Transplant-Related Travel Travel Request Transplant-Related Travel Request FormThis form is to be used when a family would like to request that transplant-related travel be direct-billed to COTA once arrangements have been made through our partner travel agency. Note: The travel agency charges $25 per hotel reservation and $35 per person for flight purchase, with a max of $70 per family if more than one person is traveling.COTA Patient Name* First Last Name of Individual Requesting Travel Assistance* First Last Email of Individual Requesting Travel Assistance* Phone Number*Travel DetailsDate of Transplant-Related Appointment(s)* MM slash DD slash YYYY Beginning Date of Travel Needed* MM slash DD slash YYYY End Date of Travel* MM slash DD slash YYYY Types of Travel/Accomodations Needed*Choose all that apply Hotel Rental Car Flights Other Please enter 'other' type of travel needed.* Individual Traveler InformationPlease list the full, legal names of everyone traveling for transplant-related appointment(s).Patient Name (Traveler 1)* First Last Traveler 2 Name First Last Add another traveler?NoYesTraveler 3 Name First Last Add another traveler?NoYesTraveler 4 Name First Last Add another traveler?NoYesTraveler 5 Name First Last Add another traveler?NoYesTraveler 6 Name First Last To add more than 6 travelers please contact email@example.com or call us at 800.366.2682.Signature* Reset signature Signature locked. Reset to sign again Please use your mouse or touch screen device to sign this form. By signing you agree you are requesting that travel be direct-billed to COTA after arranging travel through our partner travel agency and understand the fee’s outlined at the beginning of this form. Next StepsThis form is a request for travel assistance/accommodations through Travel Leaders, COTA’s partner travel agency. Filling out the form does not mean travel has been arranged. 1. If the request is approved you will receive an email with a code word and the number for Travel Leaders. 2. Please call Travel Leaders during their business hours, and they will arrange the approved travel for you and send you trip confirmation. Please Note: COTA cannot help with most emergency travel after our normal business hours, Monday-Friday, 8am-5pm EST. Please speak with your social worker and/or transplant team for your emergency travel needs. Eligible transplant-related travel expenses you pay out of pocket can be submitted to COTA after the trip per our guidelines.