Hope Air Travel Assistance Request Application

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You will require the following information to proceed with this application:

Scheduled specialist medical appointment
Personal information for patient and eligible escort
Travel dates
Gross household income

Make sure you have the above information ready before moving forward with your application.

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Preliminary Eligibility

Is the patient travelling to a specialist medical appointment and already has a specialist medical appointment booked?

Yes

A Hope Air travel assistance application cannot be made without a confirmed specialist medical appointment. Please return when specialist medical appointment has been scheduled.

Does the patient have a valid provincial health card and is the medical appointment covered by a provincial health plan?

Yes

Unfortunately, Hope Air can only provide travel assistance for medical appointments that are covered by provincial health plans.

Does the patient grant permission to contact their doctors and/or specialist appointment medical facility?

Yes

A Hope Air travel assistance application cannot be made without consent to contact the patient's doctors to verify appointments and related information.

Hope Air Internal Code

This field is for Hope Air internal use only. If you are not a Hope Air associate, please leave this field blank.

Internal Submitter

Contact Information

Associate Information

Hope Air Associate Name

If you are a Hope Air staff or volunteer member completing this form, please enter your name.

Why is this request being made over the phone?

Other reason for phone request

Requestor Information

Who is this request for?

Who should we contact for follow ups to this travel assistance request?

PatientRequestor

Patient Information

Patient First Name

Patient Last Name

Patient Preferred Name (if applicable)

Patient Gender

Patient's Preferred Language

Patient Birthdate

Enter date in MM/DD/YYYY format. E.g. 01/01/1980

Patient Age

Patient Email

Patient Phone

Patient Address Information

Address Line 1

Address Line 2

City

Province

Postal Code

Is the medical appointment related to a cancer condition?

Cancer-relatedNot cancer-related

Is the patient's primary residence in the district of Algoma, Cochrane, Kenora, Manitoulin, Nipissing, Parry Sound, Rainy River, Sudbury, Thunder Bay, or Timiskaming?

YesNo

Requestor Information

Requestor First Name

Requestor Last Name

Requestor Email

Requestor Phone

Requestor Relationship to Patient - I am the patient's

Does the requestor live in the same household as the patient?

Requestor Organization Name

Requestor Province

NHTG Information

Is the patient covered by ODSP (Ontario Disability Support Program)?

YesNo

This patient is eligible for the NHTG program.

NHTG-eligible patients who receive flights through Hope Air will be required to submit a completed NHTG application form to Hope Air. The NHTG application form needs to be signed by the patient, specialist doctor, and the escort (if applicable). When the NHTG application form is completed, please submit the form by mail to Hope Air. For more information, please see our Help page.

Please note: Patients will not be eligible to submit subsequent travel requests to Hope Air until their previous completed NHTG application has been received by Hope Air.

By making an application to Hope Air for medical travel support, the patient/legal guardian acknowledge and agree to complete and submit the relevant NHTG application form to Hope Air within 14 days of completion of the medical travel. The patient/legal guardian further acknowledge and agree that by receiving travel services provided by Hope Air, all applicable NHTG reimbursement will be directed to be paid to Hope Air. Failure to submit the completed NHTG application form to Hope Air will result in denial for future Hope Air service requests.

Agreed by patient/legal guardian

NL MCP Information

Newfoundland & Labrador Medical Care Plan (MCP) Number

Newfoundland & Labrador Medical Care Plan (MCP) Expiry Date

Does the patient have a medical requirement for an escort to accompany them during travel?

YesNo

Does the patient require an escort to accompany them during travel?

YesNo

Escort Information

Escort First Name

Escort Last Name

Escort Date of Birth

Enter date in MM/DD/YYYY format. E.g. 01/01/1980

Escort Age

Escort Gender

Escort must be 16 years or older.

Escort Email

Escort Phone

Escort Relationship to Patient - I am the patient's

Does the escort live in the same household as the patient?

Escort Province

Travel Information

Travel Assistance Type

If accommodation support is available in your region, you will be able to request this on page 5 of the application.

What type of travel assistance is being requested?

