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Fillable Printable Medical Waiver Form - Hawaii

Fillable Printable Medical Waiver Form - Hawaii

Medical Waiver Form - Hawaii

Medical Waiver Form - Hawaii

04/01/14 HAL-A90
MedicalWaiver Request
Form
A refund or waiver of certain fees or charge smay be granted in docu men ted cases of hospitalization. Please note
that a refund or waiver is not guaranteed,and yo u mustbeth e hospit aliz ed party , tr av elin g com pani on, or an
immediate family* member in order to qualify for any suchrefund or waiver. Proof of relationmay be requested.
Please fill out the entire form. Any blank areas may cause a delayin our response to you. TheHawaiian Airlines
Consumer Affairs Office will respond to you within 30business days. Please returnthisform only and no other additional
documents.
Passenger Name(s):
Original Departure Date:
Original Return Date:
Flight #(s):
Email address:
Mailing Address:
Reservation Confirmation
Code(s) (six letters):
Name of Hospitalized Patient:
Relation to Traveler:
Date Admitted:
Date Released:
Name of Attending Physician:
Physic ian Address:
Physician Phone:
Signature of Attending
Physician:
Date:
*Immediate Familyis defined as spouse, child, parent, sister, brother, stepparent, stepchild, stepsister,
stepbrother, gra ndparent, grandchild, st ep grandparent , step grandchild, m other-in-law, father-in-law, son-in-
law, dau ght er-in-law, brother-in-law and sister-in-law.
I certifythat theinformation providedonthisformistrue. Bysigning below,Iauthorizemyphysician(s)and
hospital(s) to release my medical information relating to thehospitalization describedabove.I also authorize
Hawaiian Airlines to access such medicalinformation.
Patient’s Signature (if Patient is
under 18yearsold, please
provide Guardian’sSignature):
Date:
Mail or fax completed formto: Consumer Affairs | PO Box 30008 | Honolulu, HI 96820 | Fax #: 808-838-6777
NOTE:
The completed form CAN NOT be saved. It can ONLY be
PRI NTED u sin g the button to the left. Attem p ting to S AVE th e
completed fo rm will result in loss of all data fields.
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