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Make a Travel Request


 

This form allows you to submit a travel request for one patient for one trip to a specialist medical appointment(s). A travel request may be submitted for a flight (nationwide), or for a PEI bridge or ferry pass (PEI residents only). Accommodations through the Airbnb Open Homes program may also be requested as part of a travel request.

For more information, please see our Help page.

Getting Started

Please read the information below and answer the preliminary eligibility questions to ensure you are ready to make a travel request. You may also preview the form before you begin to ensure you have all the required information before starting.

Specialist Medical Appointments

  • The patient’s specialist medical appointment must already be booked before submitting a travel request.
  • If a separate trip for a future specialist appointment is required, please submit a new travel request per trip.
  • All specialist appointments requiring Hope Air travel assistance must be covered by a provincial health plan and have been referred by the patient’s doctor.

Escorts

  • Hope Air will provide flights for one escort per patient 18 years and younger.
  • Hope Air will only provide flights for one escort per patient 19 years and older with confirmation from the patient’s doctor that an escort is necessary to ensure the physical safety of the patient.
  • Hope Air is unfortunately unable to provide escort flights for patients who do not require physical or mental assistance, i.e. we cannot provide flights for escorts for emotional support.
  • All escorts must be 19 years or older.

Household Income

  • Hope Air’s mandate is to provide flights to medical appointments for financially limited individuals.
  • Income information for all household family members for the past 12 months is required to be submitted. Household family members with no income should also be listed. Non-family household members and their incomes are not required (i.e. roommates, multi-family homes, other shared households who maintain separate finances).
  • Please have income sources and totals for all household family members ready before you begin this travel request.
  • Hope Air does random checks to verify patient household income information and may request that you provide documentation of the income figures provided.

PEI: Bridge and Ferry Passes

  • Hope Air and the PEI government have collaborated to offer free Confederation Bridge toll and Northumberland Ferry passes to eligible PEI residents travelling to approved out-of-province medical appointments.
  • To be eligible for a bridge or ferry pass, the patient must be a PEI resident requiring out-of-province medical services and have received a PEI out-of-province medical services approval letter issued by Health PEI.
  • A copy of the out-of-province medical services approval letter must be provided to Hope Air before bridge or ferry travel can be arranged. The patient’s doctor must request this letter on the patient’s behalf and a copy can be obtained from the doctor’s office, if necessary. A sample letter can be viewed here. [link to pdf of sample letter]

Accommodations

  • Hope Air and Airbnb have collaborated to allow patients who are applying to Hope Air for travel to a medical appointment to also apply for free accommodations for their trip through the Airbnb Open Homes program. Accommodations may only be provided up to a maximum of 7 days.
  • If a travel request is approved by Hope Air, requests for accommodations will be managed directly through the Airbnb platform. By requesting accommodations within this travel request, the individual completing the travel request is providing consent for Hope Air to supply the patient’s relevant personal information to Airbnb, including name, email address, phone number, and travel dates.
  • A confirmed request for accommodations is not a guarantee that Airbnb will have a suitable listing available with the dates, location, room specifications, and/or mobile accessibility that the guests require. Guests must be comfortable following host-provided instructions to check themselves into any reserved accommodations.
  • Accommodations provided by Airbnb through the partnership with Hope Air are non-transferrable and valid only for the individuals, dates, and location of the corresponding approved Hope Air travel request.
  • Airbnb stays are at private residences and not hotels, therefore, all guests are expected to take care to keep the residence clean and undamaged, and to respect the household rules of the host.

Preliminary Eligibility

Does the patient have a medical appointment booked?

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X

Hope Air is not able to process travel requests until a medical appointment has been booked. If a medical appointment has not yet been booked, please submit a new travel request when the appointment date and time have been confirmed.

Ineligible Selection

Is the medical appointment covered by a provincial health plan?

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X

Hope Air is unfortunately not able to assist with travel requests for medical appointments that are not covered by a provincial health plan.

Ineligible Selection

Do you currently have the patient’s household income information on hand to complete this form?

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X

Hope Air’s mandate is to provide flights to medical appointments for financially limited individuals. You will be required to enter the employment and other financial information for each person in the patient’s household to complete this travel request.

