Transplant-Related Travel

Transplant-Related Travel Request Form

This 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 Details

Date of Transplant-Related Appointment(s)*

Beginning Date of Travel Needed*

End Date of Travel*

Types of Travel/Accomodations Needed*

Choose all that apply

Hotel
Rental Car
Flights
Other

Please enter 'other' type of travel needed.*

Individual Traveler Information

Please 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?

Traveler 3 Name

First Last

Add another traveler?

Traveler 4 Name

First Last

Add another traveler?

Traveler 5 Name

First Last

Add another traveler?

Traveler 6 Name

First Last

To add more than 6 travelers please contact familyservices@cota.org or call us at 800.366.2682.

Signature*

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 Steps

This 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.