FAA Special Issuance Support Letter (Clinician Summary)

FAA Special Issuance Support Letter

Date: [Date authored (YYYY-MM-DD)]

To: [FAA Aerospace Medical Certification Division / Regional Flight Surgeon / AME]

Re: [Patient full legal name], DOB [YYYY-MM-DD], FAA ID [PI/MID / unknown]

Certificate Class Sought: [1st / 2nd / 3rd / unknown]

From: [Clinician name, credentials, specialty], [Practice name and address], [Phone / Fax / Email], [License state and number]

Relationship to Patient: [Treating physician / Consultant], [Duration of care], last encounter [YYYY-MM-DD]

Consent: Prepared at the patient's request for FAA medical certification review and release to the FAA/AME.

Purpose and Summary

[FAA pathway: initial Special Issuance / follow-up under existing Authorization / AME-assisted reissuance / deferral response] for [trigger condition]. (If the FAA request letter was not provided, state this explicitly.)

[Executive synthesis: primary diagnosis and current status; stability duration with dates; current treatment and medication tolerance; presence or absence of complications, recurrences, and functional limitations] (2–4 sentences; use explicit dates; cite sources: per patient report, per outside record dated, per my exam)

Diagnoses

• [Primary FAA-trigger condition]: [ICD-10 code / unavailable], [active / resolved], [controlled / uncontrolled], diagnosed [YYYY-MM-DD / unknown]
• [Comorbidity affecting aeromedical risk]: [ICD-10 code / unavailable], [status], diagnosed [YYYY-MM-DD / unknown]

(Include only diagnoses that materially affect aeromedical risk.)

Clinical Summary

(Organize by condition when multiple FAA-relevant problems exist. Label source of assertions: per patient report, per outside record dated, per my exam.)

[Condition]

History and Course: [Onset/diagnosis date; diagnostic basis; interval history since last FAA exam or significant event; episodes/recurrences with dates, severity, and whether medical attention was required; hospitalizations, ED visits, or procedures with dates and outcomes]

Current Symptoms: [Current symptoms with frequency and severity] (Explicitly document assessed safety-relevant negatives: syncope, seizure, hypoglycemia, severe vertigo, cognitive changes, mood instability.)

Treatment and Medications: [For each medication: generic name, dose, route, frequency, start date, recent changes; explicitly state presence or absence of aeromedically significant side effects (sedation, dizziness, cognitive slowing, orthostasis, visual disturbance) and how assessed; non-pharmacologic treatments; specialist involvement and follow-up plan] (If no medications, state this explicitly.)

Exam Findings: [Pertinent positives and negatives relevant to aeromedical risk] (If no exam performed for this letter, state this and provide date of last in-person examination.)

Objective Data: [Test name, date, key findings with values, interpretation; note whether full reports attached] (If required tests pending or unavailable, state this with expected dates.)

Assessment and Plan: [Working diagnosis; current control/severity; monitoring plan; follow-up interval; contingency for urgent reassessment; anticipated medication changes over certification interval]

(Repeat structure for additional FAA-relevant conditions as needed.)

Aeromedical Risk Narrative

(Interpretive synthesis connecting clinical facts to FAA safety considerations. Use explicit dates and objective findings. Do not state patient is "cleared to fly.")

• Clinical stability: [Stable on current regimen since (date); no exacerbations/episodes since (date); objective trends supporting stability]
• Flight-relevant risk: [Sudden incapacitation risk (syncope, seizure, arrhythmia, severe hypoglycemia) and subtle incapacitation risk (cognition, attention, mood): state presence or absence and basis for determination]
• Medication tolerance: [Presence or absence of operationally significant side effects; how assessed; if present, severity and mitigation]
• Prognosis and monitoring: [Expected course; treatment stability vs. planned changes; follow-up plan supporting continued stability]

Attachments

[List enclosed documents with dates: clinic notes, hospital records, test reports, imaging, laboratory results] (Indicate if required documents are unavailable or pending.)

Attestation and Signature

[Clinician signature]

[Name, credentials, specialty]

[Contact information]

Statement of basis: [I personally evaluated the patient on (YYYY-MM-DD)] [and/or] [I reviewed the attached records dated (date range)]. I am available for clarification if needed.