Nkas 020 - Portable Oxygen Concentrator Medical Verification printable pdf download

ORTABLE

XYGEN

ONCENTRATOR

(

) V

EDICAL

OR OTHER RESPIRATORY ASSISTIVE DEVICE

ERIFICATION

TATEMENT

USTOMER

CKNOWLEDGEMENT

ORM

ENERAL

NFORMATION

Pursuant to Department of Transportation and Federal Aviation Regulations, a passenger who would like to use a portable oxygen



concentrator unit (or other respiratory assistive device) on-board a Spirit Airlines’ aircraft must obtain a written statement from his or her

physician addressing the items listed below.

The physician’s statement is valid for one year from the date of the physician’s signature.



USTOMER

NFORMATION

I am responsible for ensuring my unit is in good working condition and free from damage.

I am responsible for traveling with a sufficient supply of batteries to last the entire journey, per my oxygen requirements, including all

ground time (between connections), the duration of the flight, and for any unexpected delays. All batteries and/or chargers must be

transported in carry-on baggage (not permitted in checked baggage), and must be packed in a manner that protects them from physical

damage and short circuits.

I may be charged for expenses incurred by Spirit Airlines if onboard emergency oxygen supplies are utilized, or the diversion of a flight

for medical attention is required as carrying sufficient oxygen is deemed the passenger’s responsibility by 14 CFR Part 121 SFAR No.

106(3)(b).

Aircraft electrical plugs are not available for use with any electronic device.

I understand I will not be seat-assigned to an exit row seat or a bulkhead seat, and will be assigned to a window seat.

I understand that the POC (or other respiratory device) is my responsibility and the airline is not responsible for providing batteries, providing on-

board power, and providing nasal cannulas or other device-related equipment.

I, or someone I am traveling with, have the physical and cognitive ability to see, hear and understand the POC’s aural and visual cautions and

warnings and is able, without assistance, to take the appropriate action in response to those cautions and warnings.

I, (Customer’s printed name) _________________________________________________________ acknowledge by signing this form that I

agree to comply with the terms and conditions for transportation of a portable oxygen concentrator (or other respiratory assistive device), as

outlined on this form and in the Spirit Airlines Contract of Carriage.

Customer’s Signature: ____________________________________________ Date: __________________

__________________

: P

EDICAL

ERIFICATION

TATEMENT

ORTABLE

XYGEN

ONCENTRATORS

THER

SSISTIVE

ESPIRATORY

EVICE

This letter is my verification that _______________________ requires the use of an approved portable oxygen (POC) or other assistive respiratory

Customer’s printed name

device during his/her flight. (

)

I verify the following:



The use of the device is medically necessary: (check requirement that best applies)

Continuously during all phases of the flight, including taxi, take-offs and landings.

Only during the portion of the flight when common electronic devices are authorized by the crew—generally after take off and before

landing.

Intermittently during flight, but not during taxi, take off or landing.



The oxygen flow rate setting for the POC is ______________ Liters per Minute (LPM), considering the air pressure in the cabin under normal

operating conditions.

I ______________________________ certify that the passenger named above is under my care and in my opinion may travel on-board a

(Doctor’s printed name)

commercial aircraft without the likelihood of medical risk to their health and/or physical condition. The patient is capable of completing the flight safely

without extraordinary medical assistance and has been advised by me to have ample charged batteries to power the device for the length of the flight

plus three (3) additional hours to cover any unexpected delays, gate holds, diversions or cancellations.

Any change to a patient’s health that would amend the criteria listed above will require that an updated Physician’s Medical Verification Statement be

completed.

Physician Signature: _____________________________________________________ DEA: _____________________________________

Address: ________________________________________________________________________________________________________

Office Phone Number: ____________________________________________________ Date: _____________________________________

NKAS-020 01/15