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Line Up and Wait
of Transportation Federal Aviation Administration
Aviation Safety Office of Aerospace Medicine Aerospace Medical Certification Division, AAM-300
P.O. Box 25082
Oklahoma City, OK 73125-9867
OCTOBER 18, 2018
PENSACOLA FL 32505-3471
Ref: PI # 22
MID # 2 APP ID. ------
Subject: Authorization for Special Issuance of an Airman Medical Certificate
Dear Ms.
I have reviewed all information available in your agency medical file in support of your request for airman medical certification. The available medical evidence reveals an established medical history and/or clinical diagnosis of: substance dependence (alcohol). The findings are disqualifying for an unrestricted airman medical certificate under Sections 67.107(a) (4), 67.207(a) (4), and 67.307 (a) (4} of Title 14, Code of Federal Regulations, (14 CFR) Part 67.
However, based on your current clinical status, I have determined that you may be granted an Authorization for Special Issuance of a third-class airman medical certificate under 14 CFR S 67.401. This letter supersedes any prior
Authorizations and any previous determination letters of denial, ineligibility or withdrawal of an Authorization.
The enclosed medical certificate expires on February 28, 2019. certificate supersedes any previously issued certificates,
This Authorization expires on February 28, 2021.
This Authorization REQUIRES THAT YOU MUST:
. Comply with all of the following conditions or your Special Issuance will be withdrawn.
Not change your HIMS trained aviation medical examiner (HIMS AME) without prior FAA approval.
• Present this Authorization letter to your HIMS AME at each visit.
Submit the following documentation required under this Authorization directly to your HIMS AME for review prior to issuing interim certificates or undergoing periodic FAA medical examinations required by class of certificate:
********************************************************************************************************
Aviation Safety Office of Aerospace Medicine Aerospace Medical Certification Division, AAM-300
P.O. Box 25082 Oklahoma City, OK 73125-9867 Phone: (405) 954-4821
OCTOBER 24, 2018
PACE FL 32571
AUTHORIZATION FOR SPECIAL ISSUANCE OF A MEDICAL CERTIFICATION (AUTHORIZATION)
Dear Mr.
I have reviewed the information submitted by you in support of your request for airman medical certification. The medical evidence reveals a history of adjustment disorder with depressed nood. You are ineligible for medical certification under Title 14 of the Code of Federal Regulations (CFRS), revised Part 67; specifically under paragraph(s) or section(s) 107(c), 207(c), and 30740I hare determined, however, that you may be granted Authorization for special issuance of the enclosed third-class airman medical certificate under Title 14 of the CFRS, Section 67.401. The certificate expires June 30, 2019, and supersedes any previously issued certificates. This AUTHORIZATION supersedes any previously issued AUTHORIZATION.
This Authorization expires: June 30, 2019
At least 60 days prior to the expiration of this Authorization, you must submit the following:
A current history and clinical examination from your treating physician regarding your history of adjustment disorder with depressed mood. The report should address history and symptoms, diagnosis, treatment plan, current over-the-counter and prescription medications (name, dosage, indication, frequency of use and side effects), and prognosis. Include the results of any current testing deemed appropriate.
Please mail the reports in one complete package to:
Federal Aviation Administration Aerospace Medical Certification Division CAMI Bldg 13, Room 308, AAM-300 PO Box 25082 Oklahoma City, OK 73125
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