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)> 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>
