Information For...

For you and your family
Standard mileage and other information

Forms and Instructions

Individual Tax Return
Instructions for Form 1040
Request for Taxpayer Identification Number (TIN) and Certification
Request for Transcript of Tax Return

 

Employee's Withholding Allowance Certificate
Employer's Quarterly Federal Tax Return
Employers engaged in a trade or business who pay compensation
Installment Agreement Request

Popular For Tax Pros

Amend/Fix Return
Apply for Power of Attorney
Apply for an ITIN
Rules Governing Practice before IRS

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
<Street Address,
City, State,
Zip Code (if the child moved during the year show all addresses)> 

from

<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)>.

Sincerely,

<Signature of Employee>
<Insert Name>
<Insert Title>
<Insert Phone Number of Employee>