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Medevac Request Submission
Please use this form to share your experience attempting to medevac.
If you would like to share a testimonial regarding an denied request for care at an off-base facility, an on-base facility, or report a misdiagnosis or safety event,
please follow the link to fill out this form.
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* Indicates required question
Date of Request
*
MM
/
DD
/
YYYY
Which base are you affiliated with?
*
Your answer
Was your medevac request granted or denied?
*
Granted
Denied
Request is in progress
Please share the details of your experience:
Your answer
Your testimonial will be shared in a published document for JCMA share with advocacy partners, media correspondents and decision-makers (like government representatives)
How may we share your testimonial in our advocacy efforts?
(Note: identifying information will not be featured on the live denial of care tracker spreadsheet)
Yes, anonymously.
Yes, I will provide my name below.
Yes, I will provide my name and email to contact me if you need more information.
Part II: Consent
The next set of questions are for submitters that wish to be named, partially-named or contacted for further information regarding your testimonial.
Your name
Your answer
Your email address
Your answer
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