Financial Need Verification Form All forms must be completed-in-full by the patient with the exception of the Physician’s Release which must be completed by the patient’s physician and submitted before a flight can be considered. Important! Please read! LifeLine Pilots, the oldest regional humanitarian air care agency in America, provides people in medical and financial distress with access to free air transportation on small, private aircraft for healthcare and other compelling human needs. The Pilots are volunteers who donate their time and flying expenses, including the cost of fuel, to this effort. This constitutes a significant investment on the part of the Pilots. They are not reimbursed nor are they allowed to accept payment in any form from flight recipients. Therefore, we reserve our flights for people who are truly in distress. We require written verification that the patient/passenger and family have a legitimate need. Generally, we need to know that recipient’s insurance will not cover travel expenses, that their income is insufficient to bear the cost of an airline ticket(s), and that they have no other reliable means of transportation. This form must be completed every six (6) months by a professional person (social/case worker, clergyperson, physician, accountant, attorney, employer or staff person of a charitable organization, not a family member, personal friend or neighbor.) LifeLine Pilots cannot accept any patient/passenger, nor schedule any mission, until this form is completed, signed, and submittedFlight Recipient's Name* First Last Give a thorough and specific explanation as to why the individual cannot afford transportation. Include important information that supports their case of financial need.*Also, please describe their physical/mental willingness to fly in a small, unpressurized aircraft. Insufficient information or too brief of an explanation may result in the individual not being accepted or the form returned to you for further explanation. An additional page may be used.By signing this form, I acknowledge that I am familiar with the prospective passenger and their financial needs. The above information is accurate to the best of my knowledge. Name* First Last Title / Relationship*Phone*Date* Signature*Name & address of Agency being represented* This iframe contains the logic required to handle Ajax powered Gravity Forms.