This is a REQUIRED form for all Miracle Flights applicants. This form should be completed and submitted by a healthcare professional at the treatment site facility to verify the appointment and other medical details regarding the applicant's travel request within 60 days of the scheduled appointment.
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.
An 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 and the signature block bears the name and credentials of the M.D., D.O., or PA-C.
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