PLEASE NOTE

We regret to share that that, at this time, Hope Air is unable to offer accommodations in our BC General Travel Support Program. Applications for flights are still accepted.

For more information, please visit:
Hope Air Help Centre - Accommodations for British Columbia Residents

PLEASE NOTE

Domestic air passengers age 18 and older must present either one piece of government issued photo ID or two pieces of government issued non-photo ID to board their flight.

Passengers travelling internationally require a passport, NEXUS card, or other valid document.

For more information and examples of acceptable identification documents, please visit: Documents Needed for Air Travel

Is a PEI bridge or ferry voucher being requested?

Confederation BridgeNorthumberland Ferry

Please upload the patient's Health PEI letter confirming they have been approved for out-of-province medical treatment

A copy of this letter must be provided to Hope Air before bridge or ferry travel can be arranged. The patient’s doctor must request this letter from Health PEI on the patient’s behalf and a copy can be obtained from the doctor’s office, if necessary.

Travel Details

Preferred Departure City

If the city name you are looking for doesn't appear in this list, please select the closest airport city. Please note that recently changed city names may still display an older name in this list.

Preferred Arrival City

If the city name you are looking for doesn't appear in this list, please select the closest airport city. Please note that recently changed city names may still display an older name in this list.

Preferred Departure Date

Preferred Departure Time

Preferred Return Date

Preferred Return Time

Flight Special Needs

Power wheelchair (patient's own)	Manual wheelchair (patient's own)
Other mobility aid (patient's own)	Airport wheelchair
Service animal	Visual impairment
Hearing impairment	Seizures
Severe allergies	Oxygen
Physical assistance required

Select all that apply

Error

Display

Hidden Fields

Departure City ID

Arrival City ID

Escort Travel Date

Patient Age on Travel Date

Escort Age on Travel Date

Patient Less than 19?

Yes

Escort less than 16?

Yes

Appointment Information

Referring Doctor Details

First Name or Initial

Last Name

Phone

Extension

Medical Appointment Details

Appointment Date

Appointment Time

What type of appointment is this?

Appointment Duration

How long is the appointment expected to last?

Appointment illness, condition, or procedure: In the field below, type to search and select the listing that is the closest fit. If the illness, condition, or procedure cannot be found in the list, please select Other with the condition's related category.

What illness, condition, or procedure is the appointment for?

Type to search and select the listing that is the closest fit. If the illness, condition, or procedure cannot be found in the list, please select Other with the condition's related category.

Medical Condition ID

Medical Facility Name

Type to search. If the medical facility name cannot be found in the list, please select Other.

Medical Facility Address

Medical Facility ID

Medical Facility Name Not Found in List

Appointment Medical Facility Phone

Extension

Please upload appointment confirmation letter, if available

If appointment confirmation letter is not currently available, this application can still be submitted.

If travelling out of province, please upload the referral letter from a NL specialist physician, if available

If specialist referral letter is not currently available, this application can still be submitted.

Specialist Appointment Doctor Details

Do you know the details of the specialist appointment doctor?

YesNo

First Name or Initial	Last Name
Phone	Extension

Medical Facility Department Name If the patient is not seeing a specific doctor or does not know the doctor's name, please enter the known department details.	Coordinator Name
Phone	Extension

Additional Travel Services

Volunteer Pilot Program

Hope Air has a Volunteer Pilot Program, in which private pilots, approved by Hope Air, fly patients in small private planes, rather than on commercial flights. For more information, please see our Help page.

Is the patient willing to take a volunteer pilot flight?

YesNo

Patient Weight

Escort Weight

Ground Transportation

Hope Air may be able to provide an Uber voucher for ground transportation from the airport in the patient's appointment city to their medical facility or accommodation location.

Does the patient wish to request Uber ground transportation from arrival airport?

YesNo

Overnight Accommodation

Hope Air may be able to provide overnight accommodation for patients who need to stay overnight to attend their medical appointment.

Does the patient wish to request overnight accommodation?

