HARP-10763_Medical_Waiver

HAL A90 | Medical Waiver Request Form

(06/18)

A refund or waiver of certain fees or charges may be granted in documented cases of hospitalization. Please note that a

refund or waiver is not guaranteed, and you must be the hospitalized party, traveling companion, or an immediate family*

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

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

Consumer A airs O ce 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 Conﬁ rmation

Code(s) (six letters):

Name of Hospitalized Patient:

Relation to Traveler:

Date Admitted:

Date Released:

Name of Attending Physician:

Physician Address:

Physician Phone:

Signature of Attending

Physician:

Date:

*Immediate Family is deﬁ ned as spouse, child, parent, sister, brother, stepparent, stepchild, stepsister, stepbrother,

grandparent, grandchild, step grandparent, step grandchild, mother-in-law, father-in-law, son-in-law, daughter-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 A airs | PO Box 30008 | Honolulu, HI 96820 | Fax #: 808-838-6777

NOTE: The completed form CANNOT be saved. It can ONLY be PRINTED using the button to the left.

Attempting to SAVE the completed form will result in loss of all data ﬁ elds.