How recent must the physician exam be?

Airlines typically require the examination to be current, often within 72 hours for acute concerns or within seven to fourteen days for stable chronic conditions; verify Allegiant policy. Always include the exam date and physician signature on the form.

Can the form be signed electronically by the physician?

Yes, electronic signatures are generally acceptable under the ESIGN Act (15 U.S.C. ch. 96) and UETA in most states, provided intent, consent, attribution, and retention requirements are met. Ensure the platform supports audit trails and HIPAA safeguards when PHI is transmitted.

Is notarization or witnesses required for the form?

Not generally. Most physician attestations do not require notarization or witnesses unless specified by the airline or when the form is used to authorize third-party actions. Check state notary rules and the airline's instructions; remote online notarization may be available where authorized.

What if the passenger name differs from booking?

Name mismatches can cause verification delays or denial of boarding. Use the passenger's legal name as shown on government-issued ID. If names differ due to recent changes, attach supporting documentation such as a marriage certificate or court order and notify the airline.

How should oxygen device approvals be documented?

Specify the device model, flow settings, and whether the device is airline-approved. Include manufacturer approval documentation or medical necessity letters when required. Some airlines require pre-approval for battery limits and proof of in-flight compliance.

What records and retention rules apply to submitted forms?

Medical records containing PHI should be retained in accordance with HIPAA (45 CFR §164.530(j)) for six years from creation or last effective date. Airline operational records may follow different retention; consult legal counsel or airline policy for exact periods.

Electronic Signature
Templates
Healthcare
Allegiant Airline Physician Form

Allegiant Airline Physician Form

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

Physician Consent Form for an Individual Who Needs to Use a Portable Oxygen Concentrator (POC) During an Allegiant Air Flight

(Must be completed in full by the Customer’s Physician and printed on Physician’s letterhead)

Physician’s Name:

Place of Business:

Address:

Telephone:

Fax:

1. Please note that, in accordance with Special Federal Aviation Regulation (SFAR) No. 106, 14 CFR Part 121, only the AirSep Freestyle, AirSep Lifestyle, DeVilbiss Healthcare’s iGo, Oxus, Inc. RS-00400, also known as: EVO Central Air (Delphi RS-00400), Inogen One, Inogen One G2, Inova Labs LifeChoice – also known as: International Biophysics Corporation’s LifeChoice, Invacare XPO2, Invacare Solo2, Oxlife’s Independence Oxygen Concentrator, Respironics Evergo and Sequal Eclipse, AirSep Focus, AirSep Freestyle 5, Inogen One G3, Inova Labs LifeChoice Activox, Respironics Simply Go, Precision Medical EasyPulse, SeQual SAROS, SeQual eQuinox Oxygen System model 4000, Oxywell Oxygen System model 4000, and VBOX, Inc. Trooper models are approved for use during flight.

Compressed or liquid medical oxygen may not be used or transported on any Allegiant Air flight.

The following information relates to , who is a patient in my care. He/She:

has the physical and cognitive ability to see, hear and understand the POCs aural and visual cautions and warnings and is able, without assistance, to take the appropriate action in response to those cautions and warnings.

Yes No . If the answer no, the Passenger/Patient must travel with a companion who is able to perform these functions. (initial)

will require the use of the device during (check all that apply)

taxi take-off in air and/or landing .

will be using a device with a maximum oxygen flow rate of , corresponding to the pressure of the aircraft under normal operating conditions.

(Physician’s signature)

(Date*)

* Form must be dated within one (1) year of travel date.

NOT VALID UNLESS PRINTED ON PHYSICIAN’S LETTERHEAD

Revised 2/2014

What the Allegiant Airline Physician Form Is

The Allegiant Airline Physician Form is a standardized medical assessment used by Allegiant Air to document a licensed clinician's evaluation of a passenger's fitness to travel by air. It records identifying information, diagnosis, vital signs or mobility limits, oxygen or device requirements, and any recommended restrictions or accommodations. Completed forms inform airline decisions about carriage, equipment provisioning, and in-flight care. The document should be dated close to travel and signed by a physician with an active medical license to reflect current clinical status.

Why a Completed Physician Form Matters for Travel

A completed Allegiant Airline Physician Form clarifies medical needs for airline staff, reduces boarding delays, and documents fitness-to-fly decisions. It helps the carrier assess safety risks, plan equipment or oxygen, and create accommodations while providing a contemporaneous medical record for travel-related decisions.

Who Interacts with This Form

Typical users who interact with this form include medical providers, airline medical desk staff, and passengers requiring medical clearance.

Licensed physicians and nurse practitioners completing the clinical assessment and signature.
Airline medical operations staff reviewing clearance, coordinating oxygen, stretchers, or special assistance.
Passengers or caregivers submitting documentation to request accommodations or to meet carrier policy.

Accurate completion and timely submission align responsibilities, reduce operational disruption, and help avoid denied boarding or last-minute medical holds.

Critical Sections Included on the Form

Essential sections of the form collect identifying details, clinical findings, restrictions, required equipment, clearance statement, and physician credentials for airline review and recordkeeping.

Patient ID

Enter full passenger name, date of birth, booking reference, frequent flyer number if available, and a reliable contact phone number so airline staff can confirm identity and coordinate preflight arrangements.

Exam Date

Record the date of the physician examination using MM/DD/YYYY; exams are typically required within 72 hours of travel when assessing acute conditions, and more recent evaluations strengthen fitness determinations.

