Sky Nurses Care Recipient Preparation Booklet

Care Recipient Handbook

‘Making A Difference...Every Day!’

866-611-8434
[email protected]

Premier Medical Transport Company
24/7/365 Operations

Bedside-to-Bedside Care
International Stretcher Service
Highly Qualified Medical Professionals

Fully Licensed and Insured

Sky Nurses is a quality-focused, full service, medical escort company with
deep experience in a wide variety of healthcare disciplines.

Types of Medical Repatriations:
• Behavior Health
• Neurological
• Oncology
• Chronic Disorders
• Stable Post-Trauma
• Cardiology
• Other disabilities

Using the most qualified and experience clinicians and travel
professionals, our staff will plan and execute the safe bedside-
to-bedside transport of the patient or care recipient back to
their final destination from anywhere in the world paying spe-
cial attention to all the details, healthcare needs, and cultural
diversity. We work diligently with our customers to deliver the
best possible service with compassion and respect.

2

Table of Contents 4
5
Travel-Ready Checklist 6
Before we book your transport 7
Payment Authorization 8
Before we take off 9
Fit-To-Fly 10
Before we make arrangements 11
HIPAA Form 12
Power of Attorney Explanation 13
Durable Power of Attorney 14
Want to arrange your own accommodations 15
TSA and Customs 16
Care Recipients coming from a Nursing Home
Emergency Contact

3

Transport-Ready Checklist

There are quite a few factors to consider when planning a medical transport. Fortunately, our Medical
Management and Travel Coordination Team at Sky Nurses, are here to make this process as easy as pos-
sible. We transport from a bed to a business/first class seat on a commercial airline. Our medical profes-
sionals provide the same care in a business/first class seat as they do in a hospital. Sky Nurses is caring
and compassionate about every transport and therefore, our #1 priority is to safety transport your loved
one. As we prepare a quote for you, we also prepare a plan of care for the recipient. This way, at a mo-
ments notice, we can dispatch a clinician to pick up and transport your love one to their final destination.
We just need a few documents from you to get started. These documents can be found throughout your
handbook.

Name of Document What it does When we need it

Payment Authorization This form officially awards your trip to Whenever you’re ready to move forward. We
Form Sky Nurses and opens up the ability to understand that this decision takes time, so
reserve flights, hotels, and ground there’s no rush. However, please remember
Fit to Fly transportation. Once we receive this that prices of flights and hotels as well as clini-
HIPAA Release of form, we can begin to book your trip. cian availability can change at any time. The
Information Authorization longer you wait to provide this form, the more
Relevant medical records This form is a statement signed by a availability and price may change.
Power of Attorney physician stating that you or your loved No more than 10 days before your date of de-
one is physically able to travel by Com- parture. This form can take time to complete,
Copy of identification mercial Airline. Without this form, we so plan accordingly.
Activities of Daily Living cannot guarantee you can board your
fight. As soon as possible. The sooner we learn what
Form This form allows our Medical Team to your needs are, the better we can accommo-
Emergency Contact call the facility and learn more about date them throughout your trip.
the physical condition of you or your Before your date of departure.
Information Form loved one.
This will help our clinicians be prepared If this does not apply to you, it isn’t necessary.
in the event of a medical emergency However, if your loved one falls under this cate-
during your trip. The more we know gory, we need the PoA before the date of de-
about you or your loved one, the better parture.
we can serve your needs.
A Power of Attorney (POA) form grants As soon as possible. If the trip is international,
broad power to a person or organiza- we will need a copy of all passports involved. If
tion to act on your behalf in the event your ID is expired, you’ll need to get a replace-
that you are not of sound mind or body ment as soon as possible.
to do so. If your loved one is in a nurs- Before the date of departure.
ing home or has a condition that pre- Before the date of departure.
vents him or her from making decisions
independently, Sky Nurses will need to
know who to contact.
In order to provide a smooth trip
through TSA and customs, we need to
verify that you have a valid form of ID.
It also helps us book your airline tick-
ets.
This tells us how we can help you or
your loved one during the trip with daily
tasks.
This tells us who to call in the event
that something happens on the trip.

