Fillable Printable Medical Waiver Form - Hawaii

Medical Waiver Form - Hawaii

04/01/14 HAL-A90

Medical Waiver Request

Form

A refund or waiver of certain fees or charge s may be granted in docu men ted cases of hospitalization. Please note

that a refund or waiver is not guaranteed, and yo u must be th e hospit aliz ed party , tr av elin g com pani on, or an

immediate family* member in order to qualify for any such refund or waiver. Proof of relation may be requested.

Please fill out the entire form. Any blank areas may cause a delay in our response to you. The Hawaiian Airlines

Consumer Affairs Office will respond to you within 30 business days. Please return this form 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 Family is 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 certify that the information provided on this form is true. By signing below, I authorize my physician(s) and

hospital(s) to release my medical information relating to the hospitalization described above. I also authorize

Hawaiian Airlines to access such medical information.

Patient’s Signature (if Patient is

under 18 years old, please

provide Guardian’s Signature):

Date:

Mail or fax completed form to: 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.