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