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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>

Page Last Reviewed or Updated: 06-Apr-2017