Sample Template for Use by Healthcare Providers
***Ask your healthcare provider’s office to copy this template to the practice’s letterhead and input the needed information to replace the guidelines in the brackets <> and the brackets***
<Insert Today's Date>
<Insert Parent/Guardian's Name and Address>
Re: <Insert Child's Name>
To Whom It May Concern:
According to our records <Child's Name> was a patient of <Name of Your Practice> during <Insert The Tax Year From The Notice>.
Our records reflect that the child lived at
Zip Code (if the child moved during the year show all addresses)>
<Time Period Child Was A Patient>, and that the child received service on
<Insert the Dates You Provided Services During the Tax Year on the Notice>.
Our records also reflect that the child’s parent or guardian during this time was
<Parent's or Guardian’s Name(s)>.
The child’s parent's or guardian's address of record during this time was listed as
<Parent's or Guardian’s Address(es)>.
<Signature of Employee>
<Insert Phone Number of Employee>