YesNo

Do the accommodation check-in and check-out dates differ from the requested travel dates due to a stay in hospital or elsewhere?

YesNo

Check-In Date

Check-Out Date

Who will be staying overnight?

PatientEscortOther family members

Number of adults staying in room

Number of children staying in room

Number of infants staying in room

Bed Preference

Does the patient or someone staying with them have a credit card available for the hotel to keep on file for damages?

YesNoGuests will be responsible for any hotel damage costs, in the unlikely event any damages should occur. Guest credit cards will not be charged otherwise.

Other Information

If you have additional information to share relating to this request, please provide details here

Household Information

Hope Air assists patients in financial need who must travel long distances to reach specialized medical care. To qualify for support, patients must provide the total gross household income, from all sources, for all family members in the household. Gross household income is for the last full calendar year as reported by all household members to the Canadian Revenue Agency.

Household Size

Number of adults in household

Number of children in household

Household Income

Please submit the total gross annual household income from the previous calendar year. Gross household income should include ALL income sources for ALL household members BEFORE tax deductions. Please refer to all household members' tax documents, plus any additional income received.

Gross household income includes, but is not limited to, full-time employment, part-time employment, self-employment, federal or provincial income, such as CPP, Old Age Security, disability assistance, child tax benefits, child support, pension, investment, or any other income. You can verify gross income by reviewing household members’ Notice of Assessment or tax returns from the CRA.

Total gross household income from the previous calendar year

Select all applicable household income sources

Employment income (e.g. full-time, part-time, contract, seasonal, self-employment, etc.)	Federal income (e.g. EI, CPP, Old Age Security, Veteran Income Support, etc.)
Provincial income (e.g. disability support, income assistance, etc.)	Insurance income (e.g. private insurance, workplace insurance, etc.)
Other non-government income (e.g. pension, investment returns, spousal support, etc.)	Child income (e.g. child tax benefits (federal and provincial), child disability income, child special allowance, child support, foster care allowance, etc.)

Has there been a substantial change in household income this year from the previous calendar year? If so, you may provide additional information here, along with any other details relevant to your financial need for medical travel support, such as change or loss in employment, financial hardship relating to medical expenses, etc.

Other Supports

Have you applied for or received any support from other charitable or government organizations, including Income Support or Community Support Clients receiving Home Support, Financial Benefits, or Subsidized Long-Term Care for medical travel assistance for this appointment or trip?

Examples of such supports could include provincial social assistance, lodging programs, the Canadian Cancer Society, Non-Insured Health Benefits, First Nations Health Authority, etc.

Please list the organization(s) and describe the support.

Income Attestation

I confirm that I have reviewed the gross income for each household member of the patient and have included all income from all sources received by the patient and all other household members.

I confirm that the total gross household income I have stated above is accurate and true for the patient's household.

Hope Air may request income verification at any time. Failure to provide verification of household income in an acceptable format may result in denial of travel assistance.

Assignment of NL MTAP Payment to Hope Air

I hereby direct the Newfoundland & Labrador Medical Transportation Assistance Program (MTAP) to pay any travel assistance pertaining to this application to Hope Air and to share any information contained within this application with government officials relating to such reimbursement.

I understand that by submitting this application for support to Hope Air, I am ineligible for any other financial support that may be offered through the provincial government Medical Travel Assistance Program, for medical travel provided through Hope Air where the duration of my travel is 14 days or less.

Hope Air Terms of Service – Waiver, Release, and

Important: This is a legal document. By signing it, you waive certain legal rights, including the right to sue or claim compensation. Please read carefully.

Acknowledgement and Assumption of Risk

I am voluntarily requesting to access and participate in financially assisted travel (including but not limited to travel by airplane, ferry, bus, or car), accommodations, and meals (collectively, the “Services”) organized or coordinated by Hope Air, a not-for-profit organization, for the purpose of accessing medical care.

I understand that:

Hope Air may contract third parties to provide the Services, including air carriers, hotels, and restaurants (“Contracted Third Parties”); Participation in the Services involves inherent and unforeseeable risks, including property damage, injury, or death; While Hope Air strives to reduce these risks, they cannot be completely eliminated; My participation is voluntary and at my own risk.

