Healthcare Travel TSA Plan Exhibit

HEALTHCARE TRAVEL TSA PLAN EXHIBIT

This Healthcare Travel TSA Plan Exhibit documents patient-specific medical information, screening accommodations, and authorizations necessary to coordinate security screening, carrier assistance, and on-route medical support for travel. This Exhibit is completed by the patient or authorized representative and supplements any primary travel assistance agreement or medical transport plan.

Patient Information

Emergency Contact

Insurance & Responsible Party

Travel Details

Medical History & Current Treatment

Mobility & Equipment

Mobility aids to be transported (select all that apply):

Wheelchair Power wheelchair

Mobility scooter Cane / Walker

Medication Transport & Documentation

I will be traveling with injectable medications or sharps:

I will be traveling with controlled substances:

TSA Screening & Carrier Coordination Authorization

By signing below, the patient or authorized representative grants limited authorization for the release of protected health information (PHI) necessary to secure screening accommodations and to coordinate handling of medical equipment and medications with security screening personnel and carrier representatives. The PHI disclosed under this authorization is limited to clinical statements regarding mobility limitations, medical devices, oxygen requirements, and medication transport necessary for travel screening and safety.

The patient authorizes release of the limited PHI to: security screening agents, carrier representatives, on-route medical support personnel, and any contracted travel assistance coordinators solely for the purpose of facilitating screening, boarding, and safe transport. The patient understands that once information is disclosed to the receiving parties, it may be subject to additional disclosures by those recipients consistent with their obligations and authorities.

Screening assistance and identification of alternative screening procedures

Equipment handling, transport and stowage instructions

Medication transport clearance and documentation verification

The patient acknowledges that security screening procedures may involve physical inspection of medical devices, removal of coverings, or alternative screening methods. The patient accepts the risk that devices may be inspected and that screening may require temporary disassembly where medically safe to do so. The patient affirms they will notify medical staff or the signing representative immediately if disassembly or handling poses a medical risk.

Acknowledgments, Certifications & Limits of Liability

The patient certifies that the information provided in this Exhibit is true and complete to the best of their knowledge. The patient understands that this Exhibit does not guarantee specific screening outcomes or bypass of security procedures, nor does it create an obligation for carriers or security personnel to provide services beyond their established authority. The patient acknowledges responsibility to carry original prescriptions, physician letters, device manuals, and any required permits.

To the extent permitted by law, the patient releases and holds harmless the disclosing healthcare provider and coordinating organization from liability for actions taken by security screening personnel or carrier representatives acting within their authority after receiving authorization and information provided herein. This release does not waive rights related to negligence or misconduct by healthcare providers.

Additional Instructions / Advanced Directives

HIPAA / Privacy Acknowledgment

I acknowledge that I have been informed of the limited nature of the disclosure of my protected health information required to implement travel screening and accommodations. I understand that I may revoke this authorization at any time by providing written notice to the originating healthcare provider or coordinator, except to the extent that action has already been taken in reliance on this authorization.

I authorize the disclosure described in this Exhibit and understand that this authorization will expire on the Authorization Expiration date specified above or upon completion of the identified travel dates unless earlier revoked in writing.

Sign Now