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MEDICAL EVACUATION CASE EVALUATION - MEDEVAC / AIREVAC / MEDREPAT

STEP 1 – PATIENT INFORMATION



STEP 2 – PRIMARY CARE PHYSICIAN OR ATTENDING DOCTOR(S) INFORMATION



STEP 3 – MEDICAL CASE IDENTIFICATION & SUMMARY
STEP 4 – MEDEVAC CASE TYPE & PRIORITY - MEDEVAC / AIREVAC / MEDREPAT

What is the MedEvac priority based on the patient’s condition and the guarantor’s instructions?

Do you have a preference as related to the country of destination or the medical facility? Please list your preferences below.

Who will be responsible of the patient’s travel and medical treatment expenses abroad?

STEP 5 – MEDEVAC CASE ADMINISTRATION PROTOCOL - CASE EVALUATION AND HANDLING OF CONFIDENTIAL / MEDICAL INFORMATION

Upon receipt of this MedEvac evaluation request form (fully completed), the listed contact person in your form will receive a phone call to arrange a secured transfer of the patient medical report to a specialized, MedAllied physician group for evaluation. MedAlliesWorld will not open a MedEvac file until such evaluation has been completed and all logistics for patient’s travel and guarantor’s payment have been reviewed and accepted by the receiving medical facility. MedAlliesWorld and its affiliates do not charge a service fee for this preliminary evaluation of a patient’s medical report.

STEP 6 – CASE MANAGEMENT / REQUIREMENTS

Uppon submitting a MedEvac Evaluation Form online, You may send us the medical report f... AirEvac or a MedEvac case by telefax following the instructions below:

  1. Complete the Medical Case Evaluation form above;
  2. The patient medical report must originate from a fully identified primary care physician, from the attending physician(s) or from the hospital / medical clinic;
  3. Send medical report to:
    MEDEVAC GLOBAL OPERATIONS
    +1-757-932-8403.