Ineligible Selection

Do you grant permission to Hope Air to contact the patient’s doctors and/or specialist appointment medical facility?

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X

Hope Air requires permission to contact the patient’s doctors and/or appointment medical facility in order to confirm the patient’s appointment and, if applicable, escort necessity and safety to fly. A travel request cannot be processed if Hope Air does not have permission to contact the patient’s doctors and/or appointment medical facility. If you are submitting this request on behalf of someone else, selecting YES implies the patient has consented to this condition.

Ineligible Selection

This patient is not currently eligible to submit a travel request to Hope Air. For more information, please review the Getting Started section above, visit our Help page, or call us at 1 877 346 HOPE (4673).

Next Step

Patient Information

Request Details

Are you completing this request for yourself, or on behalf of someone else?

Ineligible Selection

Contact Information

Has the patient granted you permission to supply their personal information to Hope Air? (Including personal, medical, and financial information, together with consent to contact doctors)

This patient is not currently eligible to submit a travel request to Hope Air. For more information, please review the Getting Started section above, visit our Help page, or call us at 1 877 346 HOPE (4673).

Your relationship to the patient

Who should Hope Air contact in follow up to this travel request?

Ineligible Selection

Patient Details

Date of Birth

Language Preference

PEI Travel

Which form of travel assistance are you requesting?

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X

Hope Air and the PEI government have collaborated to offer free bridge and ferry passes to eligible PEI residents travelling to approved out-of-province medical appointments. Please see our Help page for more information.

Does the patient have a Health PEI letter confirming they have been approved for out-of province medical treatment?

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X

A copy of this letter must be provided to Hope Air before bridge or ferry travel can be arranged. The patient’s doctor must request this letter from Health PEI on the patient’s behalf and a copy can be obtained from the doctor’s office, if necessary. A sample letter can be viewed here.

Ineligible Selection

This travel request may be submitted, however, a Health PEI out-of-province treatment approval letter must be provided to Hope Air before travel can be arranged. The patient’s doctor must request this letter from Health PEI on the patient’s behalf and a copy can be obtained from the doctor’s office, if necessary.

Northern Ontario Travel

Is the patient a resident of Northern Ontario?

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X

Resident of Northern Ontario in the districts of Algoma, Cochrane, Kenora, Manitoulin, Nipissing, Parry Sound, Rainy River, Sudbury, Thunder Bay, or Timiskaming.

Ineligible Selection

Please answer the following questions to determine the patient’s eligibility for the Northern Health Travel Grant (NHTG). NHTG-eligible patients who receive flights through Hope Air will be required to submit a completed NHTG application form back to Hope Air. For more information, please see our Help page.

Please note: NHTG eligibility has no bearing on the approval outcome of this travel request.

Is the patient in possession of a valid OHIP card?

Ineligible Selection

Is the patient covered by the NIHB (Non-Insured Health Benefit Program for eligible First Nations and Inuit people)?

Ineligible Selection

Is the patient’s illness connected to a WSIB (Workplace Safety and Insurance Board) claim?

Ineligible Selection

Is the patient covered by ODSP (Ontario Disability Support Program)?

Ineligible Selection

Is the patient’s travel covered by private insurance or another program/organization where the patient may receive advance funding or reimbursement?

Ineligible Selection

Is the patient travelling to see a specialist doctor?

Ineligible Selection

Has a physician, dentist, optometrist, chiropractor, midwife, or nurse practitioner in the Northern Ontario region referred the patient to the appointment?

Ineligible Selection

Is the patient travelling within Ontario or Manitoba?

Ineligible Selection

This patient is eligible for the NHTG.

If this travel request is approved by Hope Air, once travel is completed, this patient will be required to submit a completed NHTG application form back to Hope Air. The NHTG application form needs to be signed by the patient, the referring and specialist doctors, and the escort (if applicable). The patient and escort should also keep their flight boarding passes. When the NHTG application form is completed, please submit the form and boarding pass by mail to Hope Air.

For more information, please see our Help page.

Escort Information

An escort is required for all patients age 18 and younger.

Does the patient require assistance by an escort to ensure physical safety?

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X

Hope Air requires confirmation from the patient’s doctor that an escort is medically necessary. Unfortunately, Hope Air is unable to provide an escort to patients 19 and older for non-medical reasons, such as emotional support. All escorts must be age 19 or older.

