Treating Physician Status Report Request (FAA)

Request for FAA Medical Documentation

From / To

From — Name/Role: [Requestor name and role]
Address: [Requestor mailing address]
Phone: [Requestor phone]
Fax/Secure Email: [Requestor fax or secure email]

To — Clinician: [Clinician name, credentials, specialty]
Practice: [Practice or health system]
Address: [Practice address]
Phone/Fax: [Practice phone/fax]

Date: [Date of request]
Requested Return By: [Due date]

Patient Information

Name: [Patient full legal name]
Date of Birth: [DOB]
MRN: [MRN] (Only include if known)
FAA Reference/PI Number: [FAA reference number] (Only include if available)
MedXPress Confirmation: [Confirmation number] (Only include if available)
Condition(s) Under FAA Review: [Specific diagnoses and/or medications FAA is evaluating]

Request

Purpose: The FAA requires a copy of the patient's current, detailed clinical progress note from a recent visit (typically within 90 days) to evaluate medical certification. An After Visit Summary or patient portal printout is generally not sufficient.

Scope: You are not being asked to determine fitness to fly or FAA certification eligibility—only to document clinical facts, current status, and treatment plan.

Authorization: A signed HIPAA authorization is attached authorizing release of medical records related to the condition(s) listed above.

Required Progress Note Elements

• ☐ Encounter details: Date, clinician name/credentials, reason for visit
• ☐ History: Diagnosis with date of onset, symptom timeline, current status [improved / stable / worsened]
• ☐ Medications: All medications for the condition(s) under review—include name, dose, frequency, start date, and explicitly state whether side effects are present or absent
• ☐ Exam/Testing: Pertinent physical exam findings and any relevant lab/imaging results with dates
• ☐ Assessment/Plan: Current stability status [stable vs. unstable / controlled vs. uncontrolled], treatment plan, prognosis if known, and any activity restrictions with duration
• ☐ Follow-up: Next appointment interval or scheduled date

FAA-Specific Statements (Document explicitly when relevant to the condition):

• • Stability duration (e.g., "stable since [date]")
• • Side effects: present or absent (Do not leave ambiguous)
• • Any episodes suggesting incapacitation risk: syncope, seizures, severe hypoglycemia, chest pain at rest, vertigo, or psychiatric emergencies—state presence or absence as applicable

Supporting Documents

(Include only if applicable)

• ☐ Medication list (if not fully detailed in the note)
• ☐ Relevant test results referenced in the note
• ☐ Specialist reports (if the treating clinician is not the diagnosing specialist)

Return Instructions

Send completed records to: [Recipient name and address]
Preferred format: [Secure PDF / Fax / Mail]
Include on each page: Patient name, DOB, and FAA reference number

Questions? Contact [Contact name] at [Phone/email]

Thank you for your assistance in providing complete documentation. This helps avoid delays in the FAA medical certification process.

Signature

Requestor Signature: _______________________________
Printed Name: [Requestor name]
Relationship/Role: [Patient / AME / Authorized representative]
Date: [Date]

Documentation Guidance for Clinicians

• If a required element was not assessed during the visit, state this explicitly (e.g., "not assessed today") rather than omitting it.
• Use absolute dates (YYYY-MM-DD preferred) rather than relative terms like "recently."
• Provide objective clinical information; avoid conclusory statements such as "OK to fly" without supporting clinical detail.