4

Before we book your transport…

Thank you for choosing Sky Nurses! If you’re reading this, then you’ve al-
ready taken the first step towards transporting your loved one.
But before we can begin locking down the prices and dates we’ve quoted
for you so far, we just need for you to fill out the Payment Authorization
Form. Once we’ve received payment, we can move forward with reserving
flights and confirming availability for the clinician who will accompany you
and/or the care recipient.
Please note that the final quoted price should have already be noted in this
form. If you choose to pay for the transport with a credit card, be advised
that there will be a 4% fee added to that quote. Please also be advised that
a wire transfer may take additional time to process, so plan accordingly as
we cannot proceed until payment has been confirmed.

5

6530 W. Rogers Circle
Boca Raton, Florida 33487
Phone: 866-611-8434
Fax: 866-633-4188
Email: [email protected]

PAYMENT AUTHORIZATION

Please sign and complete this form to accept Sky Nurses Quote #:__________________for the

□ □$500.00 Non-refundable Deposit, All Airfare Tickets totaling $____________ and/or

□ Total Quoted Amount (after deposit): $________________USD

Please select one of the following options: *Please note that if paying by credit card a
4% fee will be added to the total quote.

OPTION #1 CREDIT CARD INFORMATION: (4% Service Fee will be added to Total Quote)

Name on Credit Card: ________________________________________________
Credit Card Number: _________________________________________________

Expiration Date: _____________ CVV: ____________

Billing Address: ____________________________________________________

City___________________________ S t a t e /Province: ___________________

Country: _______________________ Zip Code: __________________________

Phone #: ______________________ Email: _____________________________

□ OPTION #2 WIRE TRANSFER INFORMATION: Account Type: Checking
Sky Nurses Account #: 8980 5543
Bank Name & Address:
Bank of America, N.A 0293
P.O. Box 25118 Wire Routing #: 026009593

Please send confirmation receipt that the wire transfer has been completed, so that the accounting
department can verify it has been received. Once received, the Travel Department will book flights
immediately and the trip building process will begin.

By signing this form, you give us permission to debit your account for the
amount indicated on or after the indicated date.

SIGNATURE ________________________________________________ DATE _____________

I authorize the above-named business to charge the credit card indicated in this authorization form according to the terms outlined above.
This payment authorization is for the services as described on Sky Nurses Quote/Invoice/Agreement for the amount indicated on this
document per the terms and conditions of said document. I certify that I am an authorized user of this credit card and that I will not dis-
pute this payment with my credit card company and will adhere to the dispute resolution clause of the terms & conditions of the Sky Nurs-
es Quote/Invoice/Agreement.

6

Before we take off…

Next on our list of documents is the Fit to Fly form. If you’re reading
this well in advance of the trip, please remember that the Fit to Fly is
only valid if it’s submitted 10 days or less before the trip starts, so
you won’t want to submit it too early. However, the Fit to Fly form
must be filled out by the physician of the care recipient, so you will
want to make your doctor’s appointment soon.
The Fit to Fly is one of the most important pieces of the puzzle when
it comes to planning your trip. Without a Fit to Fly, the airlines may
deny the care recipient a seat on their flight if they have doubts
about his or her condition. But with a valid Fit to Fly in hand, you’re
on your way to your final destination!
Because the Fit to Fly form is meant to be filled out by a physician,
questions may arise at your doctor’s office. If the physician or facility
wishes to talk to Sky Nurses about what is required, please let them
know that they can email us at [email protected] or reach us by
phone at 866-611-8434.
Sky Nurses can receive your Fit to Fly form via the email address
listed above or by fax at 866-633-4188.