Ineligible Selection

Escort Details

Date of Birth

Relationship to Patient

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Appointment Information

Referring Doctor Details

Medical Appointment Details

Appointment Date

Appointment Time

If the medical facility is not listed, please type it in the Medical Facility Name space.

Specialist Appointment Doctor Details

Do you know the details of the specialist appointment doctor?

Ineligible Selection
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Travel Details

Travel Information

Preferred Departure Date

Preferred Return Date

Accommodations

Would the patient like to apply for free accommodations with Airbnb Open Homes for the travel dates entered for this travel request?

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X

Free accommodations through Airbnb Open Homes may be requested for the trip dates outlined in this travel request. Accommodations may only be provided up to a maximum of 7 days. A confirmed request for accommodations is not a guarantee that Airbnb will have a suitable listing available with the dates, location, room specifications and/or mobile accessibility that the guests require. Guests must be comfortable following host-provided instructions to check themselves into any reserved accommodations. By requesting accommodations within this travel request, you are providing consent for Hope Air to supply the patient’s relevant personal information to Airbnb, including name, email address, phone number, and travel dates. For more information regarding accommodations, please see the Getting Started section at the beginning of this form.

Required

Please note that by selecting Yes, you are providing consent for Hope Air to share personal information relevant to this travel request with Airbnb.

The following information is required to help us locate an Airbnb listing that will meet the patient’s needs:

How many people will be staying?

How many beds are required?

Is one bed for two people acceptable if we cannot locate an available listing that has two or more beds?

Required

Does the patient or their companion have any mobility issues? (e.g. cannot use stairs, require grab bars in bathroom, have mobility aids, etc.) Please describe.

Special Needs

Does the patient have any special needs that need to be accommodated for air travel? (Select all that apply)

Volunteer Pilot Program

Hope Air has a Volunteer Pilot Program in which private pilots, approved by Hope Air, fly patients in small private planes rather than on commercial flights. For more information, please see our Help page.

Is the patient willing to take a volunteer pilot flight?

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X

Please note there is limited space for luggage and no bathroom on volunteer pilot planes. Passengers will be required to climb into the plane – please ensure patient/escort mobility.

Required

Please enter patient and escort weight.

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X

Weight information is necessary for the pilot of a small plane to properly assess the balance of the plane.

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Household Income

Household Family Members

Hope Air requires the total gross income of the patient’s household family in order to determine travel request eligibility. Income information for all household family members for the past 12 months is required to be submitted. Household family members with no income should also be listed.

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X

Non-family household members and their incomes are not required (i.e. roommates, multi-family homes, other shared households who maintain separate finances).

Please note: Hope Air does random checks to verify patient household income information and may request that you provide documentation of the income figures provided.

Please add all members of the patient’s household family below.
Income for children should be added for all household children together.
Income for adults should be added for each individual adult.

Add Adult
Add Children
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Household Summary (Calculated based on the entries above)

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Total Gross Household Income: {{totalIncome | currency}}

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Form Submission

Survey Questions

Please answer the following survey questions before submitting your travel request. These questions will not have any bearing on the outcome of this travel request, but your answers help Hope Air in our efforts to raise funds to continue expanding and enriching our services.

All individuals 18 and older require government- issued photo ID to board a commercial flight. Do you have appropriate photo ID?

Ineligible Selection

Is this the first request submitted for this patient?

Ineligible Selection

How did you first learn about Hope Air?

What illness, condition, or procedure is the medical appointment for?

What type of medical appointment is this?

Does the patient have diabetes?

Ineligible Selection

What type of diabetes?

If the requested trip is more than one day, where will the patient be staying overnight?

How will the patient get to the medical appointment if Hope Air is unable to assist?

Which best describes the patient’s household?

Anything else you would like to share about your financial or medical situation relevant for us to know so that we can best try to help you?

Submission

By submitting this form, you confirm that the information provided is true and accurate, and understand that this form is a request for travel assistance, not a confirmed booking.

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Submission Error

An error occurred and your travel request was not submitted. Please refresh this page and try again. If you continue to experience issues, please email us or call us at 1-877-346-4673.

Your travel request has been submitted.

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