In exchange for access to the Services, I agree to the terms of this Waiver and Release.

Waiver and Release of Liability

I knowingly and freely assume all such risks and agree to:

Waive and release Hope Air and its officers, directors, employees, agents, contractors, volunteers, successors, and assigns (collectively, the “Organization”) from any and all claims, demands, damages, losses, expenses, liabilities, or causes of action, whether under federal, provincial, or international law, arising from or connected to the Services; This includes claims related to negligence, breach of contract, or breach of statutory or other duties of care (including under occupier’s liability legislation);Not bring any legal claims against the Organization; Indemnify and hold harmless the Organization for any personal injury, death, property damage, or other loss arising from my participation.

Service Use and Breach of Conditions

I understand that the Services are offered on the condition that I comply with all Hope Air policies, including:

Using travel and accommodation solely for the purpose of medical appointments; Not failing to board booked flights or use hotel or transport services without notice; Not using Hope Air Services for non-medical reasons in the city of treatment; Not requesting or using Hope Air Services for travel where other financial supports have been or will be provided for the same trip or medical appointment (i.e., no duplication of benefits).

Violation of these terms may result in permanent ineligibility for future support from Hope Air.

Governing Law and Severability

This Waiver and Release is governed by the laws of the Province of Ontario and the applicable federal laws of Canada.

If any provision is held to be invalid or unenforceable, the remaining provisions will remain in full force and effect.

Binding Effect

This Waiver and Release is binding upon me and my heirs, executors, administrators, and assigns, and upon the Organization and its successors and assigns.

Eligibility and Consent

I confirm that I am the patient, or I have the legal authority or consent of the patient to submit this request. I am 18 years of age or older, or, if I am under 18, my parent or guardian will sign this form and provide supporting documentation. The information I provide is true and correct to the best of my knowledge, and I understand that it may be subject to verification by Hope Air or relevant agencies.

Consent to Collect, Use, and Share Personal and Health Information

I understand that the personal information I provide in this application will be collected, used, disclosed, and retained by Hope Air to determine eligibility and provide services, in accordance with the Hope Air Privacy Policy.

I authorize Hope Air to:

Contact and share information with third parties involved in delivering services (such as travel providers, healthcare providers, and government agencies);Use my information to coordinate and confirm travel, accommodations, and medical appointments; Communicate with me (or the person on whose behalf this form is submitted) using electronic methods such as email or text message.

I understand that I may withdraw this consent at any time by contacting Hope Air, subject to legal or contractual requirements.

Consent to Release Health Information

I authorize my physician, healthcare provider, clinic, or medical facility to release personal health information related to my medical appointment and my application for travel assistance through Hope Air. This may include details about my health condition and, if applicable, the need for a companion escort.

This information will be used solely to assess my eligibility and facilitate services. I understand that I may withdraw this consent at any time by providing written notice to Hope Air, and that withdrawal of this consent may affect my eligibility for support.

Newfoundland and Labrador-Specific Clause

If I reside in Newfoundland and Labrador, I understand that:

My personal information may be collected by the Department of Labrador Affairs under Section 61(1)(c) of the Access to Information and Protection of Privacy Act, 2015. This is for determining eligibility for reimbursement under the Medical Travel Assistance Program and may involve communication with the Department of Health and Community Services.

Acknowledgment and Signature

I, the undersigned, acknowledge that I have carefully read and fully understand the terms and conditions of this Waiver, Release, and Consent Form. I understand that by signing this document, I am voluntarily giving up certain legal rights, including the right to sue. I confirm that I am signing this agreement freely and voluntarily, and I consent to be bound by its terms.

I agree

Legal Name

Date

GA4 Tracking Code

G-Tag ID (Set default value to your Tag ID)

User Details

We're sorry, this medical appointment does not appear to meet Hope Air's minimum eligibility criteria. If you feel this may be incorrect, please call us at 1-877-346-4673 or email us at info@hopeair.ca to speak to a Hope Air team member.

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