7

Fit-to-Fly

I, _________________________________________, (MD, DO) licensed to practice medicine in the
country of _______________________________, certify that ________________________________is a
patient under my care. At the time of discharge, it is my professional judgment that this patient is
physically able to safety complete a commercial airline flight to _______________________ with a
Medical Escort. I further certify that the above-mentioned patient does not have a disease or infection that
can be transmissible to other persons during the normal course of the flight.

Date Fit-to-Fly: ___________________
Patient Name: __________________________________________
Admission Date: ________________________________________
Discharge Date: _________________________________________

Diagnosis at Discharge: _____________________________________________________________

Prognosis for the Journey: Good Fair Poor (Please circle one)

Type of Escort: Paramedic Registered Nurse Physician (Please circle one)

Equipment Needed: (Please circle one)

Portable Oxygen Concentrator Cardiac Monitor/AED Nebulizer Suction

Physician Orders ______________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
_________________________________________________

___________________________________________________ ________________________
Physicians Signature Date of Signature

Sky Nurses Medical Clearance for Commercial Airline This document contains protected health information (PHI). The

federal rules prohibit the recipient from making any further disclosure of the information unless further disclosure is expressly permitted by the written
consent of the person to whom it pertains, or as otherwise permitted by 42 C.F.R. Part 2

8

Before we make arrangements ...

At Sky Nurses, the care and comfort of the care recipient is our highest priori-
ty. In order to provide the most comfortable experience for you or your
loved one, our Medical Management will need to reach out to the facility or
doctors in charge of your or their daily care. They can provide us with the
knowledge we need to ensure that you get the most out of your trip!
In order to start this process, we need a signed copy of the HIPAA form on
the next page. The HIPAA Release of Information Authorization allows medi-
cal facilities to discuss relevant information with our Medical Management.
Without it, they aren’t permitted to tell us anything about you or your loved
one’s condition or any specific medical needs, so it’s a crucial step to plan-
ning your trip!
This form must be signed by the care recipient or a personal representative
appointed by the care recipient. As with the Fit to Fly, you may send us this
form by emailing [email protected] or via fax at 866-633-4188.

9

HIPAA PRIVACY AUTHORIZATION FORM

Authorization for Use or Disclosure of Protected Health Information
(Required by the Health Insurance Portability and Accountability Act – 45 CFR Parts 160 and 164)

1. I hereby authorize ________________________________________________ to use and/or disclose
(Name of Health Care Provider)

the protected health information described below to Sky Nurses , in regards to
________________________.

(Name of Individual)

2. Authorization for Release of Information. Covering the period of health care from
________________to _________________ OR all past, present and future periods:

a. I hereby authorize the release of my complete health record (including records relating to mental health
care, communicable diseases, HIV or AIDS and treatment of alcohol/drugs abuse).

OR

b. I hereby authorize the release of my complete health record with the exception of the following infor-
mation:

- Mental health records
- Communicable diseases (including HIV and AIDS)
- Alcohol/drug abuse treatment
- Other (please specify): _______________________________________

3. This medical information may be used by the person I authorize to receive this information for medical treatment
or consultation, billing or claims payment, or other purposes as I may direct.

4. This authorization shall be in force and effect until _______________, at which time this authorization
expires. (Date of Event)

5. I understand that I have the right to revoke this authorization, in writing at any time. I understand that a revocation
is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my au-
thorization was obtained as a condition of obtaining insurance coverage and
the insurer has a legal right to contest a claim.

6. I understand that my treatment, payment, enrollment or eligibility for benefits will not be conditioned on whether I
sign this authorization.

7. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient
and may no longer be protected by federal or state law.

____________________________________________________________ __________________
Signature of Patient or Personal Representative Date

____________________________________________________________ __________________
Print Name of Patient or Personal Representative Relationship to Patient

©Sky Nurses LLC

10

Before we depart...

