Aviation Medical Examiner Billing Form

This Aviation Medical Examiner billing form addresses the unique financial aspects of FAA-mandated medical examinations for aviators. Unlike standard medical visits, aviation medical examinations are typically not covered by health insurance and require direct patient payment. The form clearly documents examination class, certificate type, BasicMed eligibility, and any additional testing required such as EKG, vision testing, audiometry, or special issuance consultation. It includes structured fee schedules for different certificate classes and additional services commonly provided during aviation medical examinations.

The template incorporates specific aviation medical billing scenarios including initial certification versus renewal examinations, age-based EKG requirements for different certificate classes, special issuance authorization statement documentation, and charges for coordination with FAA Regional Flight Surgeons. It provides clear payment policy documentation including non-insurance status of examinations, deferral and denial refund policies, and separate charges for consultation time related to complex medical histories or medication reviews. The form supports AME practices in maintaining compliant financial records while clearly communicating costs to pilot patients before examination.