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Get HAL-A90 2014

Medical Waiver Request Form 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. 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 Mail or fax completed form to Consumer Affairs PO Box 30008 Honolulu HI 96820 Fax 808-838-6777 Print Form 04/01/14 NOTE The completed form CANNOT be saved. It can ONLY be PRINTED using the button to the left. The Hawaiian Airlines Consumer Affairs Office 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 Confirmation 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 stepbrother grandparent grandchild step grandparent step grandchild mother-in-law father-in-law son-inlaw 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. Proof of relation may be requested* Please fill out the entire form* Any blank areas may cause a delay in our response to you. The Hawaiian Airlines Consumer Affairs Office 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 Confirmation 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 stepbrother grandparent grandchild step grandparent step grandchild mother-in-law father-in-law son-inlaw 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. Proof of relation may be requested* Please fill out the entire form* Any blank areas may cause a delay in our response to you. The Hawaiian Airlines Consumer Affairs Office will respond to you within 30 business days. Please return this form only and no other additional documents. The Hawaiian Airlines Consumer Affairs Office 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 Confirmation 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 stepbrother grandparent grandchild step grandparent step grandchild mother-in-law father-in-law son-inlaw daughter-in-law brother-in-law and sister-in-law. .

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