*

Personal Physician Information (Your primary Physician)

Treating Physician Information (Physician you are traveling to see)

Passenger Data

Please include all travelers, including Service Member, if applicable

Passenger's Legal Name (As appears on Gov't issued ID)

Sex

 Male Female

Sex

 Male Female

Verification Information

Please provide the contact information of someone who can verify your request



Relationship*

Special Requests

Please detail any special needs you might have while traveling (service animal, wheelchair assistance, extra time between flights, etc).

X