Fillable Mask Exemption Request (United Airlines)

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Mask Exemption Request (United Airlines)

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The Mask Exemption Request (United Airlines) form is 3 pages long and contains:

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  • 35 other fields

Country of origin: US
File type: PDF

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Mask Exemption Request
Submit to maskexception@united.com a minimum of 7 days prior to scheduled departure
Initial
This section must be completed by passenger or designated assistant/guardian
Passenger name (print): ___________________________________________________
Passenger age: _________
Reservation confirmation number: ________________
Date(s) of travel: _____________________
Origin/destination: _____________________________________
_______
I understand that United, in its sole discretion and in accordance with CDC/DOT/TSA standards,
will determine whether to approve my mask exemption request.
_______
I understand that United requires that I provide proof of a negative COVID-19 PCR test result
taken within 72 hours of my scheduled departure.
_______
I understand that United may require me or my travelling party to move to alternate seats in the
cabin and/or change our itinerary to less-full flights to allow for greater social distancing from
other passengers on board, if possible. United will advise regarding the alternatives, and changes to
flights under these circumstances will be made at no additional cost.
_______
I understand that if United approves my mask exemption request, I need to print the approval letter
and carry it on my person at all times while traveling and will need to show it to TSA at the
security checkpoint prior to being screened.
_______
I understand that my mask exemption request is applicable only to flights in a single reservation,
and any exemption for future travel or travel in separate reservations will need to be applied for
anew.
_______
I authorize the release of medical information pertaining to this mask exemption request and
authorize my treating physician to speak with a United Airlines medical representative or any
agent acting on its behalf.
_______
I understand that if I choose to request a mask exemption, United will use the information on this
form to handle my request. In order to assess and manage my request I understand that it may be
necessary for United to disclose information relating to my health information to third parties such
as medical professionals, airport staff, health agencies, United Express and Star Alliance carriers,
and their employees, among others.
INDIVIDUALS LOCATED OUTSIDE OF THE UNITED STATES: If you are located outside of
the United States and you choose to request a mask exemption, United will use the information on
this form to handle your request. You understand that this form will be transferred to the United
States, where data protection laws may not be equivalent to those in your home country. By
signing below and affirmatively submitting this form, you give specific consent to United to
process and transfer the information for these purposes. To exercise rights granted pursuant to
applicable law, including withdrawal of consent, contact privacy@united.com. Withdrawal of
consent does not affect the lawfulness of information processed until the withdrawal, and this
information will continue to be maintained for compliance with legal obligations and for the
establishment, exercise or defense of legal claims.
Passenger or designated assistant/guardian name (print): _________________________________
Passenger or designated assistant/guardian signature: ____________________________________
Date: _____________________
Phone contact: _____________________ Email contact: ______________________________
Initial
This section must be completed by a medical provider specifically treating the passenger’s
disability
Patient/passenger name (print): _________________________________________
_______
I am a licensed medical provider currently treating the passenger’s disability.
_______
Pursuant to federal law, only individuals with a disability who cannot wear a mask or
cannot safely wear a mask because of the disability, for example, individuals who do not
know how to remove their masks, cannot remove them on their own, or cannot
communicate promptly to ask someone else to remove their mask are eligible to request a
mask exemption. Individuals for whom mask wearing may only be difficult are not
eligible to request a mask exemption. More details on the CDC order and what qualifies
for an exemption can be found here: https://www.cdc.gov/quarantine/masks/mask-travel-
guidance.html#disability-exemptions
I attest that I have reviewed the CDC disability exemption requirements (link above) and that the
passenger qualifies based on a disability as defined by the Americans with Disabilities Act.
Additionally, I attest that the passenger cannot safely wear a mask in connection with the flight(s)
for the itinerary above for the following reason(s):
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
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_____________________________________________________________________________
_____________________________________________________________________________
Can the passenger wear a face shield? Yes _______ No _______
Medical provider’s license information:
Date and type of the license: ________________________________
License Number: ________________________________
State or other jurisdiction in which license was issued: ______________________________
Your name (print): ________________________________________
Your Specialty: ____________________________________________
Signature and Date: _________________________________________
Business phone contact: _____________________________________
Business email contact: ______________________________________
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Mask Exemption Request (United Airlines)

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Completed 16 January 2022

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