Requester Cover Sheet
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3161 Donald Douglas Loop South Santa Monica, CA 90405 Toll Free (888) 426-2643 Phone: (310) 390-2958 Fax: (310) 397-9636 www.angelflightwest.org REQUESTER COVER SHEET Please follow these steps in order to request a mission with Angel Flight West: Step One: Page One- Review Acceptance Criteria for AFW Missions. Step Two: Page Two- Complete the Agency Intake Sheet (first time requesters only) and FAX it to us at (310) 397-9636 (no cover needed). Step Three: For future referrals- Make extra copies of the “Information Worksheet” (page 4) and the “Medical Confirmation” (page five). Step Four: Page Three- Review the checklist of information needed to request a flight. If you meet the criteria, complete page 4. Page Four- Complete the Information Worksheet, (make copies for future use) then CALL to request a mission – (310) 390-2958. Step Five: Page Five- Please complete the Medical Confirmation verifying the patient’s medical information. This MUST be signed by an MD, Physician’s Assistant or Nurse Practitioner. FAX it to (310) 397-9636 (no cover needed). Step Six: Page Six- Please review the informational Reminder page. If you have any questions, please call us at (888) 426-2643 Thank you! 3161 Donald Douglas Loop South Santa Monica, CA 90405 Toll Free (888) 426-2643 Phone: (310) 390-2958 Fax: (310) 397-9636 Acceptance Criteria for Angel Flight West Missions The decision to accept a patient for referral to an Angel Flight West mission depends on a number of factors, including medical, financial, and other considerations. Following are the basic requirements. Each case will be considered individually, based on all information available from all sources. Medical Status. All patients must be medically stable and able to fly in a non-pressurized plane. We may not be able to fly some patients with seizure disorders. Please call to discuss your particular patient. We cannot fly high-risk pregnancies or any pregnancy over 20 weeks. Mobility. All patients must be ambulatory and able to board an aircraft with limited assistance. Some exceptions can be made for children in wheelchairs who can be readily transferred in and out of the aircraft. Acceptance is at the discretion of the Mission Operations staff and the mission pilot. Medical Release. Prior to a patient's first mission, a medical release must be sent/faxed from the doctor or hospital to Angel Flight West stating that the patient is "medically stable and able to fly in a non-pressurized aircraft." (see page 6) There are NO exceptions. Financial Need. Patients must have some financial need as verified by a social worker, discharge planner, doctor, clergyman, etc.; or live in a remote area without easy access to commercial airports; or be immuno- compromised to an extent that disallows their being around large numbers of people. Origin of Requests. The initial request for a mission must be received from a social worker, doctor, other medical personnel, or other individuals qualified to verify the health condition and economic need of the prospective patient/passenger. After a patient's first mission, he/she may request a flight directly. For patients needing ongoing treatment and flights, the office may request an updated status on the patient from the original requester or consult with the requester should problems arise. Transplant Patients. Angel Flight West may be able to accommodate some patients needing transportation for transplant surgery. Patients awaiting notification of organ availability must pre-register with the Angel Flight West office and be aware that we are not a guaranteed service. Combative Patients. Patients who are known to be combative will not be transported. Undocumented Individuals. Angel Flight West will not knowingly provide transportation for undocumented individuals. Luggage. Luggage must be kept to a maximum of 25lbs. of soft sided luggage per person. Distance. The normal distance for a single-leg flight is approximately 300 miles. Longer distance requests may be possible by linking flights that could require a full day to complete. Advance Notice. Angel Flight West asks that flight requests be submitted a minimum of one week prior to the desired date of flight. We may be able to accommodate requests submitted with shorter notice. 