As we construct your itinerary and book your airfare and lodgings, the logistics coordinators
at Sky Nurses take great care to anticipate any issue that might arise during your travels.
However, in the event of an emergency, medical or otherwise, these plans may need to
be altered to ensure the care recipient has proper care no matter the circumstance.

For this reason, if your loved one is in a nursing home or is not of sound mind and body to
make independent decisions, we ask that you send us a copy of the relevant Power of
Attorney. A Power of Attorney grants an individual power to make decisions on another
individual’s behalf in the event that they are unable to do so for physical or mental
reasons. By having a copy of the care recipient’s Power of Attorney on file, we will know
who to contact in the event of an emergency to make decisions that are in their loved
one’s best interests. In addition to this, if the care recipient is in a nursing home, we cannot
legally remove them from that nursing home without this document in our hands.

If you do not have an active Power of Attorney, you may use the template on the next
page as a guide. Please bear in mind that this is only a guide. In order to activate a
Power of Attorney, an attorney must be contacted to finalize the draft and officiate the
process.

Once you have a copy of the Power of Attorney, please send it to Sky Nurses at
[email protected] or by fax at 866-633-4188.

11

DURABLE POWER OF ATTORNEY
FOR HEALTH CARE

I, ___________________________, am of sound mind and I voluntarily make this designation.

(Full name of care recipient)

APPOINTMENT OF PATIENT ADVOCATE

I designate ________________________, my ___________________________
(Insert name of patient advocate) (Spouse, child, friend…)

living at _________________________________________________________________

(Address of patient advocate)

as my patient advocate. If my first choice cannot serve, I designate

_________________________________, my __________________________, living at
(Name of successor patient advocate) (Spouse, child, friend…)

_________________________________________________________________ to serve as my

(Address of successor patient advocate)

patient advocate.

My patient advocate or successor patient advocate must sign an acceptance before he or she can act.
I have discussed this appointment with the individuals I have designated as patient advocate and successor
patient advocate.

GENERAL POWERS

My patient advocate or successor patient advocate shall have power to make care, custody, and medical
treatment decisions for me if my attending physician and another physician or licensed psychologist deter-
mine I am unable to participate in medical treatment decisions.

12

Want to arrange your own
accommodations?

No problem! Although Sky Nurses has travel

agents on staff able to book flights, hotels,

and ground transportation, we respect that When it comes to the logistics of your trip, Sky

you may already have a travel agent in Nurses has you covered! We have GDS certified

mind. We can easily coordinate with whoev- travel agents on staff to take care of all your ar-
er is booking your travel provided that you rangements!

provide us with the contact information of Airfare
your travel agent.
At Sky Nurses, we understand that air travel can
However, while you are making arrange- be stressful, but we’ve taken care to make your
ments, please keep the following guidelines trip as stress-free as possible! For the sake of
in mind. comfort and privacy, care recipients and clinicians

1. If you book the airfare yourself, please are usually booked in Business or First-Class
make sure that arrangements have also seating with as few stops as possible. If any spe-
been made for the clinician. In order for cial accommodations are necessary, our travel
the clinician to better assist you, they agents can arrange them ahead of time. Whether
should be seated next to the care recipi- it’s a special meal request, wheelchair access, or
ent. even oxygen in flight, we’ll have you covered on
the day of departure.
2. If you opt to book the hotels yourself,

please remember that the clinician must Hotels

be booked in a separate room from the You can rest assured that you will be comfortably
care recipient. If possible, the rooms
resting in the hotels selected by our travel agents.
should be adjoining or next to each other Sky Nurses has high standards when it comes to
so the clinician can assist the care recipi- accommodations both in terms of comfort and af-
ent at any time.
fordability, so we will do our best to have you

3. If you arrange your own ground transpor- sleeping in style after a day of sightseeing and

tation, please note that clinicians cannot fun. We only choose 3-Star hotels or better and

ride in a private vehicle (such as a rental we always strive to stay in budget. Great care is

car) for liability reasons. All ground trans- also taken to reserve our care recipients in adjoin-

portation must be by a licensed and in- ing rooms to our clinicians, so they can be close

sured provider with liability insurance. by to tend to their needs.

