Once you have completed and signed the authorization form, save a copy for your records. Submit the completed form to the Aviation Medicine Advisory Service (AMAS) by either mailing it to their address or faxing it to 303-341-4803. Ensure all required fields are filled out accurately and all necessary signatures are in place.

Not applicable for this form.

This form serves as a patient authorization for the use and disclosure of protected health information (PHI) as part of the Frontier Airlines HIMS Program. It allows the Aviation Medicine Advisory Service (AMAS) to communicate PHI to Frontier Airlines Management and Union representatives for purposes related to the program. The form’s primary objective is to ensure the effective implementation of the HIMS program while safeguarding individual privacy and promoting aviation safety.

• 1. Personal Information: Includes your first name, middle initial, last name, and date of birth (DOB).
• 2. Authorization Details: Specifies the parties authorized to receive PHI and the purposes of the disclosure.
• 3. Restrictions: Allows you to list any restrictions on the use of your protected health information.
• 4. Signature: Requires your signature and the date to validate the authorization.

Failing to submit this form may hinder your participation in the Frontier Airlines HIMS Program.

• Denied Participation: You may be excluded from the HIMS program.
• Delayed Return to Work: Your return to work may be delayed due to incomplete authorization.

• 1. Joining the HIMS Program: Required when you are entering the HIMS program and need to authorize PHI communication.
• 2. Returning to Work: Necessary when your return to work depends on the authorization of PHI release.