Delta Physician's Statement for POC Clearance
This file is Delta's Physician's Statement for passengers requiring respiratory assistive devices during flight. Passengers must complete Section 1 and have their physician complete Section 2. The completed form must be submitted to oxygen clearance at least 48 hours prior to flight departure.
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How do I fill this out?
To fill out this form, passengers need to complete Section 1, ensuring all required fields are filled. Then, have your physician complete Section 2. Finally, submit the completed form to OxygenToGo® for medical screening and approval.
How to fill out the Delta Physician's Statement for POC Clearance?
1
Complete all fields of Section 1 and have your physician complete all fields of Section 2.
2
Submit the completed form to Delta's authorized respiratory agent, OxygenToGo®, at least 48 hours before flight departure.
3
After receiving approval from OxygenToGo®, bring a copy of the completed Delta Physician's Statement for all flights.
4
If renting a POC for oxygen on a Delta flight, you must complete the OxygenToGo® rental agreement.
5
You also need to ensure you have enough battery hours to cover 150% of the flight duration.
Who needs the Delta Physician's Statement for POC Clearance?
1
Passengers who require respiratory assistive devices during Delta flights need this file to ensure they can use their POC on board.
2
Physicians need this file to provide their professional judgment on the patient's fitness to fly.
3
Passengers planning to rent POC devices from OxygenToGo® must complete this form.
4
Medical staff assisting a passenger with respiratory needs must help in completing this form.
5
Passengers needing to verify their medical clearance for flights should use this file.
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1
Upload the PDF form to PrintFriendly.
2
Select the text fields and input the required information.
3
Forward the form to your physician for completing Section 2.
4
Review the form for accuracy.
5
Save and submit the completed form to the proper channels.
What are the instructions for submitting this form?
To submit this form, fax it to 307-734-2982 or email it to info@oxygentogo.com at least 48 hours (excluding weekends) prior to the scheduled departure of your first flight. You can also contact OxygenToGo® at Phone: 307-732-0040 or 866-692-0040 for guidance. Ensure the form is fully completed and signed by both the passenger and physician before submission. My advice is to double-check all information for accuracy to prevent delays in the approval process.
What are the important dates for this form in 2024 and 2025?
The form should be submitted a minimum of 48 hours prior to the scheduled departure of the first flight in 2024 and 2025.
What is the purpose of this form?
The purpose of this form is to ensure that passengers requiring respiratory assistive devices during Delta flights can do so safely and in compliance with FAA regulations. Passengers must complete Section 1 and have their physician complete Section 2 to certify their fitness to fly. By submitting this form to OxygenToGo®, passengers receive clearance and guidance on using Portable Oxygen Concentrators (POC) on board.
Tell me about this form and its components and fields line-by-line.
- 1. Passenger Information: Includes the passenger's name, contact phone number, and Delta Air Lines confirmation number.
- 2. Flight Details: Consists of departing and returning flight numbers and dates of travel.
- 3. POC Device Supplier: Indicates whether the POC device is provided by OxygenToGo® or is customer owned/rented.
- 4. POC Make and Model: Contains the list of FAA approved Portable Oxygen Concentrators.
- 5. Battery Information: Total number of batteries required for the flight, including 150% of flight hours in battery hours.
- 6. Physician's Section: To be completed by the physician, including LPM required, flow type, and certification of patient's fitness to fly.
- 7. Physician's Signature: Physician's signature, name, license, practice state, address, and contact information.
What happens if I fail to submit this form?
Failure to submit this form may result in denial of boarding for medical reasons.
- Medical Clearance: Passengers will not have the required medical clearance to use their POC on board.
- Rescheduling: Passengers may need to reschedule their flights, causing inconvenience and additional costs.
- Non-compliance with FAA regulations: Passengers will not be in compliance with FAA regulations for in-flight oxygen use.
How do I know when to use this form?
- 1. Medical Clearance: Ensure you have medical clearance to use your POC during the flight.
- 2. Renting POC: When renting a POC from OxygenToGo® for your flight.
- 3. Battery Rental: For renting POC batteries if your own equipment lacks sufficient battery hours.
- 4. Flight Information: Detail your flight numbers and dates for proper scheduling.
- 5. Physician Certification: When you need your physician to certify your fitness to fly with a POC.
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Can I send the form to my physician through PrintFriendly?
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What if I need more battery hours for my POC?
OxygenToGo® rents batteries via next day courier if needed.
Who can help me with questions about the form?
You can contact OxygenToGo® at 866-692-0040 for assistance.
What happens if there is an error on my form?
Corrections can be made using PrintFriendly's edit tools before submission.
Is it required to submit this form 48 hours before the flight?
Yes, the form must be submitted at least 48 hours before the flight.
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