Ground Transportation

All of our ground transportation is guaranteed to
be licensed and insured, with liability coverage.
Whether you simply need a sedan or require a
wheelchair van, the travel agents at Sky Nurses
will make sure that you – and your clinician – get
where you need to go.

13

In order to pass through TSA and customs on the day of departure, the care recipient
MUST have a valid form of ID.

If your trip is domestic, you must have a valid, non-expired drivers license OR a govern-
ment-issued ID. Sky Nurses may ask to see a copy of your ID before you depart.

If your trip is international, you must have a valid passport that will not expire for at least
6 months to a year after your trip will take place. Sky Nurses will need a copy of your
passport in order to purchase your tickets.

In the event that the care recipient does not have valid ID, please let your Travel Coor-
dinator know as soon as possible so we can assist with making arrangements.

LUGGAGE PERSONAL ITEMS

Please inform your Travel Coordinator if you intend In general, you should always bring the follow-
to bring more luggage than listed on your ticket, as ing in your carry-on bag or personal item:
some ground transportation vehicles have limits to  Chargers and spare batteries for any phone
how much they can hold. Though every trip is dif-
ferent, as a rule Business Class travelers are typical- or other device you may be bringing.
ly allowed 2 pieces of large luggage, 1 carry on,  Electric adapters compatible with the out-
and 1 personal item, such as a backpack or purse.
lets in your destination. Remember to take
Make sure to only bring personal items and carry- voltage into account as well as shape.
on bags that you can personally carry yourself.  Cash for traveling, in the event that cards
Clinicians are not permitted to carry your carry-on aren’t accepted. We recommend around
luggage or personal items for you. $100 - $250.
 Any medication you are currently taking,
You will be responsible for any fees resulting from complete with instructions on dosage and
overweight bags or excess luggage. frequency.
 Inhaler, if applicable.

14

For Care Recipients Coming from a Nursing Home

In order to accommodate the wishes and needs of care recipients who live in nursing homes, Sky Nurses
needs to know the following:

1. Does the care recipient have an appointed Power of Attorney?

If yes, please submit a copy of the Power of Attorney paperwork to Sky Nurses and have the
Power of Attorney sign this form below. Sky Nurses also needs a signed Authorization for
Temporary Removal form to take the care recipient out of the nursing home.

If no, please confirm that the care recipient is capable of giving Consent to Treat throughout
the trip. This can be accomplished by submitting a copy of the relevant documentation
from the nursing home, such as the Care Plan for the care recipient. A signed note from the
care recipient’s treating physician can also serve as proof that he or she is capable of giving
consent.

Please select and sign one of the following:

I hereby state that I, ______________________, will be representing the care recipient as his or
her Power of Attorney. I understand that unless written proof of this is submitted to Sky Nurses,
the clinician cannot legally remove the care recipient from their nursing home.

_________________________________________ _________________
(Power of Attorney’s signature) (Date)

I hereby state that I, _______________________, am the care recipient, and that I am capable of
making independent decisions. I understand that this claim must be supported by the facility in
which I live or my treating physician for my own physical safety. I am submitting written proof
that I can give consent to Sky Nurses.

_________________________________________ _________________
(Care Recipient’s signature) (Date)

15

Emergency Contact Information

In the event of an emergency, please let us know who we should contact.

Name:
Relationship to Care Recipient:
Phone number:
Email address:
Physical address:
Allergies
Please inform us of any allergies the care recipient has here, so we can help him or her avoid
them.
Allergies to Medication:

Allergies to Food:

Other Allergies (to plants, animals, etc.):

Is there anything else we should know?

Does the care recipient have any fears or phobias we should try to avoid? Does he or she have
any strong likes or dislikes relevant to their travels? Let us know here, so we can make them as
comfortable as possible during their trip!

16