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 Click Here  For A Downloadable PDF Copy Of This Form

Questions? Email: ICMFHOPE@Aol.Com

In many instances care “is” available in the child’s country but the parents simply “want” the child to be treated abroad.  We can “only” help in those cases where there is “no” medical care available in the child’s native country.

All forms and other correspondence must be in English.

In many instances care “is” available in the child’s country but the parents simply “want” the child to be treated abroad. We can “only” help in those cases where there is “no” medical care available in the child’s native country.

Parents/Guardians seeking medical care assistance for their child must download this form and have the child's doctor retype it on the doctor's letterhead. A copy of this document must be submitted to ICMF and the original must be handcarried with patient on the airline(s).

All forms and other correspondence must be in English.

(DOCUMENT MUST BE FILLED OUT IN ENGLISH AND MUST BE TYPED, EXACTLY AS SHOWN HERE, ON DOCTOR'S BUSINESS LETTERHEAD)

 

TO WHOM IT MAY CONCERN: 

Date: ____________

Patient's Name:______________________

DOB: _______________________

Patient's Address: _________________________________

I certify that I am the attending Physician for the above referenced since __________________________.

I certify that there is no medical care available in our country for (Name Of Patient) __________________________

______________________, who has been diagnosed with: _________________________________

Tertiary Care abroad is needed for this medical condition. Copy of medical records are provided.

(Print/Signature Of Physician)