Sample Template for Use by Healthcare Providers


 Ask the healthcare provider’s office to use this template on the provider’s letterhead and replace the bracketed information.

<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)> 


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