Clinical Findings

Summarize diagnosis, symptoms, vital signs, mobility limitations, cognitive status, and infection control considerations. Be concise but specific to allow airline clinicians to evaluate in-flight risk.

Restrictions

List any restrictions such as 'no air travel', 'cabin altitude restriction', or 'must travel with attendant.' Specify duration and clinical justification for each restriction noted.

Equipment Needed

Document required devices such as portable oxygen concentrator approval, wheelchair assistance, stretcher, or CPAP. Include model numbers and whether airline approval or medical clearance letters are attached.

Physician Info

Provide physician name, medical license number, state of licensure, office address, phone, signature, and a printed name line. Include the physician's specialty if applicable.

Step-by-Step: Completing and Submitting the Form

Follow these steps to complete and submit the Allegiant Airline Physician Form accurately and promptly.

01

Confirm travel: Verify flight number, date, and passenger name before exam.
02

Conduct exam: Perform focused clinical exam and record findings.
03

Complete form: Fill all required fields and sign legibly.
04

Send to airline: Submit via airline medical desk instructions or secure eSubmission.

Configuring Online Submission for Allegiant Requirements

Configure online submission to match Allegiant requirements, using secure upload, correct file types, and required metadata fields.

Field name and web configuration	Enter exact naming and validation rules used by the portal.
Patient identifying information: name, DOB, ID	Required. Use MM/DD/YYYY for DOB and exact name.
Physician credentials and state license details	Include license number and issuing state; verify online.
Clinical summary, diagnosis, and travel restrictions	Concise findings and explicit travel restrictions; attach notes.
Upload settings, file types, and size limits	Accept PDF or DOCX; limit 10 MB; enable encrypted upload.

How Submission and Review Typically Work

End-to-end submission flow from physician completion through airline medical review to final clearance decision and boarding instructions.

Upload: Physician uploads completed form to secure portal.
Review: Airline medical team reviews clinical data and equipment needs.
Decision: Clearance granted, conditional, or denied with documented rationale.
Notification: Airline notifies passenger and updates booking with accommodations.

Platform and File Requirements for Electronic Submission

Use secure platforms that support PDF and DOCX uploads, encryption, and audit trails for physician-submitted medical forms.

File types: PDF/A or DOCX preferred; retain original formatting.
Authentication: Email or multi-factor signer authentication recommended.
Integration: Connects with airline medical operations systems.

Timing Expectations and Submission Windows

Key timing expectations for completing and submitting the physician form to avoid travel disruption or denial.

Recommended submission window before departure:

Submit within 72 hours of departure for acute concerns; check airline policy for exceptions.

Updates for last-minute medical changes:

Notify airline immediately if clinical status changes before boarding.

Approval timelines for oxygen and devices:

Some approvals require prior airline authorization and documentation.

Airline verification and post-submission follow-up:

Airline may contact physician to clarify entries or request records.

Consequences of late or missing forms:

Late or missing forms can cause denied boarding or required medical clearance at gate.

Common Risks and Operational Consequences

Denied boarding: Passenger may be refused travel.

Delayed departure: Operational delays and rebooking required.

Liability exposure: Carrier and provider risk if inaccurate.

Regulatory issues: HIPAA breach risk if PHI mishandled.

Insurance denial: Claims may be denied without documentation.

Financial penalties: Fees for RON or notary delays.

Frequently Asked Questions and Common Issues

Answers to frequent questions about completing, signing, and submitting the Allegiant Airline Physician Form, plus issues with electronic delivery and record retention.

Need help? Contact support

How recent must the physician exam be?
Airlines typically require the examination to be current, often within 72 hours for acute concerns or within seven to fourteen days for stable chronic conditions; verify Allegiant policy. Always include the exam date and physician signature on the form.
Can the form be signed electronically by the physician?
Yes, electronic signatures are generally acceptable under the ESIGN Act (15 U.S.C. ch. 96) and UETA in most states, provided intent, consent, attribution, and retention requirements are met. Ensure the platform supports audit trails and HIPAA safeguards when PHI is transmitted.
Is notarization or witnesses required for the form?
Not generally. Most physician attestations do not require notarization or witnesses unless specified by the airline or when the form is used to authorize third-party actions. Check state notary rules and the airline's instructions; remote online notarization may be available where authorized.
What if the passenger name differs from booking?
Name mismatches can cause verification delays or denial of boarding. Use the passenger's legal name as shown on government-issued ID. If names differ due to recent changes, attach supporting documentation such as a marriage certificate or court order and notify the airline.
How should oxygen device approvals be documented?
Specify the device model, flow settings, and whether the device is airline-approved. Include manufacturer approval documentation or medical necessity letters when required. Some airlines require pre-approval for battery limits and proof of in-flight compliance.
What records and retention rules apply to submitted forms?
Medical records containing PHI should be retained in accordance with HIPAA (45 CFR §164.530(j)) for six years from creation or last effective date. Airline operational records may follow different retention; consult legal counsel or airline policy for exact periods.

Explore Templates

Joint Motion for Judgment of Dismissal with Prejudice Complaint to Establish Easement Deed of Dedication Right of Way Instrument Standard Right of Way and Utility Easement Agreement Mississippi Utility Easement

be ready to get more

Join over 28 million airSlate SignNow users

Sign Now