Commercial Transportation Request

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. Military service status verification required. This program does not provide any compassion flights for family members without the patient present.

Items marked with * are required entries.

Service Member's Information

Please provide the following information about the service member who is applying for assistance. The service member does not need to travel on the requested trip. The passenger may be also be a dependent of the service member. You will provide the information about the passengers traveling below.

Has the service member taken part in active duty service after September 11, 2001?*

Patient Information

Please provide the following information about the person receiving treatment, who may be the service member listed above, or a dependent. One additional person may accompany the person receiving treatment as an escort. You will provide the escort information below.

Nature of Request & Reason for Travel*

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Description of the Patient's Financial Situation*

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Travel Information

Appointment date*

Appointment time*

Departure Date*

Departure Time*

Return date*

Return Time*

Departure City*

Departure State*

Destination City*

Destination City*

Facility to which you are traveling

Personal Physician Information (Your primary Physician. This is the physician who will provide your medical release, so they should be the physican most familiar with your current condition. Do not add your personal email address here ONLY physician email address - if you do not know it please do not include it.)

Escort Information

Please provide the following information about anyone who will be traveling with the person receiving treatment as an escort. If the service member listed above is traveling with the person receiving treatment, please include his or her information below. Please do not list the person receiving treatment.

Is the Service Member listed above traveling as a passenger?    

Escorts' Legal Names (As appears on Gov't issued ID)

Second Escort

Special Requests

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

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Please select the annual family income of the service member*

How many people live in the service member's household?*

Please select the category that best matches the service member's ethnicity*

IMPORTANT: I authorize Angel Wings for Veterans to contact the patient's physician through the information I have provided to obtain a medical clearance form showing proof of appointment: