Mask Exemption Request
Must be submitted a minimum of 7 days prior to scheduled departure
This section must be completed by passenger or designated assistant/guardian
Passenger name (print):___________________________________________________
Reservation and itinerary information:________________________________________
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 customers 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
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