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 year on the notice>.
Our records show the child has been a patient since <time period>, they received services on <Insert the Dates You Provided Services During the Tax Year on the Notice> and their address was listed as <street address, city, state, ZIP Code> during this time.
Our records also reflect that the child’s parent or guardian during this time was <parent's or guardian’s name(s)> and their address was listed as <street address, city, state, ZIP Code>.
Sincerely,
<Insert signature of employee>
<Insert name of employee>
<Insert title of employee>
<Insert phone number of employee>