1 Agency Intake Sheet Your Agency’s Name: _____________________________________________________ Street Address: ___________________________________________________________ City: ___________________________ State: _____________ Zip: ____________ Agency Phone: ___________________________ Fax : _________________________ Your Name: ______________________________________________ Your Full Name: ___________________________________________________________________ Job Title: _______________________________________________________________ Your Office Address: (If different from above)______________________________________________ Your Phone: (If different from above)______________________________________________________ Your Pager: _____________________________________________________________ Your E-Mail: ____________________________________________________________ How did you hear about AFW: _____________________________________________ Patient’s Name (if applicable) __________________________ Appt. Date______________ Angel Flight West Toll free: (888) 426-2643 Fax: 310 397-9636 Email: [email protected] 2 Information/Checklist Needed to Request a Flight From Angel Flight West To help us help you and your patients as effectively as possible, have the following information available when calling our office with a request. Use worksheet following this for your convenience Please make copies of the following worksheet for future flights!!! + Appointment Dates and Times: It is important to be specific. If a patient's appointment is scheduled for very early in the day, he/she may need to travel the day before, or if late in the day, travel home the following day, particularly during the winter months and on longer trips. Trips of longer length may require a full day for travel. + Pickup and Destination Airports: We can assist you in identifying airports if you provide the pickup and destination cities. We fly into many airports which may be unfamiliar to you or your patient because they do not have commercial flights. + Requester's Name and Agency and Phone Numbers and addresses for both. (Fax Requester/Agency Intake Sheet included in this packet to: 310 397-9636) See pg. 1 + Patient's Name, Address, Phone Numbers & E-mail Address (Include cell phone number, work or pager number & e-mail address if available, as contact information can be very valuable) + Patient's Illness, any other medical conditions (including pregnancy or seizure condition), reason for appointment, date of birth and weight. + Companion's Name, relationship, date of birth and weight and any additional phone numbers. Please state any known medical condition of companions. + Medical equipment or excess baggage: Please have dimensions and weights. + Facility Contact Information: Medical Facility Name and Phone Number, Lodging Location and Phone Numbers. This information is essential for a pilot trying to locate a passenger while they are at their treatment facility. + Physician's Name and Phone Numbers. + Physician's Medical Release: This is mandatory. A form is included for the MD to sign if you haven’t already received one. Please fax this to us at (310) 397-9636 . + Financial need: What is the reason your passenger needs our services? 3161 Donald Douglas Loop South Santa Monica, CA 90405 Toll Free (888) 426-2643 Phone: (310) 390-2958 Fax: (310) 397-9636 3 Worksheet for Requesting an Angel Flight Mission DO NOT FAX THIS! CALL 310 390-2958 WITH INFORMATION Please make copies of this form and use one for each referral. Male Female Veteran 1. Passenger Name: _____________________________________DOB:__________ Wt:____ 2. Appt. Date: __________ Time: _________ Reason: ________________________________ 3. Flight Date: __________________ Flight Time:_______________ Earth Angel (local ground transportation only in LA) 4. Return Date:__________________ Return Flight:__________________________________ 5. Departure City: _________________________ Arriving City: ______________________ 6. Passenger Address: _______________________________ City/St./Zip: _______________ 7. Passenger Home Phone:______________________ Cell Phone:_____________________ 8. E-mail Address: _____________________________ Primary Language English YES NO 9. Emergency contact & Relationship:__________________________ Tel: _____________ 10. Companion 1: Name _____________________________ DOB:__________ Wt:________ Need Med. Release? Relationship: _____________________________ Tel: ____________________ 11. Companion 2: Name _____________________________ DOB:__________ Wt:________ Need Med. Release? Relationship: _____________________________ Tel: ____________________ 12. Luggage Description/Weight: 25lbs. of soft sided luggage per person. Other:________________ 13. Agency Name:_____________________________________ Tel:___________________ 14. Requester Name: __________________________________ Tel: __________________ 15. Releasing Physician: ____________________ Tel:_______________ Fax:____________ 16. Treating Physician: _____________________ Tel:______________ Fax:_____________ 17. Treatment Facility Name: ________________________________ Tel:________________ 18. Lodging Name: _________________________________________ Tel: _______________ 19. Patient Illness/other